6-year-old child, "M", who witnessed the murder of her mother, "B", in September 2014. M had been looked after and subject to a child protection plan. This was stepped down to a Child in Need plan before the case closed. During the period under review, there were concerns M was experiencing neglect. The police made five reports to children's social care. M's school made a referral to the education welfare service and a multi-agency referral to children's social care. A decision that the case did not meet the threshold for a child protection investigation was challenged. A planned social worker visit did not take place because B and M moved to another authority. A referral was made to the new authority but B and M had no further contact with agencies prior to B's death. B had been looked after as a child and experienced physical and sexual abuse, she had substance misuse problems and experienced domestic abuse. Findings include: inconsistent information sharing processes resulted in no one agency having an overview of the child's history and needs; universal services were not consistently applying assessment frameworks to help aggregate repeat low-level presentations of neglect; families with known child protection concerns were not being "tracked" across local authority boundaries. Recommends the LSCB consider questions including: how confident they are that agreed thresholds in use across all services are embedded in practice, being applied consistently, and are sufficiently sensitive to identify indicators of cumulative neglect.
      
 Title:  Report of learning together serious case review: Child M: presented to the Waltham Forest Safeguarding Children Board. LSCB: Waltham Forest Safeguarding Children Board Author: Howard Jones Date of publication: 2017  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.                           Page 1 of 41      REPORT OF LEARNING TOGETHER SERIOUS CASE REVIEW                CHILD M  PRESENTED TO THE WALTHAM FOREST SAFEGUARDING CHILDREN BOARD  29 June 2016  Independent Reviewer:  Howard Jones Page 2 of 41  Preface  This report uses the Learning Together systems methodology developed by the Social Care institute for Excellence (SCIE) in Serious Case Reviews (SCR). (Fish, Munro & Bairstow, 2008). The Board and member agencies should take ownership and act in response to the findings from this SCR to put in place lasting improvements to services.   Page 3 of 41  Index    1 Introduction  Page 4 2 Methodology   Page 5 3 Synopsis of professional practice  Page 10 4 Appraisal of practice   Page 16 5 The Findings      Page 21 Appendices                                                                Page 37                Page 4 of 41  1. Introduction 1.1  Why this case was chosen to be reviewed  Learning Together to Safeguard Children (LTSC) reviews are about learning lessons for the future. They make sure that Local Safeguarding Children Boards (LSCBs) are provided with as full a picture as possible about what needs to change as well as what went well so that all relevant professionals and organisations can improve their practice. This case concerned a 6-year-old child, Child M, who witnessed the murder of her mother. The child had been looked after and subject to a Child Protection Plan in the past (initially in one borough and then a neighbouring one) and there were concerns that, during the period covered by this review, she may have experienced neglect. The LSCB took the view that this presented an opportunity for further learning about how agencies, individually and collectively, are able to identify neglect and respond to it effectively.  The focus of this SCR has been on what light inter agency working and practice with Child M and her mother throws on how these services can, individually and collectively, work together more effectively to support vulnerable children.                    Page 5 of 41   2.  Methodology Organisational learning and improvement Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including SCRs, states that:  “Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children”. (Working Together to Safeguard Children 2015, 4:7) The LSCB identified that the review of this case held the potential to shed on light particular areas of practice including addressing the following questions:  1. Are local frontline/universal services confident about when and how to escalate concerns about children who may be in need or at risk?  2. Do professionals working locally apply the thresholds relating to children in need/at risk consistently, particularly where children are presenting with signs of physical or emotional neglect?  3. Do professionals working locally routinely use past histories of children/families when assessing current needs/risks?  4. In assessing the needs of children, do professionals working locally show an appropriate level of professional curiosity about their personal history and circumstances?  5. Are professionals working locally properly aware of, and use appropriately, the mechanisms for inter-agency professional dialogue, and escalation and decision making that are in place locally in relation to concerns about physical and emotional neglect?  Statutory guidance requires SCRs to be conducted in such in a way which (Working Together to Safeguard Children 2015, 4:11): Page 6 of 41   Recognises the complex circumstances in which professionals work together to safeguard children;   Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   Is transparent about the way data is collected and analysed; and   Makes use of relevant research and case evidence to inform the findings.  It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews (Working Together to Safeguard Children 2015, 4:10):   There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice;   The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;   Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;   Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;   Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process.  In order to comply with these requirements the LSCB has used the SCIE Learning Together systems model. Detail of what this entails is contained in Appendix 1.  Reviewing expertise and independence A reviewer independent of the case under review and of the organisations whose actions are being reviewed has led the SCR. This reviewer is accredited to carry out SCIE reviews. He has no previous involvement with Page 7 of 41  this case, or any previous or current relationship with the LSCB or partner agencies.   The lead reviewer has received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the analytic process and reliability of the findings as rooted in the evidence.   Acronyms used and terminology explained Statutory guidance requires that SCR report:   “Be written in plain English and in a way that can be easily understood by professionals and the public alike” (Working Together to Safeguard Children 2015, 4: SCR Checklist)   Writing for multiple audiences is always challenging. In Appendix 2 a glossary of terms and acronyms is provided to help readers who are not familiar with the processes and language of safeguarding and child protection work.   2.1 Review Team  This case review has been carried out by a Review Team of local managers led by an independent Lead Reviewer trained in the application of the LTSC methodology. Collectively, their role was to undertake data collection and analysis and author the final report. SCIE provided methodological oversight and quality assurance. Ownership of the final report lies with the LSCB as commissioner of the case review. The Review Team was made up of senior representatives from different agencies. Team members did not have any management responsibility for, or connection with, the case being reviewed.  The Review Team:  Independent Lead Reviewer  Representative of Specialist Crime Review Group, Metropolitan Police Service (MPS)   Senior Child Protection and Safeguarding Advisor (School Improvement and Standards), Local Authority  Designated Nurse, Clinical Commissioning Group (CCG)  Head of Safeguarding and Family Support, Local Authority  Director, Worth Unlimited, Voluntary and Community Sector (VCS)  Divisional Director of Early Help Services, Local Authority  Page 8 of 41   2.3  Structure of the review process Using the SCIE model gathering and making sense of information about a case is a gradual and cumulative process. The Review Team held a number of analysis meetings and the emerging narrative and learning from these – the findings - were presented to the Case Group in what are known as the ‘Follow On’ meetings. Over the course of this review the Review Team met six times. Three of these meetings included the Case group, one for an introductory session and then for two “Follow On” meetings to discuss the analysis of the case and to consider findings.  Attendance and participation at all meetings was good. Engagement from the Case Group was excellent and they should be considered as a potential resource for the dissemination of the learning from this review. The Review Team and Case Group were also unanimous in their agreement with the Findings of the Review.  The Review Team and Case Group were of the unanimous view that, notwithstanding the fact that Child M is still recovering from the trauma of the death of her mother, this review should be published in full.  The Learning Together method usually focuses on as recent a time period as possible because the aim is to analyse the system as it stands now and identify gaps or issues within it. The Review Team therefore set the parameters for detailed analysis on the period between January 1st 2012 and September 3rd 2014. However, in order to provide some context the report also references the history of Child M and her mother’s involvement with services in the two boroughs prior to January 2012.  2.5  Sources of data  The systems approach requires the review team to learn how people saw things at the time and explore with them ways in which aspects of the context in which they were working influenced their work. This is known as the ‘local rationality’. It requires those involved in a case to play a major part in the review in analysing how and why practice unfolded the way it did and highlighting the broader organisational context. The Lead Reviewer would like to thank both the Review Team and the Case Group for the valuable contribution they made to the review.    Page 9 of 41   Data from Case Group The Review Team conducted structured conversations with staff in the following roles, which together formed the Case Group for the review:    Head teacher, local primary school  Community Liaison Officer, local primary school  Early Help (formerly Early Intervention and Prevention Service (EIPS)) Coordinator  Police Constable, neighbouring borough’s Response Team  Two Police Constables, local Response Team  Detective Sergeant placed in local Multi Agency Safeguarding Hub (MASH)  Education Welfare Officer   MASH Manager  Deputy Manager, MASH   Health Visitor, NHS Foundation Trust   Named Nurse, Bart’s Health NHS Trust  Local Children’s Social Care (CSC), Team Manager  Head, local Nursery  While they were not part of the Case Group, the Lead Reviewer also had the opportunity to meet with the current Children’s Social Care Team Manager in the Multi Agency Safeguarding Hub who took up his post in May 2015.          Page 10 of 41  Data from documentation The following documentation was available for the Review Team:  Integrated multi agency chronology  Child Protection (CP)/ Child in Need (CiN) Review Meeting 2nd November 2010  CIN Assessment September 17th 2012  Selected extracts from Frameworki  School Significant Events chronology  Record of CSC screening process/decision March 2014  Multi Agency Referral made by school on 8th July 2014  Extracts from EIPS email records July-August 2014  Summary report on past history from previous borough   Detailed health logs – Bart’s, General Practitioner (GP) and Health Visitor Service   Health Visitor Service summary of involvement Data from family, friends and community Child M’s grandmother and aunt were offered the opportunity to contribute to this review but did not take up the offer. While of an age where child M may have been able to contribute to the review, it was the opinion of the Review Team and those working with her that it was paramount that nothing compromise her recovery from what she has been through.  2.7 Structure of the report Organisational systems are complex. Therefore, findings are not presented as recommendations but as a series of issues and questions for consideration and local prioritisation. A case review plays an important part in efforts to achieve safer and more effective systems. Consequently, it is necessary to understand what happened and why in the particular case and go further to reflect on what this reveals about gaps and inadequacies.   Case Review findings therefore say something more about the LSCB area/agencies and their usual patterns of working. They exist in the present and potentially impact in the future. The Review Team has therefore Page 11 of 41  selected the findings to pinpoint those that most urgently need tackling for the benefit of service users and their carers – and these may not be the issues that appeared most critical in the context of the particular case.  Indeed some actions have already taken place that address some of the issues in this particular case e.g. the strengthening of multi-agency understanding of when and how to escalate concerns about children following the implementation of a revised Threshold Document for use by all agencies in October 2014.  In order to help with the identification and prioritisation, the systems model that SCIE has developed includes six broad categories of underlying patterns. The ordering of these in any analysis is not set in stone and will shift according to which is felt to be most fundamental for systemic change: 1. Innate human biases (cognitive and emotional) 2. Service user and carer - professional interaction 3. Responses to incidents 4. Communication and collaboration in longer-term work  5. Tools 6. Management systems  3.  Synopsis of Professional Practice   3.1 Child M Professionals who came into contact with M during the period covered by this review all noted that she was articulate and self-confident and at school she was exceeding expected progress. The following shows the family composition, with ages, in January 2012 at the beginning of the review period:  Page 12 of 41   Age  Residence  M (child and subject)   M is of White British/Black African heritage Aged 4 years 3 months at the start of the review period   It is reported that the family moved to a temporary address in early July 2014 but there is no evidence that the property in the host borough was formally given up. B (mother) B was of White British Heritage  Aged 26 years at the time of her death As above C (partner to B until July 2014) n/k As above     3.2 Outline chronology of key events during the period under review  February 2010 M is reunited with her mother at their new home in the LSCB area.  May 2010 M took up her place at the local nursery aged 2 years 10 months  July 2010 The case is formally transferred in from the previous borough to host borough. The Child Protection (CP) Plan remains in place. August 2010 The CP Plan and voluntary looked after status is stepped down to a CiN Plan  November 2010 The CiN Plan is ended and the case closed to local CSC. July 2012 M finishes at nursery  August 14th 2012 First Police Merlin report regarding an incident where M is found wandering alone in the street in their previous borough, and is placed in Police Protection before being returned to the care of her Page 13 of 41  mother. (Merlin is the name given to the reports the police make to Children’s Social Care following their attendance at an incident where a child was involved or present). September 12th 2012 M starts at local school in host borough.  September 2012 Host borough CSC undertakes a CiN Assessment in response to the Police Merlin report.  June 2013 Second Police Merlin report as a result of concerns about B’s care of M by another family member. December 1st 2013 School formally refers the case to the school Education Welfare Officer due to continuing concerns about M’s attendance and punctuality. B is also asked to participate in a Common Assessment Framework (CAF). Please note the CAF has since been replaced by the Early Help Assessment (EHA)  March 17th 2014 Third Police Merlin report in response to a call from B that she was fearful of her partner C.  March 26th 2014 Host borough CSC undertakes a CiN screening process in response to the Police Merlin report.  June 22nd 2014 Fourth police Merlin report in response to neighbour concerns about noise and disturbance at the family home late at night. July 3rd 2014 Fifth police Merlin Report regarding noise and potential use of drugs at the home address.  July 8th 2014 School submits a Multi-Agency Referral Form to local CSC.  July 10th 2014 Following an initial decision that the referral did not meet the threshold for a child protection investigation, the school and the Early Intervention Service (EIS) raise their concerns and the decision is revised. A duty visit to the family home is planned for later in the day but is cancelled when information is received from the Education Welfare officer (EWO) that the family have moved to a different borough. July 10th 2014 Case and referral information are faxed to  the receiving borough’s Social Care team. Due to a Page 14 of 41  wrong digit being inserted into the number the fax is not received and has to be re-sent several days later. July 16th 2014 In response to a request by the host borough EIPS M and B are visited by police at their temporary new address.  July 16th 2014 Case allocated in receiving borough’s CSC to a social work duty team. They contact B by telephone and B confirms that she would be sending M to a local school.  July 22nd 2014 Another parent at the school who had befriended B visited the local school’s head teacher (in host borough) to share her concerns about B’s care of M.  July 23rd  The case is allocated in the receiving borough to an Early Intervention social worker but the family was not seen prior to B’s death. August 6th 2014 The last recorded contact with B was on August 6th when the Children Missing in Education Officer in the receiving borough conducted a home visit.  September 3rd 2014 B assaulted at home address in host borough witnessed by M.  September 5th 2014 B dies of her injuries  3.3 Summary of the case during the review period  M left nursery, where she had missed 50 sessions out of 122 sessions available, in July 2012 and transferred to attached school the following September where she remained during the whole of the review period. Her attendance and punctuality were a concern for the school from the outset.  In August 2012 a Merlin Report was submitted to the local Social Care team from police in the area they were previously resident in following an incident where M had been found by a member of the public wandering alone and poorly clad in the street. This resulted in her being placed in Police Protection. In response to the Merlin report the local Children’s Social Care undertook a Child in Need Assessment as a result of which the case was closed. B was seen in school and the school consulted. It was Page 15 of 41  determined that no further action was necessary and the school were advised to refer the family to a Children’s Centre for support, which she later declined. Subsequent Merlin reports were submitted by both area police services in June 2013 and in March, June and July 2014.   The school made a formal referral to the Education Welfare Service in early December 2013 as a result of continuing concerns about M’s attendance and punctuality. In the same month the school invited B to participate in a Common Assessment Framework process which she declined. The local CSC undertook a CiN screening process in March 2014 following the receipt of a police Merlin report that indicated that domestic violence might be an issue. As a result of this process no further action was taken, B was advised how to seek assistance if she experienced domestic violence and the school was asked to monitor M in school.   The family had 21 recorded contacts with the local Hospital, mainly the A and E department, during the review period. All were for legitimate health reasons.   On July 8th 2014 the school submitted a Multi-agency Referral Form  (MARF) to CSC following increasing concerns about M’s attendance and that she may be at risk. The initial decision by the CSC Assessment Team was that the case did not meet the threshold for a child protection investigation and the case was referred to the Early Intervention and Prevention Service. The Early Intervention and Prevention Service challenged this decision and a duty visit by CSC was planned for the afternoon of July 10th. The EWO advised CSC and the school that she had learnt that the family had moved to an address in a different authority, and, as a result, the planned duty visit was cancelled and the referral details faxed to that Children’s Services the same day. Following this referral no professional or agency in the local area had any direct contact with either M or her mother before B’s death.  Home visits by the police and the receiving area’s Missing in Education Team were undertaken to the new temporary address at the request of the previous EIPS and Missing in Education Team respectively and no concerns were observed about M’s well-being. The visit by the receiving area’s Missing in Education Team on August 6th was the last known professional contact with the family during the review period.  Page 16 of 41   Family history prior to the review period B had been in care herself as a child having been looked after at the age of 15 as a result of concerns about her involvement with drugs and alcohol and that she had been physically and sexually abused. Concerns arose about her parenting of M and her continued abuse of drugs in 2008 and as a result M was placed in the voluntary care of the Council they resided in. Following an initial reluctance to engage with services by B, intensive rehabilitation resulted in her being rehoused in the local area in early 2010 and reunited with M in February of that year with a Child Protection Plan in place. Following DNA tests M’s father was identified but he has had no contact with M or B following her birth. The case was formally transferred in from the previous borough to the new one at a transfer-in conference in July 2010.  At Child Protection Review meetings in August and November 2010, social work, health visitor and nursery reports all indicated that M was doing well and that there were no assessed concerns about B’s parenting. The protective factors supporting this unanimous decision included the nursery placement, the involvement of the health visitor, the fact that B appeared to be in a stable relationship, evidence of B’s improved parenting and her commitment to bringing stability to her and M’s life. Following the closure of the case by the local Children’s Services in November 2010 there was no further contact between the family and children’s services until September 2012. During that period there was episodic contact with the local Accident and Emergency Department and the family GP.  3.5 Appraisal of Professional Practice: a synopsis This section includes the Review Team’s judgements about the timeliness and effectiveness of practice, including where practice was below expected standards. Such judgments are made in the light of what was known and was knowable at the time. The explanation for ‘why’ will be further examined in the findings in Section 4.   Summary It is the view of the Review Team that, given the family history, there should have been much more of an established plan of both support and review following the case being closed in November 2010. In the absence of such a plan, the way that professionals responded subsequently to concerns identified about M’s care did not give adequate significance to the past Page 17 of 41  history and parental vulnerabilities, and as a result the possibility that her mother was neglecting M was not raised or responded to. It can only remain as conjecture in this review as to how far B was or was not coping  – the real lived experience of M remains as unknown now as it was then. Two key opportunities to undertake a home-based family assessment, and pull together all the information about the family (the CIN assessment in Sept 2012, and again in March 2014 when the family should have been referred to the MASH), were missed. The third and final opportunity was created by the school when, in response to a deteriorating situation, it referred the case to the MASH but the process was disrupted by the family having reportedly moved to another borough. With this move the risks associated with the lack of support and review plan locally were compounded by additional risks created by the lack of adequate processes to support the transition period for vulnerable families who move.   In what ways does this case provide a useful window on our systems? In some respects M presented as a child not particularly out of the ordinary. She is described as bright and articulate and, although, she had had a difficult past, how she engaged with adults who knew her reassured them and she was never absent from school for sufficiently long (at least until the spring of 2014) to prompt the school, who knew her best, to share or escalate their concerns about her to Children’s Social Care Services. In this respect what happened to her mother in September 2014 presents professionals with an opportunity to reflect on the professional response, including the application of agreed local thresholds for concern, to a child who may be representative of a significant number of children on the “cusp of neglect “ but who do not “trip over “ into higher levels of concern.  4 Appraisal of practice   While outside our review period, the Review Team are of the view that, given the intensity of support required to rehabilitate M with her mother  (provided by Social Services in the first borough she resided through social work, family outreach, drugs rehabilitation) the case would appear to have been stood down from a CP plan to CiN to case closure very quickly in August to November 2010. No support plans or dates for review were put in place other than continued attendance at the nursery and enhanced health visitor contact. When, subsequently, the then nursery Head spoke to CSC Page 18 of 41  about issues regarding M’s poor attendance at the nursery she was reportedly advised that this was not a safeguarding issue.  When M started at school in September 2012 the nursery records in relation to past safeguarding issues did not come with her along with the education records as they had been shredded by the retiring Head. While the Head of the nursery reportedly advised the Head of the school verbally that M was vulnerable and “to look out for her,” documentary evidence of these concerns was not shared. This is unsatisfactory. The issue of sharing information appropriately is discussed in Finding 1.  The police response to a call from a member of the public, in mid- August 2012, that a child (M) had been found wandering alone in the street dressed only in a vest and “wellies” (M initially told the police she had been “kidnapped” but this did not prove to be the case), was prompt.  While police contacted their local social services Out of Hours team for advice (they advised the police that M was not known to them) good practice dictates that they should also have contacted the Out of Hours Service in the local authority in which the child lived. They submitted a Merlin report to local CSC as required and this resulted in a Children in Need Assessment being undertaken by the local CSC. The training and support provided to police officers when assessing risk in relation to vulnerable children is discussed in Finding 3.  The CiN Assessment carried out in September 2012 by the local CSC applied the family’s past history to the presenting concerns and the documentation supporting the decision to take no further action and close the case is detailed. The school were asked to refer B to a children’s centre (she declined) but the outcome of the assessment was not shared with them (See Finding 1). This was the first time that the school were made aware of M’s history of contact with social services. Mother and daughter were seen in school by the assessing social worker but no visit to the family home was made and B’s partner, C, was not involved. The absence of a home based family assessment was a serious gap in informing a fuller understanding of M and the family’s needs especially as this was the first contact between the family and CSC since the case was closed in November 2010. CSC processes for determining the threshold for cases progressing to child protection assessments and investigations are discussed in Finding 5.  Page 19 of 41   The school were pro-active throughout the review period in supporting M and attempting to involve her mother although B was often hard to contact and reluctant to accept any further offers of help. She occasionally joined in school coffee mornings and was often pre-occupied with the security of her tenancy (a privately rented flat) and money worries but again declined offers of practical help from the school. Following the submission of the MARF in early July 2014, another parent who had befriended B visited the school to share her concerns about how M had been cared for by B. The school shared these concerns with the receiving borough’s Children’s Services. (The parent also said she had spoken to B who had confirmed that she had moved and was no longer with her partner who nevertheless remained at the home address). While the school provided a very supportive and protective environment for M they could have been more challenging of mother’s reluctance to engage in support services.  When the case was closed to CSC in November 2010 the case remained open to the health visiting service at an “enhanced” level. Despite numerous attempts by the health visitor to contact B via phone, letter and unannounced home visits she had no further contact with the family prior to the case records being transferred to the School Nursing Service in January 2013. In the absence of any new indicators of concern about M and B the service was not proactive in contacting her. This is not satisfactory and important information from a service that was viewed as a protective factor in the decision to close the case in CSC in 2010 was not shared with other agencies. From late 2011 to the autumn of 2012 the health visitor was absent sick and during this period it has been reported that the health visitor service came under stress due to a reduction in the number of health visitors available, with 11 health visitors leaving over a six month period. This reportedly resulted in higher caseloads and priority being given to new and high-risk cases only, which meant that even “enhanced” category cases, such as M’s, were not given priority. See Finding 1.   A Merlin report was sent to the host borough in June 2013 as a result of a family dispute over the care of M. There were allegations by a cousin of B that she was too drunk to care for M. Police attended and saw M and B and did not consider M was at any risk. The police response was timely and conducted professionally. The police officers who contributed to this review were all very experienced in the Response Team role but had received little Page 20 of 41  or no multi-disciplinary safeguarding training and relied on their personal experience to assess vulnerability and risk. How police officers are equipped to respond to signs of vulnerability and risk to children is discussed in Finding 3  In December 2013 the school referred M to their EWO due to continued concerns about her attendance. They also invited B to come to school to contribute to the preparing of a Common Assessment Framework but, as with the earlier offer of referral to a Children’s Centre, she did not respond. The challenge of identifying and responding to cumulative indicators of neglect is discussed in Finding 2.  The EWO was proactive in pursuing B about M’s attendance but, like the school and the Health Visitor, she found B elusive and unresponsive. She did manage to gain access to the family home for one 20-minute appointment but, while B was apologetic and promised to improve M’s attendance, other attempts to engage B were unsuccessful. During this home visit she noted that the home was “lived-in” and untidy but she observed nothing that raised any concerns about M’s care. An Attendance Panel (a final stage before court action), convened to discuss M at the end of June 2014 had to be cancelled due to staff illness.   In March 2014 the police responded to a call from B’s mother stating that B was fearful for her safety at the hands of her partner. B was fearful of C’s response to her disclosure of his uncertain immigration status and the police officer assessed B against the MARAC standards. The outcome was that she did not meet the threshold for a MARAC referral. As good practice dictates B was interviewed by a female officer separately from her partner. While not meeting the threshold, and denying she had been a victim of domestic violence, B did answer positively to feeling threatened and fearful for her safety. A Merlin report was submitted to CSC as required.   The Referral and Assessment Team in CSC undertook a CiN screening process and spoke to B over the phone The case was assessed as requiring no further action with the school being asked to monitor M. B was also advised of the support available should she fear for her safety. There was sufficient presenting evidence at this point for the case to be referred to the MASH for a full assessment of the family to be carried out which would have included a visit to the family home and all members involved Page 21 of 41  and a pulling together of information about the family from the agencies known to them. The reasons for this relate to Findings 1 and 5.  When their historic concerns about punctuality and attendance were compounded by rapidly deteriorating attendance in the spring and early summer of 2014, and M started to disappear from the view of the school for up to 2 weeks and longer, they escalated their concerns appropriately by submitting a Multi-Agency Referral Form to CSC on July 8th 2014. The final prompt was information from the EWO who was told by a neighbour of the family, while the EWO attempted to visit the family home, that B was regularly heard shouting at M late at night and in the mornings and that M had been known to ask neighbours for food as she was hungry. M was reportedly kept at home by B; she did not take her to the doctor when unwell and was not allowed to attend friend’s parties.  The school referral contained both their current and past concerns since M had arrived at the school in September 2012. Initially the case was assessed by CSC as not meeting the threshold for a child protection investigation and referred to the Early Intervention and Prevention Service (EIPS). However, triangular discussions between the CSC Referral and Assessment Team, the school and EIPS (who sent the case back to CSC as in their view it did meet the threshold) over the following 36 hours saw this decision reversed. While this reflects positive inter-agency challenge, it also raises questions about the consistent application of the threshold in the Referral and Assessment Team at this time. By the time the decision to visit the family home was made on July 10th 2014 information had been received from the EWO that the family had moved address and another opportunity for M to be assessed in the family home was missed. See Finding 5.  During the review period there were 21 contacts between the family and local hospital mainly with the Accident and Emergency Department. Only two related to M and all were for legitimate and appropriate health reasons. The family GP practice was notified on each occasion but there was nothing exceptional or untoward about the number or nature of these contacts that prompted any broader concerns about M or the family. M received all the required immunisations for a child her age.  Each Police Merlin report was screened and noted by the Detective Sergeant embedded in the MASH with the final one (on July 3rd 2014) Page 22 of 41  prompting her to note the case as  “one to watch”. However, it was not referred to CSC and assessed with a Blue rating (no further action required). Neither the police nor CSC considered the reasons for, or number of Merlins in this period exceptional. There are no automatic numeric triggers for escalating Merlin reports and the decision to do so relies on professional judgement supported by the Blue Red and Green rating system (BRAG) rating system. Screening processes in the MASH are discussed in Finding 5  By the time the MARF was submitted by the school on July 8th 2014 CSC had not seen M in person for nearly 2 years, only once in nearly four years and never at home. Intelligence from the EWO that the family had moved to another borough pre-empted a decision to conduct a CSC duty visit to the family home on the afternoon of July 10th 2014 and resulted in the referral information being faxed to that authority that afternoon.  On July 15th 2014 it was discovered, by the EIPS, that the fax had not been received by them due to an incorrect digit in the number being used. The fax had to be resent a week after but was not followed up by CSC directly. Issues concerning vulnerable families who relocate across local authority boundaries are discussed in Finding 4.  One of the questions the Review Team sought to answer at the outset of this review was whether there was an absence of ‘professional curiosity’ amongst professionals. While a determination not to lose M from their sight drove the school, the EWO and the EIPS to maintain contact with services in the new area where the family had reportedly moved, no individual agency took a professional “grip” on the progress of the case over the summer period to ensure that M was not lost from view in the transition to a new location. Similarly unclear are the circumstances surrounding the apparent ending of her relationship with her established partner C which she reported to a neighbour in mid-July. How the family ended up back at the family home in the host area is unknown. This is discussed further in Finding 4.        Page 23 of 41  5 The Findings  The Review Team has prioritised five findings for the LSCB to consider:   Finding 1 There is a lack of consistency among different agencies in the host area in using the processes that exist to share information with each other about vulnerable children, including past history and particularly when CSC is not involved, which increases the chances of no one agency having an overview of a child’s needs. (Communication and collaboration in relation to longer-term work).   Finding 2 In the local area the assessment frameworks that are in place to help professionals in universal services identify risk are not being consistently applied so as to help them to aggregate repeat low-level presentations of neglect. This increases the chances that where a child is being neglected the response is insufficient to meet their needs. (Tools).   Finding 3 In the police service the priority given to domestic abuse and mental health is not matched in relation to vulnerable children, such that the processes are less defined and there is little training. This leaves individual police officers in local Response Teams in the local area over-reliant on their own experience and judgement when assessing risk, to identify and respond most effectively to vulnerable children. (Management Systems).  Finding 4 There is a pattern whereby children who move with their families out of the borough and about whom there are known historic and/or current child protection concerns, are not being “tracked” across local authority boundaries so that these concerns are “followed through” such as they would be if subject to a current Child Protection Plan. (Management Systems).  Finding 5 The criteria for cases to be screened or MASH checks to be undertaken were not clear and the difference between screening and MASH activity was not understood. (Tools)  Page 24 of 41  4.1 Finding 1  (Communication and collaboration in relation to longer term work) There is a lack of consistency among  local agencies in using the processes that exist for sharing information about vulnerable children, including information about past history and particularly when CSC is not involved, which increases the chances of no single agency having an overview of a child’s needs.  Introduction  National, Pan-London and local guidance sets out the duties and guidance for keeping adequate records and for sharing information where there are child protection concerns. Locally the LSCB has published the 7 “Golden Rules of Information Sharing” and Team Around the Family, professionals meetings and the Common Assessment Framework are all mechanisms which professionals can use to share information outside formal child protection processes.  How did the issue feature in this particular case? A key factor in how concerns about M were responded to by agencies that came into contact with her was how far they assessed presenting concerns in the context of past history and how this history was shared and used to inform current decision-making. B had been a looked after child (aged 15) and M herself had been looked after and subject to a Child Protection Plan between 2008 and 2010. B’s misuse of drugs and alcohol and her suffering physical and sexual abuse (and her possible sexual exploitation) as a young person and as a young parent were the main presenting features of these care and child protection episodes. Past history of being looked after as a child is a key indicator of potential neglectful parenting (Missed Opportunities: Indicators of neglect, Brandon et al, November 2014). What professionals knew about the past, how they applied this knowledge to  emerging concerns in the present and how past and present information was or was not aggregated to gain a fuller understanding of M and her family’s needs is central to understanding how agencies responded during the review period.  The school did not have access to past history from the nursery and the health visiting service and only partially, as result of the CIN Assessment in September 2012, from CSC. For reasons unknown, documentary evidence of the nursery schools involvement with the family, including their attendance at the child protection conferences and review meetings in Page 25 of 41  2010, was shredded in the summer of 2011. Health visitor records were not passed to the school nursing service until January 2013 and even then did not find their way to the school.   While the social worker who undertook the CiN Assessment in September 2012 sketched out the family past for the school they did not share a level of information which could have assisted the school in their continuing assessment of M. Not having access to information about past concerns about M meant that they had no context for interpreting some features of M’s presentation in school.  What makes it an underlying issue not a quirk of the case? Information about M was held across a range of agencies – health visiting, hospital and GP, the police, the nursery, school, the EWS and CSC. The systems in place including Team Around the Family, Common Assessment Framework and professionals meetings, were not applied to facilitate appropriate information sharing to support safe decision-making and to assist individual practitioners and services to make informed decisions and when to escalate their concerns.  The nursery, the school, the EWO and the health visitor all had difficulties in contacting B during the review period. None of these services felt that this was wilful avoidance on B’s part but it is of note that the involvement of the EWS was met initially with anger by B who thought she was from social services. It is possible that, given her past involvement with social services she had a desire to keep them at arms’ length. B was reluctant to engage with support services such as those provided through a Children’s Centre and the CAF. The outcome was that B’s elusiveness with a number of agencies was never aggregated to inform a more comprehensive assessment of her willingness to engage with services.   What do you know about how widespread or prevalent it is? The issue presented itself across a range of professionals and agencies and there was a consensus among the Case Group and Review Team that there is often a lack of clarity amongst front-line practitioners about when to share information and the appropriate mechanisms for doing so.  What are the implications for the reliability of the system? Many aspects of safeguarding processes and practices are designed explicitly to support the sharing of information across agencies and Page 26 of 41  professions, in order that the significance of what is known individually about a family can be ascertained. So if these systems are compromised in any way, such as indicated by this finding, this introduces significant risk into how reliably the safeguarding of children can be conducted. If agencies and professionals do not have access to relevant information their ability to make safe decisions is undermined and leads to episodic rather than coordinated and planned responses.   Mechanisms are in place locally to facilitate effective decision making but uncertainty amongst practitioners about the boundaries between confidentiality/data protection and when to share concerns about children with other agencies, particularly where parental consent is not given, can lead to uncertainty about whether the threshold for escalating concerns is met. Whilst seeking parental consent to share information and engaging them in services plays an important part in partnership working, being clear about when and how to share concerns is paramount.   Questions for the LSCB  How confident are you that professionals working within your respective agencies understand the importance of sharing information with those who are working with children in accordance with the LSCB’S 7 Golden Rules for Information Sharing?  How confident are you that professionals understand the circumstances where they should share information without parental consent and escalate appropriately their concerns?  How can professionals be better supported to exercise appropriate professional challenge to parents who are reluctant or ambivalent about engagement with services?   4.2 Finding 2  (Tools) Locally, the assessment frameworks that are in place to help professionals in universal services identify risk are not being applied so as to help them to aggregate repeat low-level presentations of neglect. This increases the chances that where a child is being neglected the response is insufficient to meet their needs (Tools).    Page 27 of 41  Introduction LSCB’s in all local authorities have a duty to ensure that all member agencies have policies and procedures in place to support timely, effective and safe decision-making. Their consistent application across agencies is supported by multi-disciplinary training programmes and the setting of agreed thresholds to assist professionals in assessing vulnerability and risk.   How did the issue feature in this particular case? The Review Team considers that it is highly likely that M experienced neglect during the review period. However, the absence of a comprehensive, home-based assessment of the family at any point during the review period, despite opportunities to undertake one, and responses to presenting needs which were episodic rather than sustained, means that the levels of neglect and vulnerability experienced by M cannot be known for certain.   The school had significantly more contact with M and B during the review period than any other agency. Throughout her time at the school M’s attendance was a cause for concern consistently averaging around 88-89% until it deteriorated significantly in the spring and early summer of 2014.They noted and monitored, often on a daily basis,  what one Case Group member called “bubbling”, indicators of neglect, namely attendance/punctuality at school, being inappropriately dressed for the weather at school or being hungry on arrival at school. On occasion, too, she used language inappropriately asking one teacher if she “fancied” another. Perhaps most significantly, in April 2013, she asked a teaching assistant to take her home with her, as her mother did not care for her properly. This echoed an earlier comment to her teacher on a home visit prior to her starting school in July 2012 when she asked the teacher if she would be her child-minder having only just met her.  Until the early summer of 2014, when M’s attendance went in to rapid decline the schools concerns did not reach a level whereby they felt it necessary to escalate their concerns other than to the EWS in relation to M’s poor attendance December 2013.    Throughout the review period M presented indicators of potential neglect to the school, EWS, health visitor and the police. Not until July 2014 when M’s attendance at school declined rapidly was it escalated to CSC. On two Page 28 of 41  occasions CSC advised first the nursery (outside the review period) and the school (in March 2014) that poor attendance was not a safeguarding issue.  Indicators of neglect which were observed or noted by the school, the EWS, the police and health visiting service included:  Poor school attendance and punctuality  Unkempt appearance and inappropriate clothing at school and in the community  Complaining of being hungry in school and in her local neighbourhood  Use of age inappropriate language   Attention seeking behaviour with school staff  Being brought to school by a variety of adults including friends and family members  Parents hard to contact by a number of agencies  Worries about the family being evicted and related financial problems  Chaotic lifestyle at home  Evidence of actual or threats of violence between adults at the family home  Evidence of the abuse of drugs and alcohol at the family home  Reluctance or ambivalence by parent about engaging with services What makes it an underlying issue not a quirk of the case? A number of agencies who came in to contact with M and her family observed and noted behaviour or presentations which were symptomatic of child neglect indicating that this issue is generalised across agencies. While a lack of information about the family did not make it easy for some professionals to be confident that what they observed constituted neglect insufficient professional curiosity prevented them for seeking further information. Any agency can commence a CAF. In this case B was given the opportunity to participate in the CAF process but she did not respond. The absence of any initiation of the CAF or Team Around the Family processes excluded another opportunity for an appropriate sharing of information about the family.  What do you know about how widespread or prevalent it is? Page 29 of 41  Potential indicators of neglect were observed and noted across a range of agencies indicating that a consistent understanding and application of the thresholds are not yet fully embedded across the professional network.   What are the implications for the reliability of systems? Where significant numbers of children display one or a few signs of neglect in a school or a community there is a danger that professionals can be become desensitized to needs. Where this happens tolerance thresholds can be raised with the result that vulnerable children do not access the support they need. Capturing the “absence” of something e.g. good parenting providing adequate physical and emotional care is complex. The tools and training available to support professionals in this task need to be sensitive to both obvious signs of neglect and harm and the more, cumulative effect of lower indicators of neglect (Brandon et al, November 2014).  Questions for the LSCB:  How confident are you that the agreed thresholds in use across all services are embedded in practice and service delivery and being applied consistently?  Are they sufficiently sensitive to identify indicators of cumulative neglect?  Are professionals in your services sufficiently curious about children displaying indicators of neglect and confident enough to share concerns with other professionals who may know more about them?  Are professionals confident about the use of the Team Around the Family approach and the Early Help offer?  Do professionals attach sufficient importance to school non-attendance and lateness as potential indicators of neglect?  4.3 Finding 3 (Management Systems) In the police service the priority given to domestic abuse and mental health is not matched in relation to vulnerable children, such that the processes are less defined and there is little training. This leaves police officers in local Response Teams over-relying on their own experience and Page 30 of 41  judgement when assessing risk, to identify and respond most effectively to vulnerable children.  Introduction Police officers in local Response Teams are called upon to respond to a wide variety of circumstances at short notice. These range from the commission of serious crimes to responding to the immediate needs of vulnerable people both children and adults. Their training is generic with some specialist provision. Following the completion of all visits to a premises where a child has been present, police officers are required to submit a report to the local Children’s Social Care Service noting what has occurred and if there are any concerns for a child’s welfare. These are known as Merlin reports. In compiling Merlin reports police apply Every Child Matters criteria and on one occasion during this review  applied the ABCDE (Appearance, Behaviour, Danger, Capacity/ Communication, Environment) tool originally developed for assessing the needs of vulnerable adults.  How did the issue feature in this particular case? Three officers from different response teams in two local authorities described very similar experiences. The police had more direct contacts with the family during this period than CSC. Between September 2012 and July 2014 CSC received four Merlin reports from local police, three of these in 2014. These concerned complaints from neighbours about noise from the family flat, loud arguments and concerns about these escalating into violence amongst adults. In May 2013 M had been taken by mother’s cousin due to B allegedly being drunk. When police called B was sober and no welfare concerns were reported regarding M or in relation to drugs or alcohol. The flat was “cluttered but contained all the essentials” for M.  On each occasion police officers ensured that they saw M and assessed whether she was at any risk. On at least one occasion the officer applied the ABCDE assessment framework, which had recently been introduced locally and this was quality assured by the Detective Sergeant (DS) in the MASH.   The three officers across the two boroughs who contributed to this review had over 20 years of combined service in Response Teams. They all had received little by way of multi-disciplinary safeguarding training and compared their ability and confidence in responding to potentially vulnerable children unfavourably with training and frameworks for Page 31 of 41  responding to domestic violence and adult metal health. This led to them relying on personal instincts and experience to assess whether a child may be at risk. None of the officers knew in advance that they were attending the home of a child who had been looked after and had been subject to a child protection plan in the past.   What makes it an underlying issue not a quirk of the case? Police officers contrasted training to assess child vulnerability and risk with the training and procedures which had been introduced to support them in situations where domestic violence or adult mental health were an issue.  What do you know about how widespread or prevalent it is? From what was described by the officers and the Metropolitan Police Service (MPS) representative on the Review Team their experience is representative of the experience of officers across the MPS. The host area has introduced the Metropolitan Police wide ABCDE assessment framework for use by officers, and this process is Quality Assured within the MASH, but there is evidence that its application remains patchy and not always used while officers are carrying out their duties but is used rather to inform the Merlin reports they submit afterwards.  What are the implications for the reliability of the systems?  Police officers operate on the front line of protecting the public, particularly potential vulnerable members of it, from harm. If they are insufficiently trained or informed about a child being neglected or what risk looks like then a key protective agency’s ability to protect children from harm is compromised. Police officers in Response Teams are non-specialists and apply generic skills to respond to a wide range of incidents including adult mental health concerns and domestic abuse. Therefore, ensuring they can be provided balance of knowledge and skills when confronting the wide range of situations they face on a daily basis is a challenge for the LSCB and the police.  Questions for the LSCB:  Are front line police officers perceived by the professional network as key partners in identifying vulnerable children and responding to their needs?  How can they be better supported to carry out their duties Page 32 of 41  with regard to the protection of children?   Are the roles and responsibilities of Police Response Teams properly understood across the professional network?  Does the LSCB think that the balance of skills and knowledge among front line police officers needs to be re-assessed?  4.4.Finding 4 (Management systems) There is a pattern whereby children who move with their families out of the borough and about whom there are known historic and/or current child protection concerns, are not being “tracked”across local authority boundaries so that these concerns are not “followed through” such as they would be in respect of a child subject to a current Child Protection Plan.   Introduction Pan London Safeguarding procedures set out the general arrangements governing the movement of vulnerable families and children across borough boundaries for child protection cases. They place a specific duty on local authorities to cooperate when families relocate so that services are responsive and consistent. Responsibility rests with the originating authority, where a child has been residing and in receipt of services, to share information within five days working days. However, there are no agreed pan London or national procedures governing the transfer of Children in Need or Early Help cases.  How did the issue feature in this particular case? Following the case being referred to new local authority’s Children’s Services on July 10th 2014 the school, the EWO and the EIPS used their own initiative to follow up with services in the receiving area whether M and B were together and well and that B was following the required processes for securing M a local school place in September. Reassurances came both from the police and Missing from Education services there who both visited the family at their temporary address and saw nothing of concern regarding M’s welfare or living conditions. B told both the receiving borough’s CSC and the Missing from Education worker that M was fine with her and she was her priority. It was also confirmed by the receiving borough’s CSC, to the school, that the case had been allocated to a family support team and an Early Intervention Social Worker appointed.   Page 33 of 41  Over the next few weeks it was left to the school, the EWO, the EIPS and the Missing from Education service to follow up with services in the receiving borough whether M and B were together and well and that B was following the required processes for securing M a local school place in September.   What is absent is evidence of follow up by the host borough’s CSC who referred the case to the receiving one. There is a strong case that, notwithstanding the family’s apparent move (B had not given up her local address), a formal assessment of M’s needs should have been initiated and seen through wherever she was living temporarily, particularly as M had historically been a looked after child and subject to Child Protection Plan in the host local authority.  Following the faxing of the referral information to the receiving borough’s CSC by CSC in the host borough on July 10th 2014 no member of staff from the latter followed it up. Indeed had it not been for the persistence of the EIPS then they would not have been aware that the fax had not arrived. Making an error on a fax number sometimes happens and is not the issue here. What is the issue is the absence of any follow up of the referral. There is no evidence that a supported and coordinated transfer of the case to the receiving area was considered.  Despite the “desk-top” actions of the school, EWS and the EIPS to track M through the school holidays she is essentially lost from the view of professional agencies in the last month of her mother’s life. The perpetrator of the attack on B was not on the radar of any of the agencies involved with the family and it is not known how or when he came into her life.   What makes it an underlying issue not a quirk of the case? The EWS, EIPS and CSC all told the review that tracking mobile and transient families across borough boundaries is a continuing challenge, as is obtaining information from authorities from or to where families have moved.  What do you know about how widespread or prevalent it is? The responsibility of agencies making referrals does not end with the transfer of information but continues to the point where they are certain of the action being taken by the receiving agency or authority. This is even more relevant where a child or family move across local authority Page 34 of 41  boundaries and all members of the Review Team and Case Group spoke of continued problems in this regard.  All agencies that contributed to this review reported continuing challenges in keeping track of children and families across local authority boundaries. This included the host authority not being persistent in following through on cases and difficulty in obtaining information from areas to which they had moved. This is an issue for all authorities particularly in London where transience is more common.  In recognition that the systems in place for tracking children were in need of strengthening, processes have been tightened subsequently by, for example, introducing secure emails for sharing information and instituting a mandatory 24 hour follow up to notifications to other local authorities.  What are the implications for the reliability of the systems?  When families with a past history of concern, in this instance a child who had been looked after and subject to a Child Protection Plan and subject to a ”live” referral to the MASH, suddenly move without alerting any of the agencies known to them then this is reason for a heightened sense of concern. It is during such periods that families disappear from view and children may become more vulnerable. Vulnerability is heightened at the boundary between areas and services. This has long been recognised and is reflected in Pan London Procedures but particularly in London the design of services does not reflect the lives of many families who move. Moreover, while families with a troubled history should be given the opportunity to “move on” they should also have access to the appropriate support to enable them to do so on a sustained basis. In the host authority arrangements to maintain oversight of the safety of a child about whom there are current concerns do not match arrangements for children who have a current Child Protection Plan. This increases the chances that a child can be lost from view.  Questions for the LSCB:  Are there systems in place to track the movement of vulnerable families and children across borough and local authority boundaries? Are they being implemented?  How confident are you that families who move are followed through by the “home” agency to ensure that their needs Page 35 of 41  are picked up by the receiving authority?  Whose responsibility is it to track families across local authority boundaries? Is there clarity and agreement on this across agencies?  4.5. Finding 5 (Tools) Locally the criteria for cases to be screened or MASH checks to be undertaken are not clear and the difference between screening and MASH activity is not understood leading to inconsistent responses to potentially vulnerable children (Tools).   Introduction Social workers and other professionals working within assessment teams and Multi Agency Safeguarding Hubs apply agreed policies, procedures and thresholds when assessing the most appropriate response to referrals from a wide range of agencies. These include an initial “screening process” where information is collated from across agencies to inform decisions about risk and a BRAG risk assessment used by police embedded in the MASH to assess risk associated with police Merlin reports.  How did the issue feature in this particular case? Pan London Safeguarding guidance is clear that when a child is received into Police Protection then a Section 47 investigation and/or a Core Assessment should be undertaken. The Review Team consider that the nature of M and B’s past history combined with the presenting facts of the case should have prompted a Section 47 Child Protection response in September 2012 which would have included a home based assessment of the family.  The police Merlin report in March 2014 prompted CSC to carry out a CiN “screening” process but it was not cross referenced with information from other data sets to provide a comprehensive assessment of the child’s needs e.g. RiO health records via the health professional embedded in the MASH, which would have included information about the health visitors problems contacting B, nor referred to the MASH. During the screening process B was spoken to over the phone by the social worker carrying out the screening and received verbal assurances from B that she was not experiencing domestic violence. B was given advice about how to get help with this should she need it. Information provided from the school focused Page 36 of 41  on attendance problems and these were noted as “not safeguarding concerns” .The London Continuum for assessing risk was applied and the case was assessed at Level 2. As a result no further action was decided upon. The school were asked to monitor M and to contact CSC if they had any concerns.  Again, an opportunity to visit the family home was not taken which meant that throughout the review period only the EWO (once) and the police (on four occasions) had access to the family home. The absence of any meaningful home-based family assessment during the review period meant that only a partial assessment of M’s needs was carried out. For CSC the needs of M were filtered through the school and no assessment of B’s partner was made.   In March and July 2014 the case was not considered to have met the threshold for the MASH. In the first instance a decision to take no further action was taken and in the second it was decided initially to refer the case to EIPS. The screening process for Merlins in the MASH did not result in the escalation of the case in early July 2014. Despite three opportunities to do so, therefore, the host borough’s CSC did not undertake any home visits during the review period and did not carry out a comprehensive assessment of M and the family’s needs at any point. No assessment was undertaken of C and his relationship with M which would have given a more rounded picture of the quality of care she was receiving. The possible misuse of drugs and alcohol, which formed part of historic concerns about B’s parenting, was a feature of at least two of the Merlin reports but no updated assessment of these was made.  What makes it an underlying issue not a quirk of the case? The case was considered not to have met the threshold for a child protection response or referral on three occasions during the review period. Elements of subjectivity in the BRAG rating process and a lack of clarity amongst professionals in the Assessment Team would indicate that children who do not present as being at immediate risk may not get the response their needs warrants.  While the BRAG rating process is designed to support evidence based decision making in relation to the assessment of risk, there is no specific guidance setting out the referral threshold which assists decision makers in Page 37 of 41  relation to whether to refer or not. This leads to an element of subjectivity on the part of officers making the decision.  The Review Team heard that neither of the Merlin reports submitted in June and early July 2014, if they had been escalated, would have been accepted for further action by CSC. A further context is that the DS embedded in the MASH routinely processes up to 100 Merlin reports a day and sometimes more and these reports did not stand out as requiring further action. When placed in the context of the family’s history, however, there is evidence that the case should have been referred to the MASH in early July 2014. What do you know about how widespread or prevalent it is? If there is a lack of clarity and consistency in the assessment process for determining risk then vulnerable children will remain at risk. There was consensus in the case group and review team that M’s presentation of repeated, low level indicators of neglect as presented in this case (see Finding 2) is typical of many child presentations across the borough and that current guidance and thresholds struggle to pick up these indicators and aggregate them to an appropriate level of concern.  On taking up his post in early 2015 the current CSC Team Manager within the MASH told the review that he was “shocked at first” at the lack of guidance and processes governing initial screening and decisions regarding assessment. He found that there was no clear and consistent rationale for decisions about which cases should be screened or referred for assessment. A new practice guide issued at the end of 2015 has strengthened guidance and resulted in a general “tightening up” in process and decision-making in relation to responses to initial referrals, screening and assessment.  What are the implications for the reliability of the systems?  Inconsistencies in, or the misapplication of, the threshold for a child protection investigation and a failure to track patterns of cumulative neglect can lead to risk not being properly assessed and to vulnerable children not receiving the support they need. A Child Protection system designed to respond to incidents is not so adept at capturing the “drip, drip” of cumulative neglect especially in the context of high demand.   Questions for the LSCB:  Are you confident that the initial screening /assessment of Page 38 of 41  referrals into the MASH and the application of agreed thresholds are robust and consistent?  Are the systems to support decision- making sufficiently embedded to withstand changes of personnel?  Is the risk assessment framework used by CSC sufficiently fine-tuned to capture cumulative examples of neglect?     Appendix 1 Summary of the Learning Together to Safeguard Children Model Key points The ‘systems’ model helps identify which factors in the work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. The model has been adapted from the systems approach used in other high-risk areas of work, including aviation and health. Overall, it:  Provides a way of thinking about front-line practice and a method for conducting case reviews  Produces organisational learning that is vital to improving the quality of work with families and the ability of services to keep children safe  Supports an analysis that goes beyond identifying what happened to explain why it did so, recognising that actions or decisions will usually have seemed sensible at the time they were taken  Involves moving beyond the basic facts of a case and appreciating the views of people from different agencies and professions  Is a collaborative model for case reviews – those directly involved in the case are centrally and actively involved in the analysis and development of recommendations.  Introduction Page 39 of 41  This “At a glance” summary presents a new ‘systems’ model for Serious Case Reviews (and Case Management Reviews in Northern Ireland). The model provides a method for getting to the bottom of professional practice and exploring why actions or decisions that later turned out to be mistaken, or to have led to an unwanted outcome, seemed to those involved, to be the sensible thing to do at the time. The answers can generate new ideas about how to improve practice and so help keep children safe. Context When news breaks of a child’s death from abuse, the public’s response is often one of incredulity. In the case of Baby P, people were baffled that, despite 60 contacts with professionals in the eight months before his death, no one realised the extent of the abuse he was enduring. In Britain, there is a long history of case reviews into child deaths, aimed at finding out how the tragedy occurred and learning lessons for the future. These case reviews, however, tend not to dispel the public’s bafflement. After conducting an extensive inquiry into the care provided to Victoria Climbié, Lord Laming concluded that he ‘remained amazed that nobody in any of the key agencies had the presence of mind to follow what are relatively straightforward procedures on how to respond to a child about whom there are concerns about deliberate harm’. When case reviews leave such amazement at poor practice unexplained, the amazement quickly turns to anger and condemnation of those involved. It is hard to believe that a motivated, well-meaning, competent worker could act this way, so the tendency is to conclude that it must be the result of stupidity, malice, laziness or incompetence. This is bad for public confidence and also for staff morale.  The systems approach to case reviews is explicitly designed to address these ‘why’ questions. Essence of the systems approach The systems approach originates in the aviation industry. This is perhaps not surprising since when a pilot makes an incomprehensible error, such as crashing into a mountain, the pilot dies along with his passengers and crew. Therefore it seems implausible to put the error down to laziness or stupidity. Page 40 of 41  Hindsight bias leads us to grossly overestimate how obvious the correct action or decision would have looked at the time and how easy it would have been for the worker to do the right thing. The central idea of the systems approach is that any worker’s performance is a result of both their own skill and knowledge and the organisational setting in which they are working. In the aviation model, if a cockpit is designed in such a way that it is easy for a pilot to confuse two instruments, more errors will occur than if the instruments can be easily told apart. Improving safety therefore means clarifying which aspects of the work context make errors more likely to happen, and which support workers to accomplish their tasks successfully. This clarification triggers ideas for re-designing the system at all levels to better support people to carry out their work to the highest standards. The aim is to ‘make it harder for people to do something wrong and easier for them to do it right’. To err is human: building a safer health system, Institute of Medicine (1999) In order to learn the right lessons to improve practice we need first to ask: how did the situation look to the practitioner so that the action chosen seemed like the right thing to do at the time? Common misunderstandings This is not a ‘no blame’ approach The slogan of ‘moving beyond a culture of blame’ … is a call to abandon poor systems of accountability and … not a tolerance for an absence of accountability. From: Conflicts between learning and accountability in patient safety, Woods, D.D. (2004), Online The objective is to develop ‘an open and fair culture’ which ‘requires a much more thoughtful and supportive response to error and harm when they do occur.’     Page 41 of 41    Appendix 2  Glossary  SCIE Social Care Institute of Excellence LTSC Learning Together to Safeguard Children LSCB Local Safeguarding Children’s Board CCG Clinical Commissioning Group MPS Metropolitan Police Service VCS Voluntary and Community Sector MASH Multi Agency Safeguarding Hub EWO/S Education Welfare Officer/Service MARF Multi Agency Referral Form CiN Children in Need CP Child Protection CSC Children’s Social Care CAF Common Assessment Framework Please note that in the host authority has since been replaced by the Early Help Assessment (EHA) EIPS Early Intervention and Prevention Service EH Early Help BRAG  Blue Red and Green rating system NELFT North East London Foundation Trust       