Serious injury of a 4-year-old girl of mixed heritage, in March 2013. Zara was admitted to hospital suffering from stomach pains. Ruptures to her duodenum, thought to be non-accidental, were identified following surgery. Criminal charges have been brought against suspected perpetrators (not mother). Maternal history of challenging behaviour, drug misuse, social isolation, financial problems and homelessness. Paternal history of drug misuse, prolific offending and imprisonment. Family were known to a number of agencies, including children's social care, housing services, police and probation services. Approximately a year prior to the incident, mother was the victim of what the Police described as a racially aggravated common assault, which included a threat to burn mother's flat down with Zara inside. Issues identified include: mother's intelligence, unusually good level of education and articulacy diverting the attention of professionals; insufficient exploration of the impact of ethnic, cultural and religious factors; assessments being treated in isolation leading to a limited understanding of cumulative risk; and insufficient exploration of the significance and impact of father. Uses some elements of the Learning Together methodology. Makes recommendations, covering early years services, schools, children's social care, health visiting, housing and rent collection services, probation, hospitals and GPs.
      
 Title:  Serious case review: ‘Zara’. LSCB: Wandsworth Safeguarding Children Board Author: Fergus Smith Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                                                                                                                                                                                       CCOONNFFIIDDEENNTTIIAALL    WWAANNDDSSWWOORRTTHH  SSAAFFEEGGUUAARRDDIINNGG  CCHHIILLDDRREENN  BBOOAARRDD      SSEERRIIOOUUSS  CCAASSEE  RREEVVIIEEWW          ‘‘ZZAARRAA''                July 2014     Contents 1 INTRODUCTION 1 1.1 Detection of injuries to Zara & response of the Local Safeguarding Children Board (LSCB) 1 1.2 Arrangement of the overview 2 2 REVIEW PROCESS 3 2.1 Relevant agencies 3 2.2 Timetable for serious case review 3 2.3 Conduct & critique of process 4 2.4 Family details 7 3 AGENCIES’ CONTACT WITH FAMILY PRIOR TO REVIEW PERIOD 10 3.1 Introduction 10 3.2 Mother’s final year of education: 2007/08 10 3.3 Ante-natal period May- December 2008 14 4 PERIOD OF REVIEW: BIRTH TO CRITICAL INCIDENT 18 4.1 Introduction 18 4.2 1st year of Zara’s life: December 2008 – December 2009 18 4.3 2nd year of Zara’s life: December 2009- December 2010 22 4.4 3rd year of Zara’s life: December 2010- December 2011 26 4.5 4th year of Zara’s life: December 2011- December 2012 30 4.6 5th year of Zara’s life: December 2012 - incident in March 2013 34 5 ANALYSIS 37 5.1 Introduction 37 5.2 What were the key relevant opportunities for assessment? if opportunities were missed please state what they were & your understanding of why they were missed. 37 5.3 Was consideration given to the impact of cultural / racial & other equalities issues in any assessments? 40 5.4 Do assessments & decisions appear to have been reached in an informed & professional way? 41 5.5 Did actions accord with assessments & decisions made? 42 5.6 Were appropriate services offered / provided or relevant enquiries made, in light of assessments? 44   5.7 Were practitioners aware of & sensitive to the needs of the child in their work? How did practitioners establish the child’s view about what was happening in her life & how was this recorded? 46 5.8 Were professionals knowledgeable about the potential indicators of abuse or neglect & about what to do if they had concerns about a child’s welfare & was this evident in their practice? 48 5.9 Were senior managers or other organisations & professionals involved at points in the case where they should have been?  Was there sufficient management accountability for decision making? 50 5.10 Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisation?  there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave impact on the case 52 5.11 Did the organisation have in place policies & procedures for safeguarding & promoting the welfare of children & acting on concerns; was the practitioner aware of their existence & Was the work in this case consistent with each organisation & the WSCB’s policy & procedures for safeguarding & promoting the welfare of children, & with wider professional standards? 53 5.12 Additional case-specific issues 54 5.13 Missed opportunities for best practice 60 6 CONCLUSIONS 62 6.1 Introduction 62 6.2 Findings 62  Good individual practice 62  Sub-optimal systems 62 6.3 Predictability & preventability 63 7 RECOMMENDATIONS 64 8 GLOSSARY OF ABBREVIATIONS / NAMES 68 9 BIBLIOGRAPHY 70                                                                                                                                                   1        1 INTRODUCTION  1.1 DETECTION OF INJURIES TO ZARA & RESPONSE OF THE LOCAL SAFEGUARDING CHILDREN BOARD (LSCB) 1.1.1 At the time of the incident in March 2013 that triggered this serious case review (SCR) child Zara was a four year old female of dual heritage (White / Black Caribbean) living in social housing with her twenty one year old White British single mother. 1.1.2 Zara was admitted to the local hospital suffering from stomach pains and vomiting. Following extensive surgery, two ruptures to her duodenum (the short part of the small intestine connecting it to the stomach) were discovered. During surgery, Zara experienced cardiac arrests and required life-saving resuscitation. The injuries were believed by attending surgeons to be the result of trauma. Criminal charges have been brought against suspected perpetrators. 1.1.3 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 (SI 2006/90) requires LSCBs to undertake reviews of serious cases in accordance with the principles set out in Working Together to Safeguard Children HM Government 2013. A serious case review (SCR) must be initiated when abuse or neglect of a child is known or suspected and either the child has died or has been seriously harmed and there is cause for concern as to the way the authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.1.4 Its purpose is:  To establish what lessons can be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children  To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result and  As a consequence, improve intra and inter-agency working and better safeguard and promote the welfare of children 1.1.5 Following consideration by the ‘Serious Case Improvement and Learning Sub-committee on 24.04.13 and 02.05.13, members concluded the case satisfied the criteria for a serious case review. This recommendation was put to and agreed by the independent chairperson of Wandsworth’s Local Safeguarding Children Board (LSCB) immediately after the second meeting and the Department for Education (DfE) was subsequently informed. 1.1.6 On 12.09.13 Zara’s mother was informed of the initiation of this SCR and her involvement in its conduct sought as described later in this report. Zara’s birth father (currently in prison) was also informed and invited to comment on services provided to his daughter.                             2                           OVERVIEW AUTHORSHIP & CHAIRING OF SCR PANEL 1.1.7 An independently authored overview report was commissioned from CAE Ltd (www.caeuk.org) (a social work consultancy with experience of over fifty SCRs). It was agreed that upon submission of all relevant material, author Fergus Smith would, in accordance with the detailed terms of reference appended to this report:  Collate and critically appraise all individual management reviews (IMRs) and other documents  Develop for consideration by the panel, an analysis, conclusions and recommendations for action by Wandsworth’s Safeguarding Children Board, member agencies and (if relevant) other local or national agencies 1.1.8 The SCR panel was chaired by the independent chairperson of Wandsworth’s Safeguarding Children Board (Ms Nicky Pace) and the panel consisted of professionals with expertise in Health (health visiting and GP), Education, Children’s Social Care, Police and Housing.  1.2 ARRANGEMENT OF THE OVERVIEW 1.2.1 In an attempt to render more accessible what is a significant amount of detail, the remainder of the report is laid out as follows:  A description and commentary on the effectiveness of the methodology adopted and conduct of the SCR   Family details including a genogram of relevant family members   A more detailed chronological account of agencies’ involvement with the family during the review period, highlighting key events and professional decisions  An analysis of the extent to which records demonstrate best practice with respect to the issues in the terms of reference   Overall findings and conclusions   Practical recommendations for the LSCB and member agencies that are specific, measurable, achievable, realistic and timely  A glossary of abbreviations  A bibliography of general and case-specific literature of relevance                             3                           2 REVIEW PROCESS  2.1 RELEVANT AGENCIES 2.1.1 The following agencies were identified as having or likely to have information and opinions of relevance to the serious case review:  Wandsworth Education & Early Years Service  (providing secondary education and education welfare services to mother and nursery provision for Zara)  Wandsworth Children’s Social Care (initial and other assessments, ‘ad hoc’ responses and inter-agency liaison)                   St George’s Healthcare NHS Trust (health visiting services )  Wandsworth Housing (provision of tenancies & tenancy support)  Wandsworth Rent Collection Service (a part of the Finance Department responsible for pursuing tenancy-related debts)  Chelsea & Westminster Hospital (provision of midwifery and paediatric A&E and urgent care centre services)  London Probation Trust (completing offender assessments and pre-sentence reports on Zara’s father)  Metropolitan Police Service (investigating crimes committed by Zara’s father and mother and notifications of incidents involving potential risk to a child)  GP Practices (providing community based medical services) 2.2 TIMETABLE FOR SERIOUS CASE REVIEW ORIGINAL & REVISED 2.2.1 The SCR panel agreed a clear timetable which was later adjusted. Actual achievement of each specified task is (where dates differ from the original) shown in parentheses:  20.06.13: Sub-committee planning meeting with IMR and overview authors to agree membership and dates for meetings  01.07.13: Chronology from each involved agency to be submitted to SCR co-ordinator (MPS chronology received on 10.01.14)  09.07.13: Integrated chronology for panel members (22.08.13, updated 04.09.13, 20.09.13, 26.09.13 and a final version including Police entries provided on 10.01.14)  16.07.13: Set-up meeting with IMR and overview author to decide on ‘key lines of enquiry’ and revise the terms of reference  19.07.13: Learning exercise 1 with practitioners  19.08.13: Draft 1 IMRs to be submitted to co-ordinator (27.08.13 for all but Housing which arrived on 29.08.13 and Police on 21.02.14)                             4                            05.09.13: ‘Challenge meeting’ for panel to consider IMRs submitted by that date (05.11.13)  September: Overview author to meet with parent/s (deferred pending receipt of final IMRs – father seen in November and telephonic contact with mother in February 2014 respectively)  23.09.13: Final IMRs to be submitted to co-ordinator (St George’s Hospital & Early Years Service, Housing including tenancy support + Rent Collection Service and health visiting all on 30.09.13, Probation & Chelsea & Westminster received 03.10.13; Clinical Commissioning Group 09.10.13, and a final MPS IMR on 27.02.14)  30.09.13: ‘Sign off’ of IMRs and discussion of a ‘draft 1’ of an overview (05.11.13; 26.03.14)         14.10.13: Learning exercise 2 with practitioners (postponed until 21.11.13, 28.02.14, 15.05.14 and finally held 11.06.14)  11.11.13: Draft 2 overview report to be submitted (was to be 29.11.13, 19.03.14 and became 04.04.14)  21.11.13: Executive of LSCB to sign off overview and support recommendations to the LSCB (05.12.13 and became 14.07.14)  Publication of final version (due December 2013, will be after conclusion of criminal proceedings November 2014) 2.2.2 Following discussion at the panel it was determined that reports from the two Housing Associations would be useful and these were made available in mid-February. It became apparent that their value was seriously limited. Apparently archived records were no longer available and the accounts provided had been written largely from the memories of individuals. For that reason, those reports have not been used and a recommendation about the need to ensure the production and retention of professional records amongst commissioned service providers has been included in section 7. 2.3 CONDUCT & CRITIQUE OF PROCESS TRANSPARENCY 2.3.1 The SCR panel was clear from the outset that in order to maximise learning opportunities, make agencies’ self-examination transparent, and to satisfy the legitimate right of the public for professional accountability, the final overview report would be published in its entirety.  2.3.2 This report therefore provides a comprehensive account of events and professional actions, though details about people and places that would lead to the identification of individuals in the family or within involved agencies have been minimised.                             5                           METHODOLOGY 2.3.3 The panel determined that its approach would incorporate some elements of the ‘Learning Together’ methodology currently being promoted by the Social Care Institute for Excellence. Thus, in advance of drafting IMRs, an early meeting with involved practitioners was convened and their perspectives on roles played and the context within which they were operating were sought. 2.3.4 Following debate amongst panel members about the IMRs received and the development of some tentative conclusions, a follow-up meeting with practitioners was held and helped to refine the final conclusions and recommended service improvements. SCOPE OF REVIEW & QUALITY OF PROCESS 2.3.5 Aside from adding authenticity to the retrospective examination of services, closer involvement of staff in the SCR served to facilitate an appreciation of the need for and commitment to required changes. In the author’s view, the value of the first meeting with involved staff would have been greater if panel members had been as informed then about the case as they subsequently became. 2.3.6 In the light of what was known about child Zara and her family, the span of the SCR was appropriate. The terms of reference (each element of which is addressed in section 5) also explicitly allowed for the possibility of an agency addressing any event that fell outside of the defined review period. 2.3.7 The integrated chronology of all agencies’ contacts was very well presented and the standard of final versions of individual management reviews generally good, though the variation in some from established terms of reference rendered aggregation and comparison more difficult. The final draft of the health visiting IMR remains difficult to interpret reflecting a confusion in the period under review about which health visitors were responsible, difficulties in transition from paper-based to electronic records, organisational re-structuring and the introduction of ‘corporate case loads’.  2.3.8 The SCR process was delayed but not otherwise reduced in value by significant resource difficulties within the Police Service which meant that its chronology and IMR were made available considerably later than all others. 2.3.9 All the IMRs were written by sufficiently independent and suitably experienced authors who based their reports on relevant records and when necessary, interviews with specified staff. Initial versions of chronologies lacked sufficient detail and premature and different ascription of anonymised labels for professionals in some reports made it difficult to determine identities. Following confirmation of names and roles, a common nomenclature has been used in this overview.                             6                           FAMILY INVOLVEMENT  Mother 2.3.10 Zara’s mother was informed in person by Wandsworth’s head of safeguarding that a SCR was being conducted and was invited to meet with the overview author. An offer to meet was emailed in October and a further reminder sent in November. An email response was received in early December and a provisional arrangement made to meet in early 2014 by which time it was anticipated the final overdue IMR would have become available.  2.3.11 Liaison with the Police senior investigating officer (SIO) ensured that the focus of discussion with Zara’s mother was on services received. Subjects that might generate evidence for the ongoing criminal investigation were avoided 2.3.12 On two occasions the author travelled some distance to a pre-arranged venue chosen for its convenience to Zara’s mother. On both occasions, Zara’s mother when contacted, reported that she had ‘forgotten the appointment’. Further negotiations via email established that mother would make herself available for a discussion by phone. Four calls were made at agreed times and none answered. Messages were left. Finally in mid-February, mother initiated a call and spoke at length to the author. Her memories and opinions are woven into the narrative at relevant places. Father 2.3.13 The father of Zara is serving a long custodial sentence for numerous offences unrelated to Zara’s injuries which were committed during the period when he and the mother Zara were intimate partners. He agreed to meet and provide his perspectives. At that meeting Zara’s father confirmed that his relationships with Zara’s mother and (he reported) his daughter are over. 2.3.14 Father confirmed what records indicate i.e. although in an intimate and ongoing relationship with her, he had not co-habited with mother. The pregnancy in 2008 was unplanned but he said, was welcomed by them both at the time. Zara’s father reiterated what he had previously claimed to a probation officer viz: that the birth of Zara was sufficient incentive to give up use of cocaine.  2.3.15 Father indicated that because they had never lived together and because he kept his criminal activities hidden from his own and from Zara’s mother, he had never met any professionals such as midwives, health visitors, housing personnel or social workers. Thus, he was unable to comment on any services that may have been offered or provided. He was able to confirm that Zara’s mother spent significant time with his mother.                             7                           2.3.16 Father did indicate that he was wholly unaware of any threat from gangs perceived by his ex-partner and assumed that any such claims might have simply reflected her wish not to be housed in certain areas. 2.3.17 Father (whose name appears on Zara’s birth certificate and who in consequence has parental responsibility) was keen to have sight of a copy of the published report. Security considerations at his prison preclude accessing the Wandsworth LSCB website so the author undertook to seek agreement to father being given of a copy of this report. Confirmation that such an arrangement would, in due course be made, was relayed back to father by the Probation Service. Zara 2.3.18 Zara was adjudged to be too young to contribute directly. A conversation with her foster carer provided a glimpse into her formative experiences and how they may have impacted upon her presentation and performance. 2.3.19 Zara was described by her carer as a bubbly, confident, inquisitive and affectionate child who relates well to other children and to adults. She still relates more readily to younger men than to older ones with whom it appears a degree of mistrust remains. Zara has begun to speak more openly about the reality of living with her mother and of ‘being hurt’.  2.3.20 An unsurprising wish to be with her mother and yet to be safe is illustrated by Zara’s recent and touching proposal that her mother moves to the carer’s home and that they all live together. The child has coped well when, on several occasions, mother has failed to attend the supervised contact and instead, members of the extended family have come in her place. 2.3.21 Zara has a memory and (according to her mother) affection for her birth father. She has described visiting him ‘in a castle’ (possibly a reference to Wandsworth Prison where he spent time on remand). 2.4 FAMILY DETAILS Name  Gender Relationship Year of birth Ethnicity Child Zara Female Subject 2008  White / African Caribbean  Female Mother 1991  White  Male Father 1983 White / African Caribbean  Male Maternal uncle Not known White Addresses Actual / estimated dates  1. Mother: with MGM Wandsworth 2.Mother:  with MGM Early 2008 :Pimlico Westminster 3. Mother: short-term emergency B&B 17.01.08 -21.01.08 Wandsworth 4. Mother: own unknown accommodation 21.01.08 may have been at MGM where she was located by 08.02.08 (deduced) 5. Mother: 2nd short-term emergency B&B  19.03.08 – 13.04.08 Wandsworth 6. Mother: temporary accommodation specialist supported housing for 16/17s 14.04.08 – 01.06.08 Wandsworth 7 Mother: Housing Association medium level 02.06.08 – 19.04.09 (abandoned because of ‘mice                             8                           support mother & baby Unit  infestation’ triggering formal notice to quit)  8. Mother & Zara at MGM address 19.12.08 – January 2009 9. 2nd Housing Association high level support mother & baby teenage parent unit 26.03.09 – 23.05.10 prior to awaited permanent accommodation - actually on/off with PGM and awaiting a ‘move to Tooting’ according to mother 10. Mother & Zara: permanent 2 bed flat  24.05.10 – 25.11.13 [current address unknown]                                                                                                                                                    9         Father of Zara    Child Zara   Boyfriend of Zara’s mother ?  2 Maternal grandfather  MGF    PGF  Maternal grandmother  MGM   PGM Paternal aunt Mother of Zara  Maternal uncle  1 3                                                                                                                                                   10        3 AGENCIES’ CONTACT WITH FAMILY PRIOR TO REVIEW PERIOD 3.1 INTRODUCTION  3.1.1 The terms of reference allowed for the possibility that a number of agencies held historical information about Zara’s mother. It was felt that they might, in combination, offer a useful background picture of relevance in evaluating the support services offered to child Zara and her still very young mother. 3.1.2 Thus, section 3 offers a summary of the period from Zara’s mother first coming to the attention of Wandsworth agencies through to the period of formal review i.e. Zara’s birth to the incident in March 2013 that triggered the SCR. 3.1.3 The author’s comments on a number of individual events or decisions are provided in italicised paragraphs. Section 4 aggregates these and addresses and analyses a wider range of issues. 3.2    MOTHER’S FINAL YEAR OF EDUCATION: 2007/08 3.2.1 Having been privately educated at an independent boarding school located outside of London (school 1) for several years, mother was withdrawn in late 2006 reportedly because of a financial crisis in the family. Mother confirmed to the author that this event thrust her ill-prepared into a tougher environment than that to which she was accustomed. Her personal resentment of the parents’ decision was magnified because her sixth form brother was allowed to remain at the school. 3.2.2 An application to a local school was initially unsuccessful because there were no vacancies in the relevant year group. A second application in June 2007 succeeded. Though reports from school 1 had been positive, there were within weeks, reports of challenging conduct e.g. illicit smoking and in the Autumn, lateness, a failure to work, poor attitude and low attendance (only 75% in the final term of 2007). Mother described examples of ill-discipline at the school and a frightening sense of ‘survival of the fittest’. In retrospect she feels that she coped by lowering her standards of conduct to that of the worst around her. 3.2.3 The Wandsworth Early Years & Education IMR refers to involvement at this time of a member of the Youth Offending Team YOT1 (who mother has stated was much valued) seconded to the ‘Battersea Early Intervention Team’. 3.2.4 Offers of support, offer of part-time schooling and a warning letter about court action for non-school attendance seem to have made little difference. A local alternative education provider was considered and after initial uncertainty mother said she would attend. Fulfilment of her apparent agreement later became contingent upon a named friend also being allowed to accompany her.                                                11                                          MOTHER’S INITIAL CONTACT AT MEDICAL CENTRE 1:  3.2.5 A review of earlier paper records held by the GPs revealed nothing of note from her own earlier childhood and the first relevant contact was in late October 2007 when Zara’s mother (then aged 15 years 10 months) was taken to medical centre 1 by her own mother (Zara’s maternal grandmother, hereafter referred to as MGM). 3.2.6 MGM was concerned about her daughter’s reaction to imminent parental divorce. She reported her missing school, staying out late and presenting challenging behaviour. Zara’s mother acknowledged past sexual activity though denied that she was sexually active at the time of her presentation to GP1. 3.2.7 GP1 initiated a referral to the local Child and Adolescent Mental Health Service (CAMHS) (where the young woman was placed on an eleven week waiting list) and to Wandsworth Children’s Social Care. Comment: the referrals and her initial follow up suggest a doctor sensitive to this adolescent’s psychological and social needs. The waiting period was long but not unusually so. 3.2.8 In mid-November 2007 mother was reported by her mother as ‘missing’. She had left for school but failed to attend. After some text communication with MGM indicating that she was safe but unwilling to disclose her location, mother returned safe and well of her own accord two days later. Police officers had made routine enquiries and subsequently conducted an un-informative de-brief upon her return. 3.2.9 In the late evening of the day of her return, mother again walked out and within minutes had (she later admitted) stolen from MGM’s account in a local cash machine. MGM did not wish to pursue a prosecution and mother returned home next day. 3.2.10 In mid-December 2007 a letter from the local authority warning of legal action consequent on poor school attendance was sent to MGM (attendance in early 2008 was only 37%). 3.2.11 Zara’s mother failed to attend any of three CAMHS appointments, or to respond to follow-up letters sent after each. In February 2008, following discussion and agreement with her then social worker, a letter confirming case closure was sent to her and to the GP. Upon receipt of her letter, mother made an appeal (which was accepted) to keep her case open. 3.2.12 Children’s Social Care had responded to GP1’s phone referral by deploying an ‘initial contact worker’ (ICW1) who in turn initiated contact with the MGM.  The MGM went on to report her daughter as missing on two occasions in late 2007. MGM believed she was using harder drugs in addition to an acknowledged use of cannabis. MGM also reported the fraudulent use of her debit card by her daughter. 3.2.13 Information gathered during this period referred to the brother still at boarding school and to an aunt with whom Zara’s mother was ‘close’ but (according to mother) drank to excess. The young woman also referred to a fear of her father though why remained unexplored. Comment: the issue of mother’s stated fear of her father may have been an important missed opportunity to better understand her needs. That said, in her conversation with the author, mother has no recollection of this disclosure or why she might have made it.                                                12                                          3.2.14 The case was transferred to the ‘Diversion from Care’ team with a recommendation of a core assessment (an in-depth assessment of family functioning and significant environmental factors). Some assessment was undertaken but apparently not written up. Allocated SW1 in consultation with team manager TM1 planned work around housing, liaison with other agencies and a referral for a family group conference. A planned case closure in consequence of mother’s lack of engagement was postponed in response to a request from MGM for the team to remain involved. Comment: reasons why no core assessment was completed or why medical centre 1 received no feedback from its referral, have not emerged from the Children’s Social Care IMR. Mother’s recollection of this period is incomplete but her strongly held overall memory is of insufficient support. MOTHER’S INITIAL BID FOR ACCOMMODATION: JANUARY 2008 3.2.15 In mid-January 2008 mother (aged just over 16) was referred on by Children’s Social Care to the Housing Department following unsuccessful attempts by the former agency to mediate between mother and daughter. In retrospect mother acknowledges that MGM’s apparently rejecting behaviour may have been an attempt to shield her youngest child (then aged 10) from the influence of mother’s challenging conduct. 3.2.16 At that time there was a joint protocol in place to try to ensure that responses of Housing and Children’s Social Care to such young people were compatible. By the following year, a ‘Youth Homelessness Prevention Team’ had been put in place specifically to deal with 16/17 year old homeless individuals and by March 2012 explicit procedures produced to inform the responses of practitioners and managers in both departments. 3.2.17 On this occasion mother was accepted as being homeless and initially provided with a place in a bed and breakfast establishment. One IMR suggests that she may actually have spent a proportion of her time in this period living with a ‘27 year old brother (actually a step-brother) in Hampstead’. Mother anyway left behind her an unpaid bill of £125 and ignored advice about how to get the Housing Department to settle it. 3.2.18 Records indicate that MGM mentioned a [named] friend of mother’s and that he and her daughter smoked. MGM also confirmed that her husband had flown to South Africa. 3.2.19 In late January education welfare officer EWO1 sought a professionals’ meeting prior to a family group meeting on the grounds that her experience of the family was that its members kept changing their plans for this young woman. Early in February 2008 Zara’s mother returned to MGM’s address. 3.2.20 The Diversion from Care team received a notification from Wandsworth Housing Department that Zara’s mother had moved out of the first B&B in late February. An incident in early March where MGM reported finding Zara’s mother in the bath with her boyfriend at 05.00 suggests that by then anyway, she was back at MGM’s home address.                                                13                                          FAMILY GROUP MEETING 3.2.21 On a date in mid-March MGM reported to the Diversion team that she had returned home to find her bedroom door smashed and a laptop stolen. She had notified Police and suspected the then unnamed boyfriend of Zara’s mother. 3.2.22 A family group meeting was convened a few days later. Relatives involved included the maternal great grandmother (MGGM), MGM, an aunt (of Zara’s mother) and mother of child-to-be Zara.  These attempts to reconcile MGM with her daughter were unsuccessful and in spite of efforts by the social worker, several failed appointments and phone calls to her cut off by Zara’s mother, prompted Children’s Social Care to close the case on the basis of a lack of engagement. 3.2.23 Zara’s mother tried (presumably after the family meeting) to persuade Housing to offer accommodation and was advised, since she had quit her previous accommodation, to call her Diversion worker and make a fresh application. Further contact three days later with YOT1 focused on her entitlement to benefits and a need to prove she was still in education. 3.2.24 A record of supervision of the above worker indicated a place in a second B&B had been provided in mid-March 2008 and that EWO1 and the Connexions Service were being supportive. It also indicated that her father i.e. Zara’s maternal grandfather was ‘in receipt of [specified] medical treatment in South Africa. Comment: no further information about Zara’s grandfather has been provided by any agency. 3.2.25 In early April father was arrested and admitted burglary. He appeared in court, was remanded into custody and subsequently sentenced in May 2008. 3.2.26 At about this time, there was a phone discussion between consultant psychiatrist (psych.1) and a social worker (presumed to be SW1) when they discussed the family background and hypothesised the origins of its difficulties. 3.2.27 A Diversion team record of early April 2008 indicated mother still living (and reportedly happy in) a ‘bed and breakfast’ establishment (where she stayed for about a month according to Housing records). She reported that she did not wish to attend her appointment with psych.1 at Adolescent Services. The social worker concluded that as Zara’s mother had rejected all suggestions, there was no future role for his service. 3.2.28 A record of supervision within the same team dated mid-April indicated that a planned family group review meeting was to be cancelled (in fact it actually went ahead on a few days later). EWO1 confirmed that Zara’s mother was now on a school roll. 3.2.29 Children’s Social Care records of the family group meeting review indicate that mother ‘had moved into accommodation in a [named] road’ and now ‘had a career plan’ (which was train as a lifeguard). Mother’s account to the author referred only to starting a childcare course later abandoned as a result of her pregnancy.  3.2.30 The Police IMR confirms a prison visit by mother to father in mid-April.                                                14                                          3.2.31 The above move of accommodation has been confirmed by the Housing Department and a record of supervision of the social worker dated May also refers to a move to a ‘hostel for young people’ said to be supported by Connexions. 3.2.32 On a date in late April, in spite of a phone message cancelling her appointment MGM appeared and was seen by psych.1. He took a detailed family history and undertook to write to Zara’s mother and to convene a ‘large family meeting’. 3.2.33 On the recorded basis that mother stated she no longer required Diversion team support, the manager decided to close the case. The fact that mother was at that point pregnant with child-to-be Zara was unknown to this agency (and possibly to mother herself). 3.2.34 Housing records indicate that mother may have made a phased move into her hostel in the period from mid-April through to early June. Comment: it seems as though from her initial request for accommodation in January to recognition of pregnancy as described below, mother lived in 5 different locations.  3.3 ANTE-NATAL PERIOD MAY- DECEMBER 2008 3.3.1 Mother presented to hospital 1 A&E in mid-May and was discovered to be 9 weeks pregnant. Records indicate she informed staff she was ‘in care and in a youth hostel’. Recognition of the young woman’s vulnerability prompted a ‘maternity meeting’ convened at the hospital 4 days later.  The medical staff informed mother’s medical centre 1 GP of the A&E presentation and their medical / social observations. The record within Children’s Specialist Service of notification of this contact is dated late June. Comment: the elapse of some 6 weeks before a record is made of the notification may reflect delayed reporting from the hospital and/or tardy inputting to the client information system of Children’s Social Care. 3.3.2 The Practice nurse met mother for purposes of ante-natal care and re-booked her with GP2.  The GP practice had not by then received a discharge summary later received from the specialist registrar from hospital 1 A&E and indicating his view that mother was pregnant. COURT APPEARANCE OF ZARA’S FATHER 3.3.3 Meanwhile in mid May 2008 probation officer PO1 prepared a pre-sentence report by means of a video link to the prison in which Zara’s father was being held on remand. The account she was given indicated that although nominally living at his mother’s address, her disapproval of his lifestyle meant that he often stayed with Zara’s mother ‘whilst he was using’ (he later clarified with his supervising probation officer that although he was spending time with the mother of Zara she was not allowed overnight visitors). In his meeting with the author, Zara’s father confirmed that he had never actually cohabited with her mother. 3.3.4 Zara’s father claimed his awareness that his partner was expecting their baby motivated him to relinquish crime and settle down. The sentence passed next day entailed 36 weeks custody suspended for 2 years, a 2 year Supervision Order and an Attendance Centre requirement of 60 days duration.                                                15                                          3.3.5 Later that week Zara’s mother (aged 16 and living in what was described as a hostel) was seen by GP2 for antenatal booking. The age of the father of her child was not determined. The subsequent referral by GP2 to hospital 2 noted that the young woman was ‘vulnerable’…naïve as to what pregnancy is going to entail’……and ‘in need of a lot of support’.  Comment: this GP’s referral helpfully highlighted the anticipated additional needs of mother. The hospital records do not acknowledge the risks referred to by the GP. Mother re-iterated that (with the advantage of hindsight) she was very naïve and vulnerable at this stage of her life. 3.3.6 Medical centre 1 records indicate mother was not seen again during pregnancy and no confirmation of ante-natal care (usually shared with the GPs) or of Zara’s birth or discharge from hospital was received. Comment: although the reports from the hospital indicate that health visitors were alerted to mother’s discharge from hospital, the failure to involve GPs from medical centre 1 during mother’s pregnancy suggests a systemic weakness and a missed opportunity for provision of support by those with some knowledge of the family. 3.3.7 In June 2008 mother attained the statutory school-leaving age having attained an average attendance rate of only 24% in her last year. 3.3.8 In early June mother left a message with CAMHS claiming she was ‘visiting family in New York’ and was unable to attend a scheduled session. At the end of June, continuing efforts by the agency to engage with Zara’s mother resulted in it being given the misinformation (presumably by Zara’s mother herself) that she was going to live in South Africa with her father. Comment: during mother’s conversation with the author, she denied that there was ever the possibility of her going to South Africa. Constraints of time and circumstance inhibited any further challenge about whether the above reported claims confabulations or deliberately deceitful.  3.3.9 At the beginning of July, the case was allocated to a hospital 1 social worker SW2 to complete an ‘initial assessment’1. Comment: allocation of a social worker took over 5 weeks from mother’s presentation at A&E and then led only to the much delayed ‘initial assessment’ described below. 3.3.10 In late July father was again arrested having been detained on a stolen motorcycle. He was in possession of a CS spray and 2 wraps of cocaine. He was sentenced in December 2008 for these offences and for breaching his earlier suspended sentence.  3.3.11 Mother’s initial antenatal consultation at hospital 2 was in late July when 20 weeks pregnant. Records indicate that she said that she had a ‘youth worker’. Presumably in consequence of this contact, a home visit was undertaken a week later, by a Children’s Centre midwife and information leaflets were provided. No concerns were raised. A follow up support visit was arranged for September.                                                  1 An initial assessment was a standardised instrument used by Children’s Social Care departments across the country. It should capture all basic biographical information, offer an initial analysis of its significance and recommend any further required action.                                                 16                                          3.3.12 In early September Zara’s mother presented herself at Wandsworth’s ‘Referral & Assessment Service’ and sought what she described as ‘support’. She indicated she was ‘isolated and living in supported accommodation’ provided by a Housing Association. Because she was already an open case, Zara’s mother was directed toward her allocated worker at hospital 1. Comment: records accessed for the purposes of this SCR suggest that the unknown number of occasions on which SW1 tried to contact mother were unrecorded. It seems possible mother had not understood that she had an allocated social worker at hospital 1. Mother’s recent recollection of this period was simply of seeking and being refused support.  3.3.13 At her scheduled home visit by a Sure Start Children Centre midwife in mid-September, a good relationship with the father of Zara was reported. Further information about support and smoking cessation was provided. However, at an ante-natal consultation 3 days later, mother reported headaches and nausea. She also referred to starting a university course ‘the next week’ though no further reference to that has emerged from material made available to the SCR. Mother made no reference to any such course when speaking with the author. 3.3.14 Mother cancelled a pre-arranged home visit by SW2 and was admitted next day to an ante-natal ward complaining of abdominal pains. Nothing abnormal was found and she was discharged a day later and asked to return in a week for test results. She failed to do so. 3.3.15 By November and early December 2008 and at 34, 36 weeks and 38 weeks into pregnancy, further antenatal follow ups revealed nothing of significance.  3.3.16 Zara’s father was again arrested in late November and found to be in possession of crack cocaine. A warrant for his arrest also existed as a result of him failing to appear at court in early November. He was eventually sentenced to 30 months imprisonment and released in September 2010. 3.3.17 Meanwhile, the initial assessment initiated in July was ‘completed’ in late November 2008. The target for completion of such assessments at that time was 7 working days. The significant delay in this instance is explained within the IMR for Children’s Social Care as being a reflection of the difficulty presented to the social worker of getting Zara’s mother to engage in the process. The assessment concluded that in spite of mother’s age, strained relationship with MGM and that she was relatively unsupported, the housing support worker was sufficient input and there was no need for Children’s Social Care input. Comment: the conclusion of that assessment was at odds with its contents. Mother is clear she needed a lot more support than was given though clearly, her willingness or ability to  take up what was offered was then (and remains) poor. 3.3.18 The school nurse service reportedly received a Police notification of an incident in early November 2008. The record kept by the school nursing service does not explain to which incident the notification referred and no other agency refers a notification in November. The MPS chronology confirmed that mother had been present during an argument between two others and had felt contractions. An ambulance had been called but no treatment was required and Police took no further action.                                                17                                          BIRTH OF ZARA & CONTEXT OF FURTHER PROFESSIONAL ACTIVITY 3.3.19 A ‘false alarm’ in mid-December was followed next day by a further self-referral to the labour ward and Zara was born without complications a few days before Xmas. Because her mother was still very young, the midwifery team notified the ‘safeguarding midwife’ and liaison with community midwife, health visitor as well as Children’s Social Care was initiated. Comment: involvement of the safeguarding midwife was commendable. No reason why the GPs at medical centre 1 were not notified has been provided though the account from the health visiting IMR below offers some indication of confusion about addresses. 3.3.20 Following a discharge meeting involving (it has been deduced) a student social worker from hospital 1, allocated midwife and the safeguarding midwife, mother and baby were discharged to MGM’s address in Westminster. The intention declared by mother and MGM was that mother and Zara would remain there for 2 weeks and then return to what was recorded as her ‘supported lodgings’. 3.3.21 The home address recorded for mother was an address in Wandsworth (which appeared in no other IMR) and the birth notification was sent to a [named] health visiting team. At a new birth visit neighbours suggested that mother had moved out a year previously. A check with hospital 2 revealed the address of MGM in Westminster and the birth notice and records were in consequence sent to health visitors in that borough. Those health visitors in turn confirmed that mother and baby were now living in Tooting and ‘may have been visited by a health visitor there’. 3.3.22 An unnamed health visitor for the homeless made contact with mother and visited her next day. Comment: subject to further clarification, these events may explain in part why the referring GP was told nothing of the birth or what followed. An absence of names in the IMR provided prevents triangulation and confirmation of accounts. 3.3.23 The IMR evaluating the provision of health visiting services points out that in the period 2008-2010 the transition from paper to electronic records had a number of unintended consequences. Whilst clinic staff recorded their work on Rio, the health visitors for the homeless used paper until May 2009 when they moved across to a Tooting team (and even then scanners were not made available until 2010). Whilst the service was moving toward an electronic system, child health records team would have recorded birth notification and blood spot (for phenylketonuria) results on the new electronic RIO system but the health visiting teams might not have been able to directly access this information themselves Comment: the above description offers a poor impression of the management of the transition, a difficult environment for staff to work in and one in which the completeness of health records could apparently be compromised.    3.3.24 Whilst the above efforts were being made to trace mother and baby and offer health visiting services, a further initial assessment had been begun on 19.12.08 by a student social worker who was supervised by SW2.                                                18                                          4 PERIOD OF REVIEW: BIRTH TO CRITICAL INCIDENT  4.1 INTRODUCTION 4.1.1 Section 4 considers year by year, events and professional judgements in the period from Zara’s birth in December 2008 to her hospitalisation in late March 2013. The most significant periods and events are highlighted by means of headings and sub-headings respectively. 4.2 1ST YEAR OF ZARA’S LIFE: DECEMBER 2008 – DECEMBER 2009 4.2.1 Within 6 days of the birth of Zara, her father appeared at Crown Court charged with the offences for which he was arrested in July and for breaching his earlier suspended prison sentence. His was imprisoned and not released until March 2009. 4.2.2 A community midwife CM1 informed the hospital 1 Social Work team of her belief that Zara’s mother was not in fact staying with the MGM for 2 weeks as understood by the hospital at point of discharge. Nonetheless a week later on 29.12.08 a home visit to that address was completed by the student social worker from hospital 1. This individual may have made a further visit in January. 4.2.3 At this first post-natal contact by a professional, the mother of Zara reported that she had been coping well though was a bit tired. Mother reported that Zara was feeding and sleeping well and the MGM reinforced her daughter’s claim to be caring well for the baby. 4.2.4 MGM and mother described Zara’s father as ‘bad’ and there was a discussion about his future role in the care of his daughter when he was released. Records provided do not provide the content of these discussions. 4.2.5 By the second week of January an un-identified midwife was satisfied that Zara (an alert and responsive baby) and mother were well enough to be discharged from her care, though records refer also to a follow up visit. The midwife noted mother’s comments that she was happy at the accommodation provided by the Housing Association and got on well with her key worker. Mother said she would not be staying in Wandsworth, was receiving support from her own and her partner’s mother, Mother also reported that her partner was in Wandsworth prison and due out in March 2009. The student social worker’s attempt to glean information was thwarted when she offered the wrong surname to prison staff. The IMR indicates SW2 agreed to write up her student’s assessment but did not do so. 4.2.6 In mid-January 2009 mother and baby Zara registered at an alternative medical centre 2. Records indicate mother was concerned about a red mark on Zara’s neck and was offered an appointment next day. Mother subsequently rang to say she had overlooked the time given and was offered another one a few days later. She arrived 35 minutes late, was offered an appointment if she waited but was ‘unhappy’ and left the surgery before Zara was examined. Comment: the episode illustrates mother’s motivation to care for her baby as well as the limits on her ability to do so, perhaps in consequence of poor organisational skills / impatience / impulsivity.                                                 19                                          4.2.7 A record from hospital 1 suggests that HV2 made an opportunistic home visit on the same date as the above event but did not meet mother or child. 4.2.8 SW2 or probably her student (records offer no certainty) spoke by phone and was told by mother that she and her baby were doing well but that she had been told by her Housing ‘case worker’ (presumed to be same unidentified individual as her key worker) that she would not be given permanent accommodation and would instead be referred to a ‘mother and baby unit’. Zara’s mother was not keen on that option. A home visit for late January was agreed. 4.2.9 At the planned home visit the worker from hospital 1 was told that Zara would be brought to the medical centre 2 next day for Zara’s primary immunisations2. Mother referred also to a visit ‘the previous day’ by a health visitor (though records from that agency suggest no contact had at this point been established). Mother indicated that her boyfriend was at that time a category C prisoner in a Cambridgeshire prison. Comment: it remains unclear whether mother’s reported reference to a visit by a health visitor was an attempt to deceive or an inaccurate record. Her conversation with the author included a comment that she had at that time no idea what service to expect from a health visitor. 4.2.10 Records of supervision of SW2 / student social worker in late January 2009 refer to the ‘Housing Association worker’ having agreed to mother and Zara moving on from her supported accommodation. The agreed plan was completion of the initial assessment and, subject to mother’s agreement a referral to the ‘Early Years Multi-Agency Panel (EYMAP). If mother declined such support, no further follow up was considered necessary. 4.2.11 A subsequent phone conversation with the Housing Association worker confirmed that, aside from rent arrears, ‘no other concerns existed’. Comment: the report latterly provided by this provider reported that it had been observed that during her stay, mother ‘appeared not to want anything to do with the baby although she bought a lot of nice things for her’.  4.2.12 In early February 2009 Child Health provided HV2 with an address for mother and Zara and provided her with a parent-held ‘red book and labels. Which address was provided has not been shared with the SCR panel. 4.2.13 Mother failed to bring Zara to an appointment with a GP3 made for unknown reasons in mid-February.  4.2.14 Zara had not been seen by a health professional since the midwife discharged her from her care over a month previously. On 19.02.09 the baby was seen by an unidentified GP. The doctor recorded no health-related concerns, noted that mother was breast-feeding Zara and that they were living in temporary accommodation spending much of the time with the mother of the imprisoned boyfriend.  A plan was made for health visitors to follow up on weight and review the domestic situation. The Practice nurse gave Zara her first set of primary immunisations.                                                    2 A primary immunisation is a vaccine to protect against Diphtheria, Tetanus, Whooping Cough, Polio and Haemophilus influenzae type b (Hib) [DTaP/IPV/Hib]                                                20                                          4.2.15 Next day HV2 received a phone call from the Housing Association where an unnamed member of staff was concerned that mother was spending little time at the property; was tearful and depressed. A request for the health visitor to visit was made. 4.2.16 The health visitor phoned mother who sounded to be, and said she was, well. Mother confirmed her visit the day before to the GP who had said she was not depressed. Comment: mother’s reference (if accurate- GP records do not confirm the subject being discussed) to the GP’s view imply the subject of depression had been discussed at her visit to medical centre 2. 4.2.17 The health visitor called and met mother, Zara and the MGM. Mother confirmed that Zara had received her 8 week check and immunisations and was reported to be very receptive to ideas and seen to be handling her baby well. MGM was noted to be offering good support. Zara was by this stage reported to be receiving breast and bottle milk. 4.2.18 The ‘Home Detention Curfew Report’ being prepared in March required PO3 to complete a home visit to Zara’s paternal grandmother. The address was well known to Police and because a number of the associates of Zara’s father were confirmed drug dealers, MPS officers questioned the suitability of the address for curfew purposes. 4.2.19 In a phone call to mother in late March 2009 by the student social worker from hospital 1 she was told mother’s key worker ‘had been fired’ and ‘everything was messed up in regards to her accommodation being sorted out’. Mother reported she was no longer at her accommodation because of an infestation of mice. Mother indicated that she was now staying at the home of her boyfriend’s mother and that her own mother MGM ‘had gone to Spain to get married’. In her conversation with the author mother confirmed as accurate her account of an infestation of mice. 4.2.20 An email exchange later between the social work team at hospital 1, initial contact worker ICW2 and  the Homeless Persons’ Unit clarified mother had not been evicted but had been given a ‘notice to quit’ which was to expire in mid-April as she had essentially abandoned the property. 4.2.21 Next day mother phoned the student social worker and told her that Housing would be allocating her temporary accommodation and that a housing officer HO1 would contact her. Mother was indeed provided with an alternative place to live where its records indicate the tenancy began on 20.04.09 though where (according to Housing records) mother remained until her move to her permanent accommodation a month later. 4.2.22 Other agencies’ records suggest mother’s place had been allocated from a date in late March. Mother revealed to the student social worker that she was anyway still staying with the mother of her imprisoned boyfriend. Comment: mother and Zara clearly spent substantial amounts of time with the associates of Zara’s father. The report provided by the Housing Association claims that ‘concerns were raised with social services [sic] regarding mother’s non-engagement with the service as well as health professionals; baby not residing at the premises and rent arrears’. These may be a reference to contacts made with the health visitor and/or to the hospital student social worker. No record of the reported meeting and a requirement that mother committed to being at the unit for 2 days per week has been located.                                                21                                          4.2.23 In late March 2009 Zara was seen by the Practice nurse for her second set of ‘primary immunisations’. During the remainder of her registration at medical centre 2, correspondence relating to 2 recorded attendances at Accident and Emergency (A&E) was received (one for diarrhoea and the other for a viral infection). No concerns were raised about general welfare in either.  Zara’s father was released from prison at this time. 4.2.24 In late April 2009 HV2 tried to contact Zara’s mother and establish her latest address. HV2 noted concern about the frequent moves by this young mother. She forwarded records to Tooting-based health visitor colleagues. Upon receipt, an invitation for a ‘transfer-in’ appointment a week later with HV6 was immediately sent. The system then in place meant that this individual would be the named health visitor until Zara was 1 year old (at which stage a child would ordinarily become part of a corporate case-load). 4.2.25 Supervision notes from the social work team at hospital 1 dated 07.05.09 indicate that the student social worker was to follow up with mother her anticipated housing move and check that she (and presumably Zara) had registered with a GP. It was noted that Zara had been reported to appear healthy and well on the last visit. It was agreed that the supervisor SW2 would write up the initial assessment and complete a closing summary. 4.2.26 The closing summary referred was completed and described mother as ‘vulnerable, supported by her mother (MGM) and housing support worker who is ensuring she had good enough independence skills before moving into her own accommodation. No need for further Children’s Services was identified’. Comment: the impact of Zara’s father’s release from prison was not addressed. 4.2.27 Meanwhile, efforts continued to be made by HV2 to contact mother who did not respond to cards left at what was understood to be the relevant address or to messages on her mobile. 4.2.28 In early June 2009 PO2 who was writing a ‘pre-sentence report’ faxed Children’s Social Care to ask whether Zara was ‘known to the agency’. 9 days later SW2 left a phone message for the probation officer in which she confirmed that Children’s Social Care had, in consequence of mother then being only 17, been involved in a pre-birth assessment. The social worker reported that mother was now in high support accommodation designed for use by mothers aged less than 18 and that the child’s MGM was supportive. Comment: no good reason for the delay in responding to Probation has been provided. 4.2.29 It seems likely there was a follow-up conversation between social worker and probation officer in that PO2 records she informed the social worker of father’s drug abuse history and of the crimes for which he was awaiting sentence. PO2’s report does not explicitly address any implications of him spending time with mother and Zara, and indicates an assessment by Children’s Social Care of 6 month old Zara was being completed. 4.2.30 PO2’s assessment of the ‘risk of serious harm to children’ was assessed as ‘low’. Comment: the extent of harm of relevance to Children’s Social Care is encapsulated by the term ‘significant’ defined in s.31 Children Act 1989 as amended by s.120 Adoption and Children Act 2002. How the term ‘serious’ is defined by probation officers i.e. does it differ from significant harm? may be a significant factor in evaluating respective understandings of risk to Zara (and others).                                                   22                                          4.2.31 Mother was due to meet with the Practice nurse on 17.06.09 although neither confirmation of the reason for the appointment, nor whether she attended has been found. IMPRISONMENT OF ZARA’S FATHER  4.2.32 Zara’s father at the end of June, received a 30 month custodial sentence for the offence of possession with intent to supply a class A drug. 4.2.33 In mid-August 2009 MGM reported to the Practice nurse that her daughter (mother of Zara) had attended A&E where swine flu had been diagnosed and Tamiflu administered. 4.2.34 A phone call from an unnamed professional at medical centre 2 in mid-September elicited from Zara’s mother than she was planning to register at an ‘Upper Tooting Practice ‘soon’. FIRST & SECOND PRESENTATIONS OF ZARA AT A&E 4.2.35 Later in September 2009 mother brought Zara to hospital 1 A&E where her baby was diagnosed as having a viral infection and sent home in her care. No other concerns were noted 4.2.36 At a second presentation Zara was diagnosed as having an upper respiratory tract infection and diarrhoea. The discharge letter notes no other concerns. Details of this event were only scanned into the patient information database ‘Rio’ about 3 months later.  Comment: the delayed inputting of this routine notification may have been a one-off or represent a more systemic problem. 4.2.37 Contact with the health visiting service had been very limited. A very brief contact occurred in early November when mother reassured health visitor HV3 who seems to have made an opportunistic home visit that she was fine and that Zara was attending a nursery. 4.2.38 At medical centre 2 it was recognised that Zara was overdue her 3rd set of immunisations and an invitation was sent out. Neither mother nor Zara were seen again that this centre. 4.3 2ND YEAR OF ZARA’S LIFE: DECEMBER 2009- DECEMBER 2010 4.3.1 Available records suggest that local agencies had no further involvement with Zara and her mother until February 2010. ASSESSMENT OF NEED / RISK DURING THIS PERIOD 4.3.2 In early February 2010 a ‘risk assessment summary’ within the social work team of hospital 1 noted that no member of the household (defined as mother, Zara and the child’s father) was on the local authority ‘aggressive persons’ register nor on the sex offender register. According to the guidance on this pro-forma, if any of a number of factors were present a full risk assessment would have been required.  Comment: the motivation for such a register is understandable, the wide range of (some subjective) criteria that justify inclusion suggest to the author that interpretations will vary considerably.                                                23                                          4.3.3 Mother with others and accompanied by Zara was caught shoplifting in early February 2010. Zara appeared well and the MPS records indicate a notification was sent to Children’s Social Care. 4.3.4 A week or so later Police were called to the mother and baby unit. A named woman who claimed to Godmother to Zara was proposing to take care of Zara because her mother was unwell. The named individual was for unknown reasons, banned from the unit and a row ensued. With mother’s consent, this woman did later take Zara (noted by officers to be wrapped up warm with a bottle).  4.3.5 Later that month a ‘move-on’ assessment was completed by the supported housing provider and confirmed that it would be appropriate to offer mother permanent accommodation. This assessment notes Zara’s father as mother’s partner. The records note mother’s objection to moving to the proposed area because the [named] gang could cause problems for her partner which in turn could impact on the safety of her child. Comment: No evidence for mother’s assertion was sought or provided. In conversation with mother, she confirmed she had wanted accommodation in a more salubrious area but accepted that she had never been threatened by any gang member and denied any personal involvement in gangs. 4.3.6 Mother was contacted again in March by Housing Lettings and indicated that Roehampton and Putney would be inappropriate areas because of the gang connections of Zara’s father but that certain estates in Battersea would be acceptable. 4.3.7 A week after the above exchange mother was asked by the temporary accommodation officer to attend a meeting where she was given a verbal warning for (an unspecified) breach of house rules. This may refer to an incident in the MPS chronology where mother and two others attended the flat of a friend who subsequently realised £100 had gone missing. 4.3.8 The day after her verbal warning PO2 called and spoke with SW2 who confirmed that the case was closed shortly after Zara’s father had been sentenced and that there was no ongoing Children’s Social Care involvement. SW2 is recorded as having indicated that there were no concerns about Zara in her mother’s care.  Comment: Children’s Social Care IMR reports this significant exchange was not recorded by SW2. 4.3.9 The social worker had no current information about the status of mother’s relationship with Zara’s father e.g. whether there had been contact with him during his imprisonment. Her advice was that a new referral would be required in order to obtain an updated assessment in the event that father lived with mother after his release. This advice was reflected in PO2’s ‘home detention curfew report’ drafted by her in late April 2010.  Comment: the fact and nature of any ongoing relationship would have been significant information insofar as father might, upon release have had a high level of contact with Zara.                                                24                                          OFFER OF PERMANENT ACCOMMODATION & CONTACT WITH CHILDREN’S SPECIALIST & HEALTH & HOUSING SERVICES 4.3.10 In early April 2010 Mother was offered the tenancy of what remained until November 2013 her address. The policy then should have ensured that being less than 18 years of age, she was offered ‘tenancy support’. Mother was not offered it. The reason for this oversight has been attributed to a problem with the use of the Housing Department’s software. Comment: the oversight had no adverse impact on Zara’s mother and what is clearly a useful system has since been extended to tenants aged less than 20 years old. 4.3.11 Mother made a visit to the Referral & Assessment Team of Children’s Social Care on 10.05.10 where she was seen by an unnamed initial contact worker (ICW). She reported that as a result of her passport and bank cards being stolen some 3 months previously she was experiencing difficulties obtaining Benefits.  The ICW liaised with mother’s accommodation providers and obtained confirmation of the difficulty of obtaining a loan or grant without adequate identification. Records supplied do not indicate what further action if any was taken. Mother mentioned that she was planning to move to her permanent accommodation a week later though in fact her move was completed a few days after that. 4.3.12 A check in late May by a service manager in Children’s Social Care SM1 identified a number of tasks not completed before the case was closed e.g. a chronology, list of all involved professionals, details of religion and GP and a closing summary. Comment: it is unclear whether the case had been closed (with the specified tasks incomplete) or would not be authorised for closure unless they were completed. 4.3.13 During a visit to the clinic mother sought information about local services indicating she ‘will [sic] be moving soon’ to [name provided] Road. Mother was advised to register as a temporary patient with a GP.  If this record of when she moved is accurate, mother might in fact have delayed her move into the permanent accommodation provided. 4.3.14 By early June her rent arrears triggered an initial alert and a request she contact Housing. Perhaps in response to this warning, mother attended and asked for forms for a ‘management transfer’. She is known to have sought legal advice from a local law firm citing harassment from some individuals in the area as a justification for a transfer to Westminster. The law firm was unable to follow up mother’s request for help because the numbers she provided were unobtainable. Comment: it seems that mother was unable to sustain engagement even when she had the possibility of representation from a source of local expertise. 4.3.15 Mother persisted in her attempt to be re-housed and at a meeting in early July asked for a letter she could present to Westminster to confirm she was unsafe in Wandsworth. During the author’s interview with the father of Zara he doubted that his ex-partner was fearful of any gang-related issues (and mother later confirmed that in conversation with the author).                                                 25                                          4.3.16 Mother anyway offered no evidence at the time for her contention and was advised she could apply for a different property in Wandsworth or (if she continued to feel unsafe) to approach the ‘Housing Options Service’ (a service for those claiming to be homeless). Mother was unwilling to pursue that possibility and no further action was taken. THIRD PRESENTATION OF ZARA AT A&E & FOLLOW-UP 4.3.17 In late August 2010 and accompanied by an unidentified friend, mother presented Zara at the paediatric A&E department of hospital 2. The toddler was reported to have pulled a small cup of hot water off a table. The injuries were judged to be consistent with the account provided. 4.3.18 Mother volunteered that she was known to Children’s Social Care though her case was closed. She also accurately reported that Zara’s father was in prison and that the child was not registered with a GP; nor were the child’s immunisations up to date. 4.3.19 The hospital’s liaison health visitor was informed of the circumstances though her records do not provide confirmation that she in turn linked with the health visitor for the family to address GP registration and follow-up of overdue immunisations. 4.3.20 The injuries required only routine follow-up and during the course of the first contact a day after Zara’s visit to A&E, mother suggested that her relationship with the child’s imprisoned father was over. The reasons for father’s imprisonment were apparently not sought. Comment: insufficient curiosity about significant males / biological fathers is a common finding in SCRs. The available evidence suggests some form of relationship with Zara’s father did continue e.g. she visited him in prison in September 2012 and regular letters have been exchanged. 4.3.21 Because Zara was not registered with a GP, there was no relevant community location to which to send the medical records of the child’s treatment. 4.3.22 Medical centre 2 had in January 2010, noted Zara was overdue her 3rd set of immunisations and sent a letter inviting attendance. Zara was not seen again. 4.3.23 HV4 followed up the August A&E presentation. In a phone call she was told that although MGM had advised against immunisations, Zara had received 2 immunisations and that mother was hoping to arrange her 3rd. A home visit was agreed though mother was not in when HV4 called at the end of the month. There was no further follow-up. HOUSING RELATED DIFFICULTIES & FATHER’S RELEASE FROM PRISON 4.3.24 By late September 2010 records of liaison between HO2 and rent collection officer RCO1 confirm mother’s growing rent arrears and refer also to ‘anti-social behaviour issues’. The outputs of the meeting held in early July 2010 were shared with the RCO. 4.3.25 In late September Zara’s father had been released from prison and he sought to convince his probation officer PO4 that his ongoing relationship with Zara’s mother and determination to be a positive role model for his daughter would help him lead a law-abiding life. Father indicated to PO4 that he has ceased to use crack cocaine and any other drugs in 2008.                                                26                                          4.3.26 In late October 2010 the RCO made an unsuccessful home visit to mother’s address. RCO left a card and about a fortnight later mother rang back promising to make payment of rent. 4.3.27 Mother attended the Housing Department office in November and spoke with her previous temporary accommodation officer HO1. A referral was apparently made to ‘Centrepoint Floating Support’ and an appointment was made for mother to meet with the senior estate manager next day so as to discuss again a management transfer. The relevant form was not completed and it is assumed that mother remained unable to evidence risk and that in consequence no further action was taken. 4.3.28 The Rent Collection Service records indicate numerous attempts by phone, letter and visits from this period until Spring of 2011 to collect rent owed. 4.3.29 Mother, Zara’s father and three others were stopped in a stolen car in November 2010. There was insufficient evidence of guilty knowledge so no further action was taken against them. Comment: this was the first and only time that mother and father appear to have been operating together. Father assured the author that he kept his criminal life well away from his ex-partner. 4.3.30 In mid-December 2010 there was an altercation at mother’s flat involving a friend of Zara’s father who assaulted a female friend of mother. Police attended but the victim did not substantiate the allegation. Neither mother nor father was interviewed. 4.3.31 Zara’s father had further supervision appointments in December. At the former he provided accurate details of his daughter when told that Children’s Social Care would need to be notified of his involvement with her. At the latter session with PO4, father referred also to a son whom he saw weekly. When interviewed by the author of this report, Zara’s father stated clearly he has no other children and had no recollection of the claim referred to here. Comment: a delay of more than 6 weeks ensued before communication with Children’s Social Care was made. No other reference has been found to a son. If he did make such a claim it should also have been explored and followed up. 4.4 3RD YEAR OF ZARA’S LIFE: DECEMBER 2010- DECEMBER 2011 MORE HOUSING-RELATED DIFFICULTIES & FATHER’S RETURN TO PRISON 4.4.1 On a date in mid-February 2011 it is now known that Zara’s father robbed a pregnant woman. He was later arrested and charged with that and 20 other similar offences between 2007-2011. 4.4.2 On 17.02.11 a request from PO4 for information on the family was made to Children’s Social Care. The officer confirmed that father was serving a sentence for possession of class A drugs with intent to supply and that Zara was child living at the home address. Comment: it appears that PO5 (who dealt with father’s recall to prison the following month – see below) left it to PO4 to update Children’s Social Care; in the context of a demanding workload, he accepts that he overlooked the task.                                                 27                                          4.4.3 In late February father committed a further robbery also involving significant violence. 4.4.4 Although Probation records do not confirm receipt of a response from Children’s Social Care, PO4’s fax was apparently responded to by an ICW who reportedly indicated ‘family known, no child protection concerns. S/he recommended case closure and this was later ratified by a manager. Comment:  the term closure probably refers to ending this specific duty episode but might reflect an uncertain status following the manager’s identification of a number of tasks that required completion before case closure. 4.4.5 As result of breaching his licence conditions (in consequence of a series of robberies on lone females for which he had been arrested in February 2011), Zara’s father was recalled to prison. He was sentenced in September 2012. 4.4.6 By late April court action for non-payment of rent was being contemplated by the ‘Rent Collection Service’ (RCS) within the local authority Finance Department and any relevant information held by Children’s Social Care was sought. An unnamed ICW was asked to respond to the request and then initiate case closure. The ICW wrote to mother informing her of the contact from the RCS and invited her to meet.  4.4.7 The ICW also informed Housing of her action and confirmed there would be no further involvement of that agency. No record of subsequent case closure has been provided. An unnamed RCO who checked ‘Framework I’ and thought the case was still active queried if there was current involvement and was told the case had been closed in May 2009. Comment: it remains unclear precisely when the case was closed by Children’s Social Care. 4.4.8 By early May, given the threat of eviction, the Finance Department’s Rent Collection Service, referred to Housing’s Tenancy Support Service. Staff from the latter service tried to contact mother by means of phone calls, letters and a visit. All attempts proved unsuccessful failed and the case was closed. DRUGS RAID & FOLLOW-UP  4.4.9 In late June 2011 Children’s Social Care was notified by Police about a drugs raid on the home of a man described as ‘mother’s boyfriend’. Mother was found in bed with a named man and a large quantity of drugs was found in that bedroom, a bathroom and in a drawer in the bedroom where Zara was sleeping. 4.4.10 Mother and her friend were arrested for possession with intent to supply and later bailed. Further information from Police confirmed that mother had been previously caught shoplifting with friends whilst Zara had been present. The male was known for criminal damage, dangerous dogs and had received warnings for drug possession. Mother was arrested and made ‘no comment’ at interview. After investigation and CPS advice, no charges were preferred.                                                 28                                          4.4.11 The duty manager TM3 (actually a ‘principal social worker’) required an initial assessment to be completed to ascertain the impact on the child of exposure to drug use. Checks with health and drug services were also requested and the issue of mother’s association with drug users, personal use and financial management were to be established. The manager also indicated there might need to be s.47 enquiries in the event that significant concerns about Zara’s living arrangements were revealed. Comment: this manager’s careful response illustrates good practice. 4.4.12 Responsibility for completion of the initial assessment was allocated next day to a social worker SW6 who liaised with DS1. That police officer was able to confirm that Zara had been within easy reach of a wrap of cocaine and that mother and boyfriend had been arrested for possession with intent to supply and had been bailed until a date in early September. Mother had been bailed to her Tooting address. 4.4.13 SW6 tried to contact mother by phone and made a home visit where s/he left a note. Over the course of the next few days SW6 repeated her/his attempts to contact Zara’s mother. A phone call to the Tooting Health Clinic revealed that the allocated health visitor was HV5. 4.4.14 Mother together with a relative believed to be her aunt attended the Referral and Assessment Team at the end of June 2011. She denied use of drugs or being in a relationship with the male [who according to the MPS was ‘known to be her boyfriend’ at this time]. The record of this meeting noted that Zara appeared happy and well cared for. 4.4.15 Next day in response to the Police notification of the drugs raid, HV4 made an appointment to meet with mother. The details noted in that agency’s records refer also to a lock knife found during the raid. A call by her to Children’s Social Care confirmed an assessment was being conducted but that ‘no CP plan will be instigated’.  Comment: it is unclear how the result of an assessment could be known before its completion. 4.4.16 In July 2011 supervision records in Children’s Social Care suggest that the social worker was completing a core assessment. The rationale for switching to a core assessment has not been traced. 4.4.17 In a phone conversation with SW6 mother indicated that Zara ‘might be registered with a surgery ‘off [a named] road’. She could not recall the name and suggested the member of staff call again later. Mother indicated her intention to register herself at a new local GP that day (which she did – see below)  4.4.18 At the suggestion of the supervisor, SW6 had contacted medical centre 3 to seek information. The response next day from a GP4 confirmed that Zara was registered there as a temporary patient and that she had been seen twice (once for conjunctivitis and once for swelling of a toe on her right foot). The surgery had no concerns about Zara. GP4 confirmed that mother was not registered at the centre. 4.4.19 Though the time of either visit is unclear, it seems the social worker completed a home visit and met mother and Zara (said to look ‘happy and well’) and HV4’s visit failed to locate mother and daughter.                                                29                                          REGISTRATION OF MOTHER AT MEDICAL CENTRE 4  4.4.20 On 06.07.11 Zara’s mother (though not Zara) registered at the medical centre 4.   4.4.21 A call was made a week later to GP5 at medical centre 2. She recalled an altercation with staff when mother had arrived late for an appointment and confirmed that mother and Zara was registered with the Practice though neither had been seen since 2009. No concerns about care of Zara or about drug misuse had been noted. 4.4.22 A call to GP6 at medical centre 4 was made by SW3 (why SW6 had ceased involvement is unclear) who informed them of the drugs raid and Zara’s access to class A drugs. 4.4.23 The social worker was asked to encourage mother and Zara to register and the child protection lead at medical centre 4 (GP6) was informed of the exchange. Comment: in fact mother (though not her daughter) was already registered here. 4.4.24 Zara went on to be registered at medical centre 4 on14.07.11 but was not seen during the timeframe of this SCR. Further correspondence was sent to mother in 2012 encouraging her to present Zara for her overdue immunisations. Comment: it appears that the information provided by Children’s Social Care was not acted upon. COMPLETION OF CORE ASSESSMENT & ONGOING CONTACTS WITH AGENCIES 4.4.25 In the core assessment completed in July 2011 mother denied that the man with whom she had found during the drugs raid was her boyfriend. He was she claimed ‘just an acquaintance with whom she stayed one night’ and she denied any knowledge of his use of drugs. The social worker provided a letter to support her to obtain a community care grant and offered advice about ‘acquaintances’. The recommendation of this assessment ratified by the manager TM5 was to close the case. That decision was phoned through to HV4 next day. Comment: were the risks of her toddler accessing lethal drugs explored and was mother’s account credible? 4.4.26 HV4 managed to complete a home visit in early August 2011 and noted that the flat was strewn with toys. Mother expressed no anxieties about Zara and, in discussing her arrest in June, the health visitor was offered mother’s reassurance that she was going to now focus on the care of her child. Mother was encouraged to bring Zara who was ‘lively but thin’ to clinic for weighing and to put the child’s name on a waiting list for a school. 4.4.27 Later in September mother sought help from Children’s Social Care when she claimed her cooker had broken down. Aside from the fact that she was given a £5 voucher, nothing else is recorded about this office visit. About a month later mother again sought financial help this time because she claimed, her (unnamed) cousin had withheld Benefit money from her. She explained that her Benefits were being paid into the account of that cousin because she owed her money. Unspecified advice was given and no further action taken. Comment: the arrangement sounds fraudulent.                                                30                                          FURTHER CRISES INVOLVING POLICE 4.4.28 In early October mother became the victim of what was described by Police as a racially aggravated common assault which had included a threat to burn the flat down with Zara in it (a friend’s boyfriend was arrested for the offence which had been committed at Zara’s home with her present). A Police notification (Merlin) was completed though its receipt was not confirmed in the Children’s Social Care IMR. 4.4.29 Some 2 weeks later Police were called again to Zara’s home. A friend was staying and her ex-boyfriend made threats against her mother and against child Zara. The man was subsequently arrested. 4.4.30 A month later, officers attended the home address at the request of the London Ambulance Service. A man there was becoming violent. He was later taken voluntarily to hospital. On this occasion it is unclear whether mother and child Zara were present. 4.5 4TH YEAR OF ZARA’S LIFE: DECEMBER 2011- DECEMBER 2012 MOTHER’S ARREST  4.5.1 A further (Merlin) was received by Children’s Social Care in December 2012. It indicated that mother had been arrested for taking prohibited articles into Wandsworth prison and a maternal great aunt of Zara was looking after Zara. The notification referred to Police suspicion (reinforced by comments of the aunt) of mis-users of drug and alcohol frequenting mother’s home and that Zara’s mother might be a drug user. 4.5.2 In response the duty manager instigated an assessment under s.17 Children Act 1989 i.e. to establish whether Zara was a ‘child in need’ in consequence of maternal neglect or insufficient parenting capacity. The manager raised the possibility of a child protection conference if concerns about mother’s misuse of drugs or her inability to make changes were substantiated. The case was allocated to SW4. 4.5.3 A supervision record dated specified the checks amongst local agencies required by the team manager and include asking a health visitor to see Zara. The family network was also to be explored. A second record of supervision (3 weeks after receipt of the notification from Police) seems only to repeat what needed to be done. Comment: the delay in completing (clear and sensible) tasks specified in supervision may have reflected overload and/or lack of organisational skills or commitment by SW4 and/or the fact he left during the course of this assessment. The work was then allocated to SW5 (who also failed to liaise with Probation and the health visiting service).  4.5.4 A phone call to the maternal aunt of mother confirmed her familiarity with Zara’s mother from the age of 3, and elicited the advice that the MGM was in Spain and would not want to know about her daughter or granddaughter. Mother’s contact details were provided. 4.5.5 Mother’s aunt reported that Zara’s mother was not drug or alcohol dependent but was in with the ‘wrong crowd’. A home visit later that day by SW5 found her in the company of a female who was described as her best friend.                                                31                                          4.5.6 Zara was observed to be comfortable and have a good relationship with her mother. The child was observed to be able to communicate very clearly. Mother indicated that she was awaiting confirmation from the Police about charges arising from her visit to Zara’s father in prison. Mother referred also to her daughter’s use of a nursery ‘until she had graduated from College’. Comment: the record is written in a manner that suggests mother had at that point graduated and that the need for and use of a nursery had consequently gone. In fact mother did not and has not gained any further / higher or vocational qualifications. Concerns about drug and alcohol misuse in the flat seem not to have been raised. 4.5.7 On 11.02.12 medical centre 4 wrote to SW4 to confirm that Zara was a registered patient though had not been seen at the Practice and that there was no known ‘PMH’ [presumed to mean ‘previous medical history] Comment: it is unclear whether the acronym PMH was used in real time in the letter or just in the development of the chronology for this SCR; either way, it represents an unhelpful obstacle to clear inter-agency communication since many non-medical recipients would  not be familiar with the term. 4.5.8 The IMR from hospital 1 confirmed that the Police notification about mother’s attempt to convey illicit articles into Wandsworth person was sent also to medical centre 4.  Comment: No record of receipt or of a subsequent communication between an unnamed duty health visitor and an aunt of mother was inputted to the agency’s database (though paper records exist). 4.5.9 SW5’s supervision in mid-March 2012 reaffirmed the need to complete the tasks begun by SW4. An additional need identified at this point was that of an unannounced home visit. SW5 tried to visit mother at home later that day but got no response and left a letter inviting mother and Zara into the office. It would appear that this was followed up by a further letter and a successful home visit on 22.03.12. Comment: the home visit was by appointment not unannounced. CASE CLOSURE BY CHILDREN’S SOCIAL CARE & FURTHER EVENTS 4.5.10 A closing summary in late March 2012 confirmed a belated referral to health visiting services, an understanding Zara would be attending (an unnamed) nursery and is reported to have included advice to mother not to engage with friends who abuse drugs and alcohol. SW5 in a phone conversation with GP8 that day, was informed about the overdue immunisations. 4.5.11 A manager TM4 ratified SW5’s recommendation for case closure and mother was (in accordance with best practice) informed in writing and provided with a copy of the completed assessment. Comment: the IMR author pointed out that in spite of tasks specified by the manager in supervision with SW4 and SW5, neither had informed the health visiting service of the assessment whilst it was being conducted or sought information from that source. HV4 was sent a copy of the completed assessment. She does not recall seeing it and it was not inputted to Rio.                                                32                                          4.5.12 Children’s Social Care received a prompt response from HV4 who undertook to follow up the health-related issues with Zara’s mother (though no record of this conversation was found on Rio). At about this time mother dropped in to a local Montessori nursery and completed a registration form. She claimed she would be attending [a named] College but failed to make any further contact. 4.5.13 Approximately 2 months after case closure, PO6 sought information for his court report about father. ICW3 cited  the previous contacts i.e. the agency had been involved in a pre-birth assessment of mother who lived in supported accommodation for under 18 year olds; that she had the support of MGM and appeared to be coping well with Zara. ICW3 also confirmed the case was closed following safeguarding concerns explored and resolved in January of drug and alcohol misuse at the home address. 4.5.14 Probation records indicate father’s history of drug misuse had been previously shared with relevant agencies. It seems though that details of current offences in particular children witnessing robberies, was not shared. Comment: by mid-2012 the level of support being provided from MGM to Zara’s mother would have been unknown. The fact children were present when their mothers were assaulted / robbed could have informed thinking by Children’s Social Care. 4.5.15 Though not of direct relevance to mother or child Zara, a friend called Police from the home address on 14.04.12 to inform Police of her assault by a boyfriend. The male concerned was arrested at another location. 4.5.16 By May 2012, an un-attributed suggestion is that the home address was being used by Tooting gang members for purposes of class A drug supply.  ZARA FOUND IN STREET  4.5.17 A further significant incident occurred in early June 2012 when Zara (then 3.5 years old) was found by a neighbour wandering the street unaccompanied. The explanation provided by Zara was consistent with that offered by mother and her aunt with whom Zara had been left.  4.5.18 Because there had been 3 previous assessments, the manager decided to instigate an assessment and, according to its conclusions consider the need for a transfer to a child in need (CIN) team for ongoing support. The case was allocated to SW6. Comment: the decision by the manager was a commendably cautious one that took account of known history. The need to treat the incident seriously had also been reinforced in a supervision session at which time the possibility of an initial child protection conference was mooted. 4.5.19 A planned home visit had been cancelled because SW6 had been delayed and she instead met in the office with the mother of Zara and her aunt. A credible explanation of how Zara had managed to exit the house was provided. Zara was noted to be a chatty and engaging child about whom no other concerns were recorded. A phone conversation with HV4 elicited the facts that she had last seen Zara in August 2011 and had had no concerns. HV4 reported that Zara had had her primary immunisations and ‘just needed pre-school boosters’ so as to be fully up to date                                                33                                          Comment: the response to the Police notification was justified and proportionate and conclusions drawn about the incident within reasonable limits and therefore justified. In that almost a year had elapsed since her last sighting of Zara, HV4’s observation could offer only partial reassurance. 4.5.20 Presumably triggered by SW6’s contact, opportunistic visits were made by an unnamed medical centre 4 duty health visitor. A letter was also later sent inviting mother to make an appointment for Zara and providing times of clinics. Rio was not updated with the Merlin received from MPS but a health review was booked for 31.12.12. 4.5.21 On 19.07.12, a member of staff at nursery 1 (a friend of Zara’s mother and ‘Godmother’ to Zara) asked for an application form. A subsequent response from the nursery thanked mother for returning the waiting list application and offered a 3 year old grant-funded place from September 2012 on 3 afternoons a week term time only.  Comment: a Godmother for a nominally Moslem child seems unusual. The same staff member was amongst those authorised to collect Zara from nursery implying a trusting relationship with mother. 4.5.22 The case was formally closed to Children’s Social Care on 30.07.12.  IMPRISONMENT OF ZARA’S FATHER   4.5.23 A pre-sentence report dated 31.07.12 by PO6 assessed the ‘risk to children’ represented by Zara’s father’s offending as ‘low’. He made reference to the information provided by SW2 at hospital 1 in 2010 and the more recent notification of case closure. Comment: it seems likely that the ‘risk to children’ evaluation did not address the possible physical and probable psychological impact of seeing one’s mother violently assaulted and robbed [the method favoured by father and his associates was to target visibly wealthy women, some pregnant, who were additionally vulnerable because they were accompanied by children]. 4.5.24 The father of Zara was sentenced in September to an extended sentence for public protection which took account of robberies committed during the period of his relationship with Zara’s mother [he asked for 256 other offences including an attack on a Post Office van to be taken into account when being sentenced]. 4.5.25 Meanwhile, Zara had begun part-time attendance at nursery 1 (by November this had become full-time because mother said she would be attending college). The arrangement ended in late November when Zara was withdrawn with unpaid fees of £416. 4.5.26 Staff at this nursery have reported Zara presented as a very tall and mature child who was well cared for and wore designer clothes. Good interactions between her and mother were observed. Mother although reserved in manner, was articulate and appeared affluent. 4.5.27 Zara herself was described as strong willed having good listening skills and very chatty, a bit of ‘Tom boy’, independent, full of life, active and outgoing; a child who did not cry. 4.5.28 Mother had picked up her daughter only during her first week at this nursery; thereafter Zara was taken home by staff member nursery worker 1. Staff report that they did not know about Zara’s paternity or that her father was imprisoned at this time.                                                34                                          Comment: there were no aspects of Zara’s appearance or behaviour or her relationship with mother that should have aroused any concerns, though the fact that staff were unaware of the identify of Zara’s father or that he was in prison is surprising. 4.5.29 A review at the end of October at medical centre 4 flagged up that Zara’s immunisations were still not up to date. The health visiting service was alerted and reported on the several unsuccessful attempts to contact Zara’s mother. Comment: the administrative system for acting upon overdue immunisations seemed to work well. PRESENTATION AT URGENT CARE CENTRE  4.5.30 On early November 2012 Zara was brought to the paediatric urgent care centre by MGM because of abdominal pain and headaches. Paracetamol reduced the level of reported pain and Zara was discharged. Records of this visit indicated that Zara was now registered with a GP and that immunisations were up to date. Comment: this may have been an example of a clinician accepting at face value what an apparently reliable and concerned caregiver was saying. 4.6 5TH YEAR OF ZARA’S LIFE: DECEMBER 2012 - INCIDENT IN MARCH 2013 4.6.1 In early January 2013, a review at medical centre 4 picked up that Zara was not yet on a list for a school. Her mother was noted to be registered with a GP in a [named] area (it was actually medical centre 2) and the difficulty in making contact noted. A plan to contact ‘Schools Admission Service’ and to liaise with involved health professionals was made and followed up in an email to HV4. She in turn sought and obtained confirmation of mother’s current address from Children’s Social Care where a manager subsequently determined ‘no further action’. Comment: such a review was useful but partly misinformed in that mother had been registered at medical centre 4 since 06.07.12. That centre was able to supply an email address for mother as her mobile number no longer supported calls, texts or voicemails. SUSPICIOUS CHARITY COLLECTION  4.6.2 In early January 2012 mother and an un-named male were stopped by Police whilst acting as charity collectors for ‘Kids Integrated Cancer Treatment’ (a genuine registered charity). Both were wearing purple jackets carrying a logo and had collection boxes. Neither possessed accreditation. Aside from a warning, no further action was taken. 4.6.3 By the middle of that month increasing levels of rent arrears triggered the serving of a ’notice of seeking possession’. Next day Zara’s mother called the Rent Collection Service and reported that she had a baby, was working part-time and that her Housing Benefit had been cancelled. She was advised to initiate a new claim and keep the office informed. Comment: no IMRs have confirmed that mother was in work of any description. It is uncertain whether the term ‘baby’ referred to Zara or whether mother was seeking to deceive.                                                35                                          4.6.4 Liaison between staff at the prison where father had begun his sentence and local Probation staff identified as a central part of his ‘sentence plan’ the objective of maintaining contact with family. Zara’s father reported regular contact with his family. Comment: it is unclear if this referred to his mother and/or to Zara and her mother. 4.6.5 Following an introductory visit at which her father’s imprisonment and Zara’s visits to him were acknowledged, Zara started to attend on an afternoon-only basis a nursery class at nursery 2. Zara’s attendance rate diminished over the following 6 weeks and some 4 days before the incident triggering this SCR, she ceased attending. 4.6.6 Staff reported that, aside from mother, 3 other adults (including MGM) were authorised by mother to collect Zara. Zara herself was described by staff as being popular, having a strong character, leading the play of others and one who was missed even months after her withdrawal. Staff were unaware of Zara’s previous attendance at nursery 1. Comment: as was the case at her previous nursery, no aspect of mother or child’s appearance or behaviour aroused any concerns or suspicions. A passing reference by mother of previous use for a year of a fee-paying Montessori nursery was checked during the course of the SCR. She had been offered but failed to take up a place. 4.6.7 By 08.03.13 Children’s Social Care had been notified of the pending court proceedings and an (unnamed) initial contact worker was asked to respond and offer advice. An attempt to advocate for mother was unsuccessful and this was relayed to her by phone. Mother’s proposal to pay £20 per week toward arrears and submit fresh Housing Benefit claim was noted and passed on to the Rent Collection Service. The duty task was then considered completed and no further role identified for Children’s Social Care. 4.6.8 The Police IMR revealed that child Zara apparently fell over and grazed her knee whilst taking MGM’s dog for a walk after nursery of 21.03.13. The injury was reported to have appeared trivial. However, Zara later complained to MGM twice that day and again on 22.03.13 that she had a stomach ache. 4.6.9 The Police report also relays detail of importance to the issue of culpability for the injury suffered by child Zara. The following analysis in this report however, has relayed and addresses only those issues that reflect the services offered and provided to Zara and her family. 4.6.10 A&E PRESENTATION 4.6.11 Zara was taken to A&E at hospital 1 on 26.03.13 and subsequently admitted with a perforated duodenum thought likely by medical staff to have been caused by trauma. The safeguarding nurse notified Children’s Social Care and medical centre 4 was sent written confirmation. 4.6.12 Discussions between Police and attending registrar at the Paediatric Intensive Care Unit (PICU) noted the preceding 24 hour history – ‘Zara said to have complained of stomach pain and vomited; no external trauma, 1 small mark in the middle of her back and another behind an ear; ? small vaginal discharge (swabs from surgery and from examination sent for analysis)’.                                                36                                          4.6.13 Upon notification of the incident Children’s Social Care liaised with the Rent Collection Service and recovery of rent arrears action was suspended. 2 weeks later on SW7 from hospital 1 contacted the Rent Collection Service, referred to what was recorded as a ‘chest injury’ and said Zara would be in hospital for some weeks to come. She indicated mother had not caused the injuries but that there were going to be legal proceedings and mother and Zara might need to leave their current address. 4.6.14 SW7 also indicated that mother and Zara had not anyway been living there ‘due to safety issues’, so that mother would not have been receiving her post. SW7 was asked to prompt mother to initiate a Housing Benefit claim. The unnamed rent collection officer (RCO) asked to be kept informed and subsequently left a message for SW7 on 12.04.13 to which she received no response.  Comment: aside from the anatomical inaccuracy with respect to the injury, the term ‘safety issues’ reportedly used by SW7 had no meaning without explanation. A failure to respond to a message suggests poor individual practice. 4.6.15 The RCO persisted in her attempt to get an update and on 19.04.13 reached SW7 who informed her that a SW8 was now allocated and that legal proceedings had begun, SW7 agreed to ask SW8 to liaise with the rent collection officer. 4.6.16 Medical centre 4 received a phone call on 23.04.13 from a SW10 who confirmed that Zara’s injuries were considered non-accidental and were being investigated by Police. Zara, now subject of an interim Care Order, was to be discharged to a foster home. Comment: it is presumed that SW10 was a member of hospital 1. 4.6.17 The rent collection officer emailed SW8 on 24.04.13 and confirmed that because mother had not been awarded Housing Benefit and has paid nothing toward her rent debt, legal action was planned to recover monies owed.                                                37                                          5 ANALYSIS 5.1 INTRODUCTION 5.1.1 Section 5 addresses each element of what are regarded as generic terms of reference for SCRs and then the case-specific ones identified by the SCR panel. It then lists a number of missed opportunities for what could have been ‘best practice’.   5.1.2 Naturally the degree of relevance of each of the 11 elements of the main terms of reference varies across agencies with the result that for some, the comment made is very brief. 5.2 WHAT WERE THE KEY RELEVANT OPPORTUNITIES FOR ASSESSMENT? IF OPPORTUNITIES WERE MISSED PLEASE STATE WHAT THEY WERE & YOUR UNDERSTANDING OF WHY THEY WERE MISSED. Education & Early Years 5.2.1 The opportunities for action by Education Services in mother’s final (poorly attended) year of statutory education were very limited. The approaches taken e.g. part-time and alternative schooling were reasonable responses, though they failed. In the circumstances, the proceedings initiated by the Education Welfare Service were justified albeit also ineffective. 5.2.2 With respect to Zara’s time-limited attendance at nursery 1 and nursery 2, feedback from staff confirm the formal records that indicate nothing of significance emerging. 5.2.3 Nursery staff would have had no knowledge of any previous Children’s Social Care involvement and poor or erratic attendance for a pre-statutory school age child would not of itself prompt sufficient concern to prompt action.  5.2.4 As indicated earlier, it would be helpful for those arranging admission to early years provision to agree with a parent (when relevant) why a child had not received all recommended immunisations and what information e.g. an absent father, could be shared with those staff dealing with a child; also that admitting staff ensure they receive or seek from known previous settings information of relevance to current care and education. 5.2.5 The recommendations in section 7 reflect the above needs. Children’s Social Care 5.2.6 The IMR author counted 6 significant referrals all leading to an assessment, though only the first led to any service or plan. Each assessment the author noted, was focused on a particular incident and did not reflect adequately on the pre-existing records i.e. no cumulative picture of mother or Zara’s life emerged. 5.2.7 The 3 assessments that were undertaken in 2011 / 2012 all concluded that if there were further concerns s.47 enquiries would be considered. In the event, no such action was taken and the IMR author was unable from records found to discern why not.                                                38                                          5.2.8 What was lacking in each assessment was an analysis of the known or suspected facts e.g. the significance of the radically changed personal circumstances of mother. The IMR author wondered if this was a function of the involvement of an initial contact worker rather than a social worker. However, the failure in early 2008 to complete the then scheduled core assessment involved a social worker and a manager which suggests a more systemic issue of ‘limited expectations’. 5.2.9 The price paid for not completing an effective core assessment was insufficient understanding of her needs at a time before mother’s life was rendered even more complicated by pregnancy and Zara’s birth. 5.2.10 The pre-birth initial assessment was based on very limited contact with mother, minimal information about father and was unduly optimistic in its conclusions.  5.2.11 The 3rd assessment led by a student social worker was characterised by the IMR author as more about support than assessment and took over 4 months to ‘complete’. The significance of the tension between mother and MGM and father’s behaviours and anticipated role remained unaddressed. 5.2.12 The remaining 3 assessments were responses to MPS notifications and mother’s powers of persuasion seemed to be enough for an acceptance that the grounds for concern were erroneous. The IMR author cites Brandon et al 2005 [see bibliography] who in their biennial evaluation of SCRs referred to a tendency to accept parental assurances rather than exercise professional judgments. 5.2.13 The chance to challenge mother’s inaccurate assertion she had no health visitor and was at a disadvantage in sorting out Zara’s pre-school booster, was lost in January 2012 when neither SW4 or SW5 complied with the manager’s instruction to contact the health visitor. Health Visiting  5.2.14 Early assessments were deemed sufficient and adequate but later the significance of mother’s apparent compliance may have been underestimated as a result of her assertive presentation. Housing Service 5.2.15 The assessment of entitlement to accommodation in early 2008 was managed effectively in close collaboration with the Diversion team of Children’s Social Care. 5.2.16 When the Rent Collection Service referred mother in May 2011 with a view to being offered ‘tenancy support’, the response of 3 attempts to make contact was consistent with the policy in place at the time. Rent Collection Service 5.2.17 This service, when contemplating eviction in 2011 initiated an appropriate referral to the tenancy support service within Housing. The service also showed sensitivity and persistence in April 2013 when it was seeking to re-assess its next steps following the incident leading to this SCR.                                                39                                          Hospital 2 5.2.18 The vulnerability of mother spelt out by GP1 in his referral to this hospital was not reflected in ante-natal records subsequently maintained. However, the recognition that as a consequence of mother’s age and circumstances, a pre-discharge meeting was required was commendable. Probation 5.2.19 The types of assessments of the father of Zara accorded with the Probation Trust’s expectations at the time but there was scope for improving the quality of some. 5.2.20 The records maintained of family contact (in person and by phone) did not adequately distinguish contact by mother or by Zara. 5.2.21 PO7’s assessment of father’s risk to children as ‘medium’ is considered an underestimate and on the basis of the details of the robberies justifies a ‘high risk’ rating. 5.2.22 The IMR provided acknowledges that in February 2013 when PO7 formulated her ‘start custody’ assessment (a requirement for an offender assessed as high risk of serious harm to the public and serving a custodial sentence of more than 12 months) she did not seek a further update from Children’s Social Care. This would have enabled the question of potential risk associated with his contact with Zara to have been explored.  5.2.23 Feedback from the prison concerned has subsequently provided reassurance that the potential risk has been assessed in accordance with that institution’s ‘public protection manual’ and that because contact is supervised, no restrictions are required. Police 5.2.24 Each occasion officers had contact with mother and/or Zara represented at least a potential opportunity for an assessment of need. They responded appropriately on each occasion.  GP Service 5.2.25 The initial assessment of need by GP1 in October 2007 was thorough and child-focused and informed timely referrals to CAMHS and to Children’s Social Care 5.2.26 Initial follow-up was also good but confirmation that mother had failed to use the offer of help from CAMHS did not prompt a formal review with her or her family and uncertainty about mother’s psychological and social needs remained. 5.2.27 The referral for ante-natal care in May 2008 was accurate and sensitive and the primary responsibility for initiating liaison and shared care lay with the hospital. Nonetheless the medical centre might (ideally) have reviewed the case and sought an explanation for the absence of feedback from hospital 2. 5.2.28 Zara’s 8 week check in early 2009 offered an opportunity that was not fully exploited to recognise and respond to a very young mother in temporary accommodation with her baby’s father in prison. The possibility of a review of Zara following the drugs raid in July 2001 was not pursued.                                                40                                          5.3 WAS CONSIDERATION GIVEN TO THE IMPACT OF CULTURAL / RACIAL & OTHER EQUALITIES ISSUES IN ANY ASSESSMENTS? Education & Early Years 5.3.1 Though such details may have been captured by the settings concerned, the IMR supplied did not confirm that Zara’s ethnic origin or ascribed religion was known to staff at nursery 1 or nursery 2. Children’s Social Care 5.3.2 The ethnicity of Zara’s father was not captured in any of the assessments undertaken and the significance of his family’s origins, experiences and their religious affiliations and how these might impact on behaviours remained un-explored. 5.3.3 Mother’s stated intention that Zara (to be coached by her father upon release from prison) would be raised as a Muslim was not addressed at the time nor when mother later claimed that her relationship with Zara’s father was over. 5.3.4 Mother’s stated determination that her daughter should live in a better area than their current accommodation also remained un-explored. The IMR indicates that (possibly reflecting her own affluent upbringing) mother did not want Zara playing with local children. Observations of the nursery staff were that Zara experienced no difficulty or maternally-imposed constraint in relating to peers, but mother’s aspirations and what she was prepared to do to achieve them would have been a productive avenue to explore. Health Visiting Service 5.3.5 Records confirm mother is of White British origin and comes from an affluent background; child Zara’s father was of dual heritage (White/African Caribbean) and a Muslim. According to her mother, Zara was to be raised as a Muslim. The IMR provided does not explain how the services were influenced by this knowledge of ethnicity, culture or Faith. At his meeting with the author, Zara’s father acknowledged that his commitment to his Faith was limited. Housing Service 5.3.6 Whilst the services provided (offers of accommodation and ‘tenancy support’ to sustain it) were generally provided in an efficient manner, no evidence has emerged to indicate any particular recognition of needs associated with ethnic or cultural origins. 5.3.7 The question of needs related to gang affiliation or avoidance is addressed below. Rent Collection Service 5.3.8 In April 2011 the Rent Collection Service appropriately sought confirmation of any ongoing involvement of Children’s Social Care. The possibility of mother’s fear of gang-related responses became apparent to this Service only in April 2013 (after the incident that triggered this SCR) when mother reported that she had not been living at her allocated property.                                                41                                          Hospital 2 5.3.9 The records kept by staff and evaluated by the IMR provided, suggest no appreciation of the significance of the ethnic or broader cultural origins of mother or daughter. Probation 5.3.10 With respect to the agency’s work with Zara’s father, Probation’s records initially mis-recorded his ethnicity as ‘Chinese and no Faith’ before correcting it to ‘dual heritage White British / Black Caribbean and Muslim’. Nothing seen suggests that the significance of his ethnicity or Faith was sufficiently recognised or addressed with him e.g. how did he personally reconcile his Islamic Faith with the crimes he committed? Police 5.3.11 There is no indication that issues of race or culture impacted upon responses given. Police actions with respect to Zara’s father were entirely a function of the extensive investigations of the many serious crimes it is now known he committed whilst in a relationship with the mother of child Zara. GP Service 5.3.12 Nothing in the medical records suggests an appreciation of how the racial or cultural origins, beliefs and practices or experiences of MGM, mother or Zara’s father might have been impacting, or might in the future impact upon their behaviour or personal development 5.4 DO ASSESSMENTS & DECISIONS APPEAR TO HAVE BEEN REACHED IN AN INFORMED & PROFESSIONAL WAY? Education & Early Years 5.4.1 Both nurseries clearly had and were able to share comprehensive accounts of Zara’s attendance, appearance and behaviours whilst in those settings. Children’s Social Care 5.4.2 As detailed in section 5.2 above, the consistent weakness in all assessments undertaken by Children’s Social Care was a near-exclusive focus on the here and now, rather than considering events in their historical context coupled with an unquestioning overdependence on mother’s responses. Health Visiting Service 5.4.3 The failure by a health visitor in Tooting in March 2012 to record the Children’s Social Care assessment and her discussions will have reduced the value of the electronic records for future users. 5.4.4 Similarly, the later failure to record the MPS notification (Merlin) received in June of that year reduced the accuracy and validity of the records                                                42                                          Housing Service 5.4.5 Housing Service determinations of need and co-ordination of provision appear to have been completed in an informed and professional manner consistent with current policies. Rent Collection Service 5.4.6 Officers from this service acted in an informed and professional manner, were clear about their central task and liaised as required with colleagues in Housing and Children’s Social Care.  Hospital 2 5.4.7 Following Zara’s presentation at paediatric A&E in August 2012 the opportunity for exploration with mother and liaison with the relevant health visitor about overdue immunisations, lack of GP and father being in prison was not taken. Probation 5.4.8 The ‘pre-sentence report’ of July 2012 should have evaluated Zara’s father as more than ‘low’ risk to children and the ‘start custody’ report of February 2013 should, given what was known of the family have included a complete risk screening and analysis section reflecting that knowledge and assessing risk to children including Zara. Police 5.4.9 All actions within the chronology supplied and explained in the Police IMR appear to have been informed by the information available at the time and shared appropriately when in the interests of safeguarding child Zara or others. GP Service 5.4.10 The assessment of mother when in the care of MGM was an informed and thorough one. The ability of those GPs to contribute further was constrained by the absence of feedback from hospital 2 or Children’s Social Care and the IMR supplied notes that no post-natal assessment of risk or post-natal depression was recorded.  5.5 DID ACTIONS ACCORD WITH ASSESSMENTS & DECISIONS MADE?  Education & Early Years 5.5.1 Nursery 1 and nursery 2 acted in accordance with the (unremarkable) needs of Zara. The recommended changes to practice in section 7 do not represent a criticism of their good work; rather an opportunity to further enhance it. Children’s Social Care 5.5.2 There were several examples where actions did not follow decisions or assessments e.g:  A 5 week delay at hospital 1 social work team between the decision to initiate an ‘initial assessment’ and actually doing so                                                43                                           A period of almost 5 months to complete that initial assessment (the required time limit was then 7 working days) and a conclusion at odds with the needs described in it  The failure of SW2 to write up her student’s initial assessment begun following the birth of Zara  An unexplained delay in June 2009 for SW2 to respond to PO2’s request for information about father  The failure of SW2 to record her (out of date) reassurance to PO2 in March 2010 that there were no concerns about Zara in her mother’s care  The check by a service manager in May 2010 revealed a number of tasks that should have been / still needed to be completed before case closure (no proof has been found that the tasks were then completed)  Following mother’s arrest in January 2012 SW4 and SW5 failed to liaise with Probation and health visiting services as instructed by the manager  Health Visiting Service 5.5.3 The failure to input the MPS notification of mother’s attempt to convey illicit articles into prison served to reduce the value of the electronic records for subsequent users.  Housing Service 5.5.4 The only exception to what was otherwise efficient and effective service delivery was overlooking the need to offer tenancy support to mother (then aged less than 18). The oversight made no difference in practice to mother and Zara. The IMR reports that a subsequent recent policy shift has extended the age range and increased the reliability with which those who are eligible are identified. Rent Collection Service 5.5.5 The limited involvement of this service indicates that all their actions were in accordance with assessments and decisions made. Hospital 2 5.5.6 In the ante-natal period, the hospital failed to engage with the referring medical centre 1. Post-natally, although mother’s discharge was handled carefully, there was further scope for involvement of health visiting colleagues in the community. 5.5.7 Further contacts led to responses that accorded with assessments of need. Probation 5.5.8 The potential for heightened recognition of potential risk to children within assessments completed by Probation staff has been outlined above Police 5.5.9 Decisions made by the Police followed logically from assessments made by officers. The author has no criticism of the manner in which this was done.                                                44                                          GP Services 5.5.10 Assessments made by GPs involved generally resulted in appropriate actions and decision making although there was an apparent lack of response at medical centre 2 to do more than alert health visitors to the domestic situation reported at the post natal check. 5.5.11 At medical centre 4, there could have been  a more prompt follow up on the information provided at registration that Zara was behind on her immunisations or to ‘code’ the concerns that were reported by Children’s Social Care. 5.6 WERE APPROPRIATE SERVICES OFFERED / PROVIDED OR RELEVANT ENQUIRIES MADE, IN LIGHT OF ASSESSMENTS?  Education & Early Years 5.6.1 Services provided by both nursery 1 and nursery 2 were entirely appropriate.  Children’s Social Care 5.6.2 The initial collaborative approach between Children’s Social Care and Housing in response to mother’s request for accommodation was commendable. IMRs provided have not included the detail of precisely what mother sought and how the distinction was drawn between a need for somewhere to live versus a potential need to be accommodated under the provisions of s.20 Children Act 1989 (and becoming a looked after child with associated ‘after care’ advantages). 5.6.3 The critical difference between each status was spelled out the following year in the ‘Southwark Judgement’ R (On the Application of G (FC) (Appellant) v London Borough of Southwark (Respondents) 2009.  Insofar as the evidence supplied refers to no disagreement between MGM, mother and both Wandsworth Departments about the nature of need, it is assumed that there was a consensus that mother merely required somewhere to live independently. 5.6.4 The subsequent vulnerability of mother and later her daughter casts doubt on the presumption that mother was ready to cope with the level of independence implied by forms of accommodation provided. Also assessments undertaken in 2009 should have anticipated and explored the implications of the anticipated release from prison of Zara’s father. 5.6.5 The response to notification of the Police raid in June 2011 (including confirmation of Zara’s exposure to Class A drugs and mother’s arrest) was rightly upgraded to a core assessment (though not re-defined as one being undertaken under s.47). The assessment seems to have been closed off with insufficient challenge about the immediate and indirect risks to Zara of exposure to drugs and drug dealers.  Health Visiting  5.6.6 The provision of effective health visiting services was inevitably rendered more difficult because of mother’s initially frequent moves, changes of GP registration for herself and for Zara and by mother’s ongoing unreliability in responding to offers of help.                                                45                                          5.6.7 However, it appears that those difficulties were compounded by organisational change and consequent muddle which is reflected in the IMR provided. Had the level of confusion been less, it seems likely that the overall health visiting service offered (though possibly not accepted by mother) would have been of a better quality, Housing Services 5.6.8 There were few opportunities for improvements in the services provided by or via the Housing Department. Arguably, further advice might have been sought when mother claimed to be in fear of violence from a local female gang Rent Collection Service 5.6.9 The actions of rent collection officers were consistent with the functions of that service and showed an appropriate sensitivity following the trauma experience by Zara in March 2013. Hospital 2 5.6.10 The ante-natal services provided to mother were appropriate (the failure to liaise with medical centre 1 is commented upon elsewhere).  5.6.11 It remains uncertain whether reassurances provided by MGM at the visit to the urgent care centre on 08.11.12 about Zara being up to date with immunisations were accurate. Probation 5.6.12 Appropriate forms of assessment were applied on the several occasions that the courts required advice or information. Missed opportunities for making some of those assessments more precise and child focused are commented upon elsewhere. Police 5.6.13 Responses made followed appropriately from the facts as they were known at the time. GP Services 5.6.14 GP assessments resulted in referrals to CAMHS, Children’s Social Care and antenatal care for mother, all which resulted in appropriate services being offered. 5.6.15 At the postnatal check it was established that mother and Zara remained vulnerable but the only action initiated at that point was to ask health visitors to follow up.   5.6.16 It is a matter of speculation what might have been possible with more multi agency collaboration. The fact that there was no feedback from Children’s Social Care or from Midwifery to inform a more thorough risk assessment and that this information was not actively sought by GP was characterised by the IMR author as relative ‘blind spot’.                                                46                                          5.7 WERE PRACTITIONERS AWARE OF & SENSITIVE TO THE NEEDS OF THE CHILD IN THEIR WORK? HOW DID PRACTITIONERS ESTABLISH THE CHILD’S VIEW ABOUT WHAT WAS HAPPENING IN HER LIFE & HOW WAS THIS RECORDED?   Education & Early Years 5.7.1 The descriptions of Zara relayed by the IMR author and provided directly at the practitioners’ learning events by staff who worked with the child, offer reassurance that Zara was developing normally and manifesting no signs of abuse or neglect. Descriptive records including a photograph illustrate a pretty, confident and popular child always well-presented and exhibiting no more reserve about family than many others. 5.7.2 Unless specifically commissioned e.g. following a child protection conference, staff should not ‘push’ a child to reveal more about home than s/he might do spontaneously.  Children’s Social Care 5.7.3 The independent IMR author acknowledged and commended the fact that when MGM first sought help from the agency, mother (then aged 15) was given an opportunity to be seen alone. The focus on and to some extent sympathy for her was subsequently lost at the time of the unsuccessful family group conference. The IMR author also formed the view that the circumstances in which Zara was living and her needs were effectively lost in the assessments undertaken following her birth e.g.  The initial assessment immediately after Zara was born failed to explore mother’s reasons for quitting her property nor explore the suitability for Zara of her father’s home   The core assessment following the drugs raid did not challenge mother’s denials and address head-on the life –threatening exposure of her daughter to Class A drugs or the associated chronic risks if mother and/or her boyfriend and associate were dealing  Consideration of the potential for Zara to lose her mother if she were to be imprisoned for attempting to convey illicit articles into prison was subverted by mother’s blunt denial of culpability 5.7.4 The day to day experiences of Zara e.g. how often did she stay with her mother’s aunt, how often did she see her father (in and out of prison) do not emerge from any assessments and it seems that Zara was never spoken to alone. 5.7.5 All agencies agreed that Zara related positively to her mother but the IMR author refers to the need (in addition to offering good enough physical care) also for ‘reflective functioning’ in a good parent i.e. a capacity to keep the emotional needs of her/his child in mind and to be empathetic to her/his feelings.   5.7.6 Mother’s criminal behaviours and association with serious offenders suggest that her own needs often outweighed her ability to award priority to those of her daughter.                                                47                                          Health visiting  5.7.7 The fragmentation of health visiting services across place and time significantly reduced the extent to which any one health visitor was able to get to know Zara and evaluate what impact her mother’s chosen lifestyle was having on her and whether there were explicit indicators of risk that required action. 5.7.8 The current national approach of corporate caseloads further reduces the probability of a relationship-based service and critically depends upon accurate evaluation of need / risk in attributing families to the 3 categories that now exist viz: ‘universal’, ‘universal plus’ and ‘universal partnership plus’. Housing Services 5.7.9 The opportunity for sensitivity to the needs of mother (still technically a child until 18) and later Zara were limited to the provision of suitable accommodation. In spite of mother’s abandonment of some, she never produced evidence to support her contention that what was provided was unsuitable. Rent Collection Service 5.7.10 This service showed sensitivity to Zara’s needs when it initiated contact with Children’s Social Care in early March 2013 and again in its exchanges after her assault later that month. Hospital 2 5.7.11 Whilst the individuals no doubt acted in good faith, the confusion that ensued around the time of Zara’s discharge from hospital remains insufficiently understood and was clearly not in Zara’s best interests. Probation 5.7.12 The primary focus of the Probation Service was naturally on Zara’s father. As indicated elsewhere in this overview, what may usefully be described as the ‘mind-set’ in relation to the notion of ‘risk to children’ was directed toward children in general rather than the narrower and more immediate issue of Zara or indeed the son father is reported to have claimed to have. Police 5.7.13 On each occasion that child Zara was present at an incident, the standard procedure for notifying Children’s Social Care was followed. GP Services 5.7.14 The sensitivity to the needs of a vulnerable child was more obvious when medical centre 1 was dealing with mother (then aged 15). The extent to which GPs pursued the lack off their involvement by hospital 2 pre and post-natally or the issue of overdue immunisations was reasonable but could (ideally) have been improved upon.                                                48                                          5.8  WERE PROFESSIONALS KNOWLEDGEABLE ABOUT THE POTENTIAL INDICATORS OF ABUSE OR NEGLECT & ABOUT WHAT TO DO IF THEY HAD CONCERNS ABOUT A CHILD’S WELFARE & WAS THIS EVIDENT IN THEIR PRACTICE? Education & Early Years 5.8.1 To the extent that an Ofsted evaluation may be regarded as a useful indicator, both nursery 1 and nursery 2 are rated ‘good’ and this would have included an evaluation of their safeguarding arrangements. 5.8.2 The ability in practice to discern and act upon suspected abuse or neglect was untested during the short periods that Zara attended (7 and 11 weeks respectively at nursery 1 and 2). Children’s Social Care 5.8.3 There are no indications that staff lacked knowledge of what to do in the event of clear indicators of abuse or neglect. The challenge presented in this case was that the indicators were not clear. 5.8.4 Given the context of what might be labelled ‘understandable uncertainty’ and the reasonable presumption that staff were busy enough and not seeking additional work, the best hope of the agency achieving a level of objectivity was through regular effective supervision. The nature and value of the supervision actually provided is explored below. Health visiting  5.8.5 The IMR provided to the SCR confirmed that staff were sufficiently trained and that protected time for supervision was available. However, the author’s experience of other comparable situations raises the question of the usefulness of supervision (regardless of its intrinsic quality) if it is only provided with respect to cases identified by the supervisee? 5.8.6 The dilemma is comparable to that observed in the evaluation of risk by probation officers (and discussed elsewhere). If the determination of threshold for discussion / supervision / ratification of a recommendation by a more senior colleague, remains with the less experienced, how does an agency ensure that less obvious but nonetheless high risk cases are nor overlooked or otherwise down-graded ? In other words, self-selected cases taken to safeguarding supervision may identify some but not all those which carry the highest risk of significant harm. Housing Services 5.8.7 The IMR of Housing-related services provides evidence that staff are sufficiently aware of indicators of abuse and neglect and that none emerged in the time mother spent in specialist mother and baby units. Rent Collection Service 5.8.8 This service initiated a check in April 2011 with the intention of establishing any ongoing contacts between Adults’ or Children’s Social Care and in the author’s view took sufficient account of safeguarding issues in their responses.                                                 49                                          Hospital 2 5.8.9 Hospital 2 was formally committed to the London Child Protection Procedures and recognised the expectation of a pre-discharge meeting for this vulnerable young mother. 5.8.10 The extent to which the omission of the referring GPs and relevant health visitors was a function of misinformation provided by the family had yet to be determined. Probation 5.8.11 Staff initiated several contacts with Children’s Social Care from June 2009 onwards suggesting an awareness of required responses if there are concerns about a child’s welfare. 5.8.12 The IMR author was able to confirm the attendance of PO4 and P6 on safeguarding children training but was unable to confirm attendance by other colleagues. The recommendations in section 7 address this uncertainty. Police 5.8.13 The responses of officers indicate that they were aware of and acted upon indicators of neglect or abuse. GP Services 5.8.14 There is evidence that GP staff had knowledge and understanding of potential indicators of neglect and acted to address them e.g. the insufficiency of immunisations was conveyed to Children’s Social Care and health visitors.    5.8.15 GPs appear to have actively sought, been aware of and acted sensitively towards the needs of mother in the early period of this SCR.  5.8.16 There was though, insufficiently assertive outreach during mother’s pregnancy and in the postnatal period.  5.8.17 Zara appears to have been a ‘hidden child’ with whom GPs were unable to establish face to face contact. In the absence of direct contact little more could have been done to determine a response to mother’s lawful and not uncommon failure to ensure her daughter’s receipt of all recommended immunisations.                                                50                                          5.9 WERE SENIOR MANAGERS OR OTHER ORGANISATIONS & PROFESSIONALS INVOLVED AT POINTS IN THE CASE WHERE THEY SHOULD HAVE BEEN?  WAS THERE SUFFICIENT MANAGEMENT ACCOUNTABILITY FOR DECISION MAKING?  Education & Early Years 5.9.1 There was no occasion when involvement of a manager was required in either nursery. Children’s Social Care 5.9.2 All the assessments undertaken were signed off by a manager. None seemed to have discerned the extent to which their conclusions were rooted in mother’s denial of any responsibility for matters that had led to Police involvement. 5.9.3 The decision of more than one manager that any further concerns should lead to consideration of more formal safeguarding action was justifiable but was overlooked when the opportunity to do just that arose. 5.9.4 A multi-agency meeting could usefully have brought together and clarified mother’s chosen lifestyle and its current and future impact on Zara. 5.9.5 The IMR author believes that some current developments should serve to enhance quality of future assessments i.e. a new single assessment focused on professional judgement and the use of ‘signs of safety and of wellbeing’. 5.9.6 Without regard to the intrinsic values of these initiatives, monitoring by local managers and audits by more senior staff will remain necessary if sufficient quality is to be assured. Health visiting 5.9.7 In contrast to the arrangements within Children’s Social Care, unless a case is identified as being of particular concern, there is no requirement or expectation within health visiting services that it should be brought to supervision. Hence, until the incident in March 2013 Zara’s case had never been discussed with a more experienced and objective practitioner or manager. 5.9.8 The effectiveness of a system of ‘exception reporting’ is that it depends upon sufficiently complete and accurate records and having practitioners able to recognise and raise the cases that trigger their concern.  In this instance some inadequacies and fragmentation of records and organisational muddle (transition from paper to electronic records and shifting lines of accountability) represented an unfavourable professional environment. Housing Services 5.9.9 The IMR provided confirmed that managers were involved at each required stage of the involvement of Housing Department staff. This SCR has highlighted a need for a review of the current expectation within the tenancy support service of a standard 3 attempts to contact a tenant.  The intention is to develop an approach that better recognises the vulnerability of some young tenants and is especially alert to the potential need to engage other agencies if they are parenting a child.                                                51                                          Rent Collection Service 5.9.10 Managers were involved appropriately by the Rent Collection Service staff. Senior managers have though identified a need for further child protection training and for a procedural change such that cases where a concern has been identified will be regularly reviewed with senior managers. Hospital 2 5.9.11 The involvement of the safeguarding midwife at the time of Zara’s birth offers evidence of a readiness amongst staff at that time to involve more senior staff. The failure in the ante and post natal period to liaise with medical centre 1 remains unexplained. Probation 5.9.12 In accordance with policy, the decision to recall father to prison in 2011 was made by a senior manager. There were no other occasions when a manager was supposed to be consulted and was not. 5.9.13 Probation has a similar system to that which exists with health visiting services i.e. only if a case if considered ‘high risk’ must it be discussed with a senior colleague. Because father had been assessed as a ‘high risk’ to the public, both the ‘start custody’ and ‘pre-sentence reports of February and July 2012 respectively were countersigned by a senior probation officer. Earlier reports deeming father to be ‘low risk’ did not require countersignature by a manager. 5.9.14 The inbuilt weakness of such an arrangement is that if the level or nature of risk a client poses is underestimated by a practitioner, the potential check and balance that could be provided by a senior colleague is absent.   5.9.15 The IMR author illustrates this issue well when he suggests that the risk of serious harm to children in the pre-sentence report of July 2012 should have been more than ‘low’. Police 5.9.16 Until the serious assault that triggered this serious case review, incidents had not required the involvement of more senior managers. Though strictly beyond the scope of this review, it appears that senior officers have been involved in supervising and supporting the criminal investigation of Zara’s injuries. GP Services 5.9.17 GPs are self-employed and are not accountable to senior managers. Their contractual obligations to provide a service was (until April 2012) to the local Primary Care Trust and is since then to the ‘Local Area Teams’ of NHS England. Nothing in this SCR suggests any actions by GPs that were inconsistent with standard contractual arrangements.                                                52                                          5.10  WERE THERE ORGANISATIONAL DIFFICULTIES BEING EXPERIENCED WITHIN OR BETWEEN AGENCIES? WERE THESE DUE TO A LACK OF CAPACITY IN ONE OR MORE ORGANISATION?  THERE AN ADEQUATE NUMBER OF STAFF IN POST? DID ANY RESOURCING ISSUES SUCH AS VACANT POSTS OR STAFF ON SICK LEAVE IMPACT ON THE CASE Education & Early Years 5.10.1 There were no operational difficulties with either involved nursery or between them and other agencies. Ofsted’s evaluation of both settings as ‘good’ suggests an adequate number of staff and the ability of those who worked directly with Zara to provide for the IMR author and at the practitioners’ events, a comprehensive and sensitive account suggests Zara’s early years experiences were very positive. Children’s Social Care 5.10.2 The IMR author who conducted some interviews for the purposes of compiling her report, and provided an opportunity to comment on the issue, was not made aware of any shortfall of staff or any comparable resource constraint within the settings involved. 5.10.3 Given the uncertainty about precisely when the case was closed, the author has though speculated about how clear a distinction there is between the role of the Referral & Assessment Team and that of the team within hospital 1? e.g. for how long is a case which is opened at hospital 1 dealt with from that team and at what point might it transfer elsewhere. Health Visiting  5.10.4 The IMR provided does not suggest that any absolute shortage of health visitors adversely impacted upon the service provided but does make it clear that the context in which staff from different locations operated was rendered more difficult by a (slow and varying across workplaces) transition from paper-based to electronic record keeping in 2008 and the re-structuring and re-allocation of accountabilities in 2010. 5.10.5 As highlighted by some practitioners interviewed, the position that still pertained at the time of their interview (but which has since been resolved) whereby a family could be allocated to more than 1 ‘cluster’ was a recipe for confusion. Housing Services 5.10.6 There is no suggestion within the IMR submitted or seen in the reports of others that there were any organisational difficulties or capacity-related constraints to the service provided by the Housing Department including its Tenancy Support function. Rent Collection Service 5.10.7 Nor is there any indication of organisational difficulties or capacity-related constraints with the Rent Collection Service.                                                53                                          Hospital 2 5.10.8 In the relatively brief and limited period of involvement of hospital 2, no shortage of resources or other organisational difficulty is believed to have constrained the actions taken. Probation 5.10.9 At his interview PO4 referred to a significant overload of work when he joined the agency in July 2010 and indicated that this explained the later delay in him contacting Children’s Social Care instructed by the senior probation officer in December of that year and to a failure to visit father at home. It should be noted that the senior probation officer does not agree with those views. 5.10.10 PO4 also referred to some difficulty in obtaining information from the local MPS Intelligence Unit but provided no examples from this case. It would therefore be wrong to draw any conclusions about this important example of inter-agency co-operation. Police 5.10.11 No resourcing difficulties were identified in the Police IMR and none is apparent from the whole picture that emerges from collation of all available material. GP Services 5.10.12 The GP IMR reports that until April 2012 there was no ‘named GP for child safeguarding’ (a formal role offering support and advice to GPs) and that this might have impacted upon the readiness or confidence of doctors to escalate their concerns. 5.10.13 The author agrees that the unfilled post represented a theoretical risk but has seen no evidence that it did in fact constrain the actions taken by involved GPs. 5.11  DID THE ORGANISATION HAVE IN PLACE POLICIES & PROCEDURES FOR SAFEGUARDING & PROMOTING THE WELFARE OF CHILDREN & ACTING ON CONCERNS; WAS THE PRACTITIONER AWARE OF THEIR EXISTENCE & WAS THE WORK IN THIS CASE CONSISTENT WITH EACH ORGANISATION & THE WSCB’S POLICY & PROCEDURES FOR SAFEGUARDING & PROMOTING THE WELFARE OF CHILDREN, & WITH WIDER PROFESSIONAL STANDARDS? 5.11.1 All the agencies involved were formally committed to the London Child Protection Procedures and no IMR has suggested that staff were insufficiently trained or aware of them. 5.11.2 The various lost opportunities identified by this SCR did not represent gross breaches of any lawful or procedural requirement; rather they reflected judgements being made on the basis of less than all potentially available information.                                                54                                          5.11.3 Some obstacles preventing access to the whole picture of Zara’s life were contextual / systemic and some more individual; they included:  Poorly planned transitional arrangements within the health visiting service to support staff in the move from paper-based to electronic records and from traditional relationship-based health visiting to the phenomenon of ‘cluster working’ and ‘corporate caseloads’ – the net result being uncertainty about accountability  Insufficient quality control within Children’s Social Care such that tasks identified at case closure-related audit as ‘incomplete’ could continue to be so  A self-imposed constraint amongst probation officers limiting their consideration of the impact of father’s behaviours and accomplices on Zara’s welfare  A traditional role distinction whereby even sensitive and caring GPs tend to be relatively passive and await incoming information 5.12  ADDITIONAL CASE-SPECIFIC ISSUES Were agencies aware of the mother’s lifestyle & connections with gang & criminal activities when making assessments of the child? 5.12.1 Mother was recognised by several agencies as different from other young mothers in local temporary accommodation. Though the impact on involved professionals of such factors was insufficiently explored, it seems likely that mother’s intelligence and an unusually good standard of education provided her with a level of confidence and articulacy which she applied to denying and diverting attention from a significant level of personal need. 5.12.2 Mother’s pursued her position on certain issues without regard to an absence of evidence (e.g. mice infestation of accommodation, threats from local gangs). She also bluntly denied events or allegations for which evidence did exist (shoplifting, attempting to smuggle illicit goods into prison, an awareness of drug and alcohol misuse by boyfriend and others). These observations illustrate her ability and tendency to block professional attempts to form open and honest relationship with her. 5.12.3 Her ability to argue for and obtain what she wanted e.g. accommodation was matched by her success in avoiding adverse consequences when she failed to act responsibly e.g. no payment of fees to the nurseries nor rent to the Housing Associations. 5.12.4 Aside from Police and Probation where Zara’s father was clearly the respective officers’ central concern, other agencies held very limited information about him and made little effort to find out more. Hence the GP on learning of mother’s pregnancy did not seek the identity, age or ethnicity of the father; similarly hospital 2 lacked curiosity about the paternity of Zara and what impact he might have on his daughter’s welfare; nursery 1 staff also remained unaware of the identity of Zara’s father or of the fact he was in prison. 5.12.5 This apparently widespread insufficiency of curiosity was reinforced by mother’s reluctance to acknowledge too much about Zara’s father. Given the duration (albeit interrupted by spells of incarceration) of their relationship, the large number of father’s crimes and the observed affluence implied by the way mother and Zara were dressed, it seems unlikely to Police and this author (though mother claims it to be so) that she was unaware of at least a proportion of her partner’s offences.                                                55                                          5.12.6 Clearly, mother would not have wanted to draw attention to her lifestyle and the ability to present herself and Zara well in social situations coupled with an observed disinclination to get involved at the nursery (where many young parents form significant and mutually supportive relationships) served her well. 5.12.7 Mother did cite a fear of a female gang in Summer 2010 but when asked by a generally attentive and efficient Housing Service produced no evidence to substantiate her stated fears. When asked by the author in the course of compiling this report, mother did not press her historic claim of a fear of gangs. The Police IMR confirms that none of the contacts with mother or her child reveal any link or association with gangs. 5.12.8 Even the Probation Service with its focus on Zara’s father remained unaware of any gang affiliation Zara’s father had / has. 5.12.9 The net result of all the contacts and assessments completed is that there was insufficient exploration of the way mother and Zara were living, no agency knew or indeed knows now to what extent it was being financed or otherwise shaped by drug dealing. 5.12.10 In hindsight, a multi-agency meeting could have pulled together the many and separate strands to formulate a more complete picture. Was information appropriately shared about the drug culture & impact of this on Zara’s development? 5.12.11 In spite of her parents’ concerns about possible use of hard drugs (her cannabis use seemed to have been an accepted ‘given’) there was limited early challenge about mother’s possible usage. Because the issue of drug mis-use was not addressed in either the pre-birth or immediate post-partum initial assessments, the implied risks to baby Zara in utero or subsequently as a baby remained uncertain. 5.12.12 The MPS had expressed doubts to Probation in February 2009 about the suitability of the home of the paternal grandmother’s home as a base for purposes of a court-imposed curfew. This was based on awareness within the MPS that a number of his associates were drug dealers. 5.12.13 This information was not shared with Children’s Social Care at the time nor was the potential impact on them of Zara and her mother spending time at the address reflected in the pre-sentence report later prepared by PO2 in June 2009. 5.12.14 Although her place had been allocated in late March it seems likely that mother and Zara actually remained at the above location (and were thus exposed to father’s associates and the drugs they possessed / traded) for several further weeks. 5.12.15 Almost a year later there was a further phone exchange between SW2 and PO2, with the former indicating that a new referral would be required to prompt an updated assessment if father, upon his scheduled release in September, moved back to his mother’s address. 5.12.16 In February 2011 PO4 sought information from Children’s Social Care and reported that father was serving a sentence for possession of class A drugs and that Zara was living at his home address.                                                56                                          5.12.17 Police notification to Children’s Social Care of the drugs raid of June 2011 revealed a new and significant intimate relationship (albeit one denied by mother) as well as the fact that Zara (aged 2.5 years of age) had been directly exposed to potentially fatal drugs and a weapon. 5.12.18 Mother’s arrest implied that she was aware of the drugs and had placed her own personal needs above those of Zara. Aside from her reserved manner and limited personal involvement with nurseries, nothing (setting aside her failure to pay any fees) untoward was noted. Zara’s appearance, affect and conduct all fell well within normal parameters and gave no cause for concern. 5.12.19 No information about drug culture and its impact on child Zara has emerged that had not been shared between individual agencies. Was sufficient consideration given to the impact of cultural / racial & other equalities issues in any assessments? 5.12.20 Across targeted agencies, aside from recognition of  an obvious difference (mother being more articulate and better educated than most comparable service users) there seemed to be little appreciation that behind those features lay potentially more significant issues e.g.  What were the parental aspirations and expectations when they paid substantial fees for a private boarding school education for Zara’s mother?  How did Zara’s mother respond when she was removed from the boarding school she ‘loved’ and a brother remained to complete his schooling? (her conversation with the author suggests that ‘jealous and resentful’ were amongst the feelings she experienced)  How did mother feel about the parental separation and father’s move to  South Africa   Why did she say she feared her father? (mother now says she has no recall of that)  Did her claim to be moving to live with her father represent a fear or a hope?  To what extent was entering into intimate relationships with those involved in crime and anti-social behaviour chance and/or a rejection of parental values?  What was the cultural / religious background/s of the parents of Zara’s mother?  What were mother’s religious beliefs and how did they influence her day to day life?  Was MGM pleased or distressed about her daughter’s pregnancy and was the ethnicity of Zara’s father important to her or her ex-partner?  What implications for mother and Zara did MGM’s new partner have?  How did mother feel about MGM’s new relationship?  Of what significance was the fact that Zara’s father was a Muslim to mother and/or her parents?  What were mother’s expectations of the ‘Godmother’ nominated by Zara’s mother?  5.12.21 Records supplied offer no answers to these and many more questions that together identify a proportion of the cultural / religious / racial context in which a distressed and challenging adolescent became a teenage parent with a very dangerous partner. Mother’s own vulnerability was probably greater than she herself appreciated.                                                57                                          5.12.22 The Children’s Social Care IMR points out that even basic data was not captured e.g. ethnicity of Zara’s father and his family (a further example of his ‘invisibility’ as a parent). 5.12.23 With respect to its work, Probation’s records initially mis-recorded father’s ethnicity as ‘Chinese and no Faith’ before correcting it to ‘dual heritage White British / Black Caribbean and Muslim’. The significance of ethnicity or Faith remained un-explored. 5.12.24 Passing references to the maternal grandfather receiving specified medical treatment in South Africa also raised the possibility of certain issues, which remained unexplored. Was consideration given to the escalation of the lack of response by mother to immunisation & developmental assessment opportunities?  5.12.25 The issue of delay is Zara receiving all the standard pre-school immunisations needs to be placed in the context of law and national policy. There is overwhelmingly sound evidence of benefit to the individual and to wider society (through herd immunity) of maintaining a high take up rate for immunisation. However, (with respect to a child too young to make her/his own informed decision) whether s/he does receive any or all such immunisations is at the discretion of a parent. A failure or refusal to allow such interventions is neither unlawful nor (unless other evidence points that way) necessarily irresponsible. 5.12.26 The evidence within the IMRs suggest that although her own mother (MGM) was opposed in principle to such interventions, mother was at worst ambivalent and at best willing but too distracted by a chaotic lifestyle to ensure that it happened. 5.12.27 Thus, in January 2009 Zara was given her first set of DTaP/IPV/Hib and in March that year received her 2nd set of primary immunisations. 5.12.28 Monitoring of the issue in medical centre 2 picked up by January 2010 that Zara was overdue her 3rd set of immunisations and a letter was sent.  It remains unknown whether mother received that correspondence. 5.12.29 When Zara was seen at paediatric A&E department in August 2010 (at which point neither mother nor Zara were registered with a GP) the fact the child was overdue for further immunisations was picked up but was not pursued with the relevant health visiting service. 5.12.30 Zara remained registered with medical centre 2 for only a further 6 months after its attempt to contact mother by letter. The fact that she was overdue her further immunisations emerged again only after the drugs raid in June 2011. It was not raised as a concern with SW6 in her phone conversation in early July 2011 with GP4 at medical centre 3 (where Zara had been registered as a temporary patient), nor by GP5 from medical centre 2 a week later. 5.12.31 The phone conversation between SW5 and GP8 in late March 2012 probably occurred after the decision had been made in Children’s Social Care to close the case. Had the health visiting service been involved in the formulation of that core assessment, the scope for persuading and assisting mother to organise Zara’s 3rd set of immunisations would clearly have been greater.                                                58                                          5.12.32 Following Zara’s registration at medical centre 4 in July 2012 further efforts were made to encourage mother to bring Zara in for the overdue immunisations. In fact the child was not seen for that or any other health-related issue in the 18 months before the incident triggering this SCR. 5.12.33 The average annual rate at which under-fives are seen at Wandsworth GP Practices is 5.It is a matter of speculation as to whether Zara was unusually healthy, her mother more confident in management of or less sensitive about, day to day morbidity or whether a combination of such factors prevailed.  5.12.34 The GP Service IMR author evaluated the efforts made to ensure Zara’s full set of immunisations as ineffective and the involvement of health visitors belated. In the author’s view however, the absence of other grounds for concern rendered the responses made proportionate to the perceived need. 5.12.35 The author does concurs with the suggestion that a consultation with the named or designated doctor for safeguarding children could have been useful but otherwise concludes that the issue of mother’s overall care of her daughter would best have been addressed in the context of a multi-agency meeting. As discussed below, such a meeting was never convened.  Were historic records systematically reviewed to evaluate & assess risk? 5.12.36 The IMR that evaluated the responses of Children’s Social Care highlighted that there were 6 formal assessments and that all lacked a clear purpose; that little use was made of previous assessments with each incident being treated in isolation. In consequence there was limited cumulative understanding of risks or strengths. 5.12.37 The IMR author also found little evidence of formal reviews of records. An audit undertaken by a service manager in May 2010 helpfully identified a number of uncompleted tasks and agreed that these were to be pursued with the relevant social worker. There is no documentary evidence to confirm that they were. 5.12.38 Regular supervision was provided to allocated social workers. The focus of that supervision though was on immediate tasks rather than on critical reflection on the developing picture. 5.12.39 There is also evidence of insufficient rigour with respect to follow-up of overdue or incomplete pieces of work e.g. failure to complete the requested core assessment in 2007, the write up of the initial assessment begun after Zara’s birth and (by two social workers) to comply with the instruction in January 2012 to liaise with Probation and health visitors. 5.12.40 The result of the insufficiently reflective approach was to reinforce the tendency of practitioners to react to the latest event without placing it in its historical context. Thus, a number of decisions by managers along the lines of ..’if there are further referrals about Zara, safeguarding responses should be considered’; were made but not then enacted. 5.12.41 A balance is required between supervision as a means of progress chasing and its potential to offer space to step back and invite examination of the impact on a developing child of all known relationships, circumstances and events.                                                59                                          5.12.42 Within Probation records a good deal of repetition was apparent and levels of understanding about father’s thinking or offending do not seem to have risen over time. 5.12.43 The IMR evaluating health visiting services attributes failures to take full account of existing records to the disruption in the period 2008/2009 when paper-based systems were gradually replaced by electronic records and to a contemporaneous reorganisation. 5.12.44 Best practice would have prompted nursery 2 to seek a transition report from nursery 1 though not doing so caused no obvious problem in this case. 5.12.45 All Police response seems to have appropriately drawn upon its available databases. This case did not meet the criteria for services from a number of agencies; if all information had been shared about this case, would this have met criteria & services provided or risk assessment made? 5.12.46 It is significant that at no time in the 5+ years considered within this overview, was there any face to face meeting of all involved professionals. 5.12.47 The early efforts made when mother was first referred to Children’s Social Care to understand and meet the family’s needs quickly became focused on satisfying mother’s insistent demand for her own accommodation and upon other related practical matters such as Benefit entitlement. 5.12.48 There were potentially useful individual exchanges e.g. SW1 and psych.1 in April 2008 who had then sought to develop hypotheses about the origins of the difficulties within the family. In essence though, each event or crisis from then till March 2013 was handled by a specific agency (sometimes in consultation with or informed by the records or views of another). 5.12.49 The discharge meeting held in hospital 2 immediately after Zara’s birth in December 2008 might usefully have been enlarged in its scope and membership to address the high level of vulnerability reported by GP1 a year previously and reinforced by the pre-birth initial assessment (albeit the conclusions of the latter could see no role for Children’s Social Care). 5.12.50 A further chance to pull together and better understand the respective concerns, risks assessments and efforts of health visitors, probation officers and staff from the social work team at hospital 1 emerged in early Summer of 2009. Instead of any such meeting, the initial assessment begun by a student seems to have remained unwritten and the case closed off by her supervising social worker SW2. 5.12.51 Zara’s 3rd A&E presentation (the first  at hospital 2) in August 2010 could have been more effectively handled by the liaison health visitor who could usefully have sought a multi-agency meeting to address GP registration, overdue immunisations and the stated termination of relationship with the then imprisoned father of Zara. 5.12.52 The last clear chance for a full exchange of information, concerns and proposals could have followed the drugs raid of June 2011 when reported events may well have justified awarding enquires s.47 status (Zara could easily have accessed and died from ingestion of the illicit drugs) and convening an initial child protection conference.                                                60                                          5.12.53 The author of the IMR evaluating health visiting services is of the view that if that agency’s records had been better kept and applied, there would have been a recognition that mother and Zara required more than ‘universal’ level of support i.e. would have become eligible for ‘universal plus’ status. Had the health visiting service attributed a ‘universal plus’ status, it would naturally have served to raise the profile of the case.  5.12.54 Without regard to that agency-specific issue, the value of a multi-agency meeting would have been to aggregate and evaluate the variety of apparently low level concerns and probably to better recognise the risks to Zara inherent in mother denying and diminishing crime and drug related conduct by herself or her associates. 5.13 MISSED OPPORTUNITIES FOR BEST PRACTICE 5.13.1 The following section lists actions or decisions that fell short of accepted ‘best practice’. Its length is misleading. It does not indicate that services offered or delivered were generally of a poor standard; rather that an honest, thorough and self-critical examination has unsurprisingly, found many ways in which quality of service might have been improved.  GP1 (whose initial referral was commendable) did not follow up Zara’s failure to engage with CAMHS  A reference by mother in early 2008 to Children’s Social Care’ initial contact worker, about her fear of her father (now denied or forgotten by mother) remained unexplored  Children’s Social Care failed to involve GP1 in its assessment of need (indeed it appears not to have completed the core assessment deemed necessary at that time)  In June 2008 PO1 when preparing the pre-sentence report, did not establish that his girlfriend (mother of Zara) was less than 18 thus denying herself the opportunity for recognising that it would be appropriate to liaise and share information about drugs misuse / potential risks to mother  The impact of father’s release from prison on Zara was not addressed in the closing summary completed by SW2 in May 2009  The delay of 9 days in SW2 responding to Probation’s request for information to inform the pre-sentence report in June remains unexplained  There was a significant delay before information about Zara’s presentation to A&E in December 2009 was actually inputted to the Rio database  In February 2010 mother’s objection to being housed in a proposed area because of gang-related fears remained unexplored and un-challenged  SW2 apparently failed to record a significant exchange with PO2 on 26.03.10  The failure to automatically offer tenancy support in April 2010 was unfortunate but had no impact in practice  PO4 was slow to involve Children’s Social Care in December 2012 and failed to initiate any response with respect to father’s reported claim (denied him) to have a son with whom he had weekly contact  PO4 should have updated Children’s Social Care in March 2011 about the victim being a pregnant woman with a small children following father’s recall to prison on a ‘conspiracy to rob’ charge  Zara’s presence and exposure to class A drugs (and a weapon) at the drugs raid in June 2011 merited a more significant multi agency response                                                61                                           Medical centres 2 and 4 could have tried to engage and persuade mother to complete Zara’s immunisations by earlier involvement of health visitors rather than depending upon written invitations  The initial and core assessments undertaken by SW4 and SW5 in early 2012 both failed to involve (as directed by the team manager) health visitors or Probation  PO6 in his exchange with Children’s Social Care in May 2012 could usefully have informed that agency of the presence of young children at the series of violent robberies father was by then known to have committed  Children’s Social Care case closure in July 2012 might usefully have been managed in a more incremental manner and a level of ongoing support been negotiated  PO7 in February 2013 when preparing the ‘start custody’ OAsys could usefully have sought an update from Children’s Social Care and sought an opinion as to any risks in ongoing contact between Zara and her father                                                62                                          6 CONCLUSIONS 6.1 INTRODUCTION 6.1.1 This section encapsulates the learning from this case for the way in which agencies worked to safeguard and promote Zara’s welfare. It offers a brief summary of good and sub-optimal responses (individual and systemic). 6.2 FINDINGS GOOD INDIVIDUAL PRACTICE 6.2.1 Examples of ‘good’ practice by professionals (i.e. exceeding what would be expected in comparable cases) were as follows:  The response of GP1 and GP2 at medical centre 1 in late 2007 showed a sensitive awareness to the vulnerability of Zara’s mother  The flexibility of CAMHS in responding positively to mother’s plea not to close her case in early 2008  The involvement of the safeguarding midwife at the point of Zara’s birth   Children’s Social Care Diversion and the Housing Options Teams worked well together in responding to mother’s initial request for accommodation in 2008  The initial response of the manager in Children’s Social Care in response to notification about the drugs raid in June 2011 (though conversion to s.47 status did not take place)  The careful response of another team manager in June 2012 to the report of Zara being found alone on the street 6.2.2 The IMR author who evaluated the service provided by GPs to mother and Zara was able to report upon and commend an internal reflective exercise conducted by staff within medical centre 4. The suggestions for improvements are consistent with those of the independent IMR author and are reflected in the recommendations in section 7 of this report. SUB-OPTIMAL SYSTEMS 6.2.3 Section 5.13 above listed opportunities where the possibility of best or optimum practice was missed by individuals. Of greater significance for local systems, the following provide examples of agency responses which fell below the minimum standard a service user might reasonably expect:  Hospital 2 failed to notify medical centre 1 of mother’s attendance for ante natal care or about Zara’s birth and discharge from maternity services  Children’s Specialist Care failed to provide any feedback to GP1 who had initiated a helpful referral of mother in October 2007  A delay of some 5 weeks before case allocation and then of over 18 weeks to complete an initial assessment by hospital 1 Social Work Team (the then target time was 7 working days)                                                63                                           Inadequacy with respect to its first initial assessment in 2007 (scope, depth and recording), the family group meetings in early 2008, initial assessments of Summer and Winter 2008 and the further 3 triggered by Police notifications, undertaken by Children’s Social Care  A failure across most agencies to explore the significance and possible impact on Zara of her father (or later the man described by Police as mother’s boyfriend)  The (undetected) failure of SW4 and SW5 to complete the tasks required by their team manager in January 2013 following mother’s arrest   The failure within Children’s Social Care to reflect on or follow-up on the conclusions of previous assessments that further incidents should prompt s.47 enquiries  An (undetected)  failure by an unidentified duty health visitor in the first half of 2012 to enter relevant records into the information system 6.3 PREDICTABILITY & PREVENTABILITY 6.3.1 On the basis of known history (her relationship with Zara’s father throughout a lengthy period of very serious offending) it was predictable that this vulnerable young woman could become involved in relationships with other men involved in anti-social and/or criminal conduct. However, her visible care of Zara remained adequate. 6.3.2 Limited evidence existed (e.g. arrest for possession with intent to supply in 2011 when Zara was exposed to class A drugs) to suggest that she knowingly neglected, abused or allowed the neglect or abuse of Zara by others to the extent of causing ‘significant harm’. 6.3.3 The assault on Zara by an individual yet to be identified and tried in court could not therefore have been predicted by those professionals who had contact with mother and daughter, nor is it clear that any action that might reasonably have been predicted by a local professional could have served to prevent what appears to be a spontaneous event. 6.3.4 Current Care Proceedings will judge the extent to which the significant harm suffered by Zara is a function of inadequate parental care and where the best interests of this little girl now lie. Similarly, the criminal process will determine culpability for the physical harm suffered by Zara.                                                  64                                          7 RECOMMENDATIONS RECOMMENDATIONS  INTENDED OUTCOME   SAFEGUARDING CHILDREN BOARD  1. Wandsworth Safeguarding Children Board should complete an exercise to gather and evaluate intelligence from all member agencies about the perceived effectiveness with respect to ‘inter-agency information sharing’ of existing:  Policies   Procedures   Practice (by means of case audits) - the results of the above exercise should inform any further action required     A clearer, more consensual and more reliably implemented approach to involvement of other agencies and sharing of relevant information 2. Wandsworth Safeguarding Children Board should seek confirmation from member agencies that any services that may be commissioned are being required to satisfy the obligations of s.11 Children Act 2004 Ensuring the retention across time of accurate records of service providers’ contacts with service users   SERVICE DELIVERY BY LOCAL AGENCIES     Wandsworth Education  3. Early Years Service & Schools should issue      guidance to:   Clarify that relevant information should be shared (i.e. passed over by the originating setting or if necessary, sought by the new one) in unplanned as well as planned transfers / transitions   Recommend that existing attendance rate monitoring (even for pre-statutory school age children) is used to inform discussion with parent/s and (if concerns about welfare arise) to inform any request for early help support services   Encourage the capture of reasons why a child may not be up to date with all her/his recommended immunisations e.g. parental choice    Staff will have a more complete understanding of history of early years experiences and be better able to interpret a child’s appearance, affect and behaviour   A more evidence-based approach to working with parents and other agencies     Acceptance of lawful parental choice and an enhanced opportunity to recognise and support those parents wanting their child to be immunised and whose organisational ability needs support                                                  65                                          4. Compliance levels with existing systems for   responding to children / young people who go missing from education (including sensitivity to the risk of sexual exploitation) should be confirmed by audit More effective multi-agency services   Wandsworth Children’s Social Care  5. Children’s Social Care should develop      guidance about ‘adolescent neglect’ to complement existing training  Improved recognition by practitioners 6. The existing audit of assessment schedule should be amended to include a section on parental self-report Increased likelihood of respectful uncertainty and confidence to challenge – leading to better informed assessments 7. The results of all audits so far completed in 2013 should be circulated Learning derived from identification of themes and issues identified in the report 8. Develop practice guidance for initial contact team / Referral & /Assessment Service duty that clarifies type and quality of information to be shared with other agencies More informed, efficient and confident information sharing (the current development of a multi-agency safeguarding hub should facilitate this) 9. Children’s Social Care should require each person who provides professional social work supervision to include in their reflective practice, the following 3 questions:  Have we taken sufficient account of known personal history (including development and maintenance of a chronology)?  Do we know enough about the father or significant other males in the case?  Would our understanding be enhanced if we convened a multi-agency meeting?  St George’s Healthcare NHS Trust (health visiting)  10. St George’s Trust should:  Review the Rio cluster system to ensure clarity about which health visiting team is responsible for a child  Implement a robust record-keeping methodology  Introduce mandatory record keeping training for all community health care practitioners working with children  Introduce a procedural expectation that all cases where a Police notification (MERLIN) has been evaluated by the Safeguarding Team  as requiring specified action is taken to safeguarding supervision   Clearer accountability  Clearer distinction between facts, self-reporting etc  Up skilling the workforce   Enhanced risk management                                                      66                                           Review and re-launch the policies / procedures associated with ‘no access’ / ‘did not attend’  Wandsworth Housing   11. Wandsworth Housing should:  Remind all staff of the availability of multi-agency safeguarding children training  Organise refresher safeguarding training for all staff to include the implications of gangs  Review tenancy support procedures to under 20s especially in relation to case closure following a failure to locate or engage a tenant  Complete the already scheduled review of the joint working protocol between with Children’s Social Care (ensuring that gang-related issues are reflected in it)  Better informed workforce   Heightened awareness of a contemporary challenge  A more sensitive service    Revised arrangements informed by experience Wandsworth Finance (Rent Collection Service)  12. The Rent Collection Service should:  Confirm that the ‘rent collection manager’ is the lead officer for safeguarding of children and accountable for ensuring all cases of concern are referred to ‘Tenancy Support’ and/or Children’s Social Care  Deliver training to officers to enable identification of cases of concern  Require the rent collection manager to introduce stringent procedures for follow up of safeguarding referrals initiated by rent collection officers  Clarity about accountability     Better informed workforce   A safer and more rigorous service London Probation Trust  13.  London Probation Trust should brief all relevant staff in the borough’s local delivery unit so that:  Communications with Children’s Specialist Care distinguishes provision of versus seeking information and a referral   A referral is initiated in every case where a service user is assessed as presenting a risk to any child  Referrals include all available details   The age of a service user partner is always checked since it may prompt a need for a referral  They become familiar with the Prison Service policy  on contact with children (chapter 2 Public Protection Manual)        More precise identification of need, enhanced clarity and quality of information provided and requests made for a response                                                67                                          Chelsea and Westminster Hospital  14. Chelsea & Westminster Hospital should: a. Ensure that GP lists are available in all paediatric clinical areas b. Require A&E staff to cross check between the current two electronic systems for attendance c. Require health visitor referral forms to be completed electronically d. Require records of immunisation status to be added to health visitor referral form e. Sustain the existing monthly meetings with community and hospital midwifery team, named midwife, and health visitors To more accurately identify and share approaches to the most vulnerable patients General Practice  It is essential that a robust system of information sharing is put in place to ensure that the ‘full story’ is available to all practitioners involved in a child’s care.  GPs must receive case based training on the importance of information sharing and assertive seeking of information which is not immediately available to them.  All agencies must ensure that their information sharing is maintained throughout their involvement and not only in times of crisis  The establishment of regular links with Health Visiting and Children’s Services representatives have already been recommended in other reports for the borough.  This practice is evolving but must be further established and embedded and needs to be encouraged and facilitated at a level that makes it standard practice independent of practice size, location or population demographic     7.1.1 Each agency has a detailed ‘action plan’ including allocation of responsibilities, deadlines and agency-specific means of monitoring progress toward, completion of specified tasks. Final overview child Zara 01.07.14                                                68                                          8 GLOSSARY OF ABBREVIATIONS / NAMES Abbreviation  Meaning EYMAP Early Years Multi Agency Panel IMR Individual management review MPS Metropolitan Police Service PMH Previous medical history SCR Serious case review UTD Up to date [used by health professionals in referring to immunisations]  Title  Meaning GP1  GP2  GP3  GP4  GP5  GP6  GP7  GP8  PN1    Health visiting  HV1  HV2   HV3  HV4  HV5  HV6    Midwifery  HV TL  CM1  CM2  CM3  CM3  CM4    Mental Health  Psych. 1    Children’s Social Care  ICW1  ICW2  ICW3  SW1  SW2  SW3   SW4  SW5  SW6  SW7  SW8  SW9  SW10                                                 69                                          TM1  SM1  TM3  TM4  TM5  Student SW  FGC1    Education  EWO1    YOT  YOT1    Probation  PO1  PO2  PO3  PO4  PO5  PO6  PO7    Housing  Pathway/ Notting Hill Housing Association  HO1  HO2     Finance Department  RCO1    Metropolitan Police MPS  DS1    Places   School 1  mother  School 2 mother    Nursery 1 for Zara  Nursery 2 for Zara                                                 70                                          9 BIBLIOGRAPHY General  Working Together to Safeguard Children, HM Government 2010 & 2013  Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008   Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial study of serious case reviews 2003-2005 Marian Brandon, Pippa Belderson, Catherine Warren. David Howe, Ruth Gardner, Jane Dodsworth, Jane Black, DCSF 2008  A Study of Recommendations Arising from Serious Case Reviews 2009-2010 M Brandon, P Sidebotham, S Bailey, P Belderson University of East Anglia & University of Warwick  Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren & Black DCSF 2009  Building on the learning from serious case reviews: A two-year analysis of child protection database notifications DFE – RR040 ISBN 978-1-84775-802-6 2007-2009  Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1April 2007 to 31 March 2008 Published December 2008  Ages of Concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011  Learning Together to Safeguard Children: A ‘Systems’ Model for Case Reviews March 2009 SCIE  New learning from serious case reviews: Marian Brandon et al RR226 DfE 2012  Case-specific   ‘Southwark Judgement’ R (On the Application of G (FC) (Appellant) v London Borough of Southwark (Respondents) 2009     