Serious injuries of C6, a baby girl aged 7 weeks, admitted to hospital with a serious head injury on 8th May 2011 and C5, her twin brother, who was subsequently found to have a healing fracture to the left clavicle. Issues include: the mother's 2005 conviction for the wilful neglect and grievous bodily harm of her eldest son; the removal of 4 older children from the mother's care; the mother's mental health difficulties; and domestic abuse at the hands of her partners. Makes single and multi-agency recommendations, including: development of a standard dataset to ensure that relevant and sufficient information is provided by GPs when booking pregnant women with a midwife; training in the use of body maps and development of a protocol for their use across the NHS trust; the need for prompt collation and assessment of evidence so that decisive action to protect children can be taken as early as possible; and child protection plan visits should focus as much on practical parenting assistance as on monitoring.
      
Title: Serious case review Family T/S: overview report. LSCB: Lincolnshire Safeguarding Children Board Author: David Ashcroft Date of publication: [2013] 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.       SERIOUS CASE REVIEW FAMILY T/S  OVERVIEW REPORT       Report by David Ashcroft, Independent Overview Report Author   FINAL REPORT APPROVED BY LSCB SENIOR MANAGEMENT GROUP    12  OCTOBER 2012  This report is embargoed until 10am on Friday 21st June 2013     Version 06/13  1  Introduction 1. This is the Overview Report for the Serious Case Review commissioned by Lincolnshire Safeguarding Children Board into the case of C6 and C5.  2. C6 was admitted to hospital on 8th May 2011 with life-threatening head injuries. Her twin brother, C5, was subsequently found to have a healing fracture to the left clavicle. The babies were 7 weeks old and both were the subjects of Child Protection Plans as a result of decisions at an Initial Child Protection Conference held, pre-birth, on 25th February 2011.    3. Their mother, A1, has previously had four children removed from her care and received a two year custodial sentence in 2005 for wilful neglect and Grievous Bodily Harm to her eldest son, C1.  The twins’ father, A2, is a care leaver from Leicestershire.  4. At a meeting of the Lincolnshire Safeguarding Children Board’s (LSCB) Serious Case Review Sub-Group, on the 23rd May 2011, the panel agreed unanimously that this case meets the criteria to undertake a Serious Case Review (SCR). The Independent Chair of the LSCB, Chris Cook, also confirmed his decision, on the same day, that this case will be the subject of a Serious Case Review.  Background and timetable  5. The case was initially considered as a pilot for a systems analysis approach and work was commissioned to undertake an overview analysis and report on that basis.  Agency IMRs were initially completed for August 2011 to contribute to this process.  When it was not possible to continue with this approach a new Overview Author was commissioned in February 2012 to undertake the work of evaluating and collating the learning from the SCR.     6. A briefing meeting of the SCR Panel was held on 9th February when the key themes and potential learning from the case were considered.  It became clear, partly as a result of the review of themes and key lines of enquiry at this point by the Overview Author and the SCR Panel, that a more substantial Internal Management Review was required of the social care involvement in the case, and that there remained significant quality assurance issues to be resolved for several IMRs before these could be signed off by each agency.  It was also clear that other agency IMRs would need to be reviewed against the narrative and analysis of the social care involvement with the family once this had been completed.  The recently appointed Director of Children’s Services in Lincolnshire considered that a revised IMR for Children’s Social Care (CSC) was required, with fresh and independent interviews of the staff involved, particularly to examine the management of the case.   The initial analysis of social care involvement was presented to an SCR Panel held on 25 May 2012 and the recommissioned IMR was submitted on 12 July 2012.  The final approved IMR from Leicestershire, concerning Version 06/13  2  their involvement with the family through their leaving care responsibilities for A2, was submitted on 26 July 2012.  7. As the content of both these IMRs was central to the issues identified for consideration in the SCR, this has meant that work on the Overview Report has been dependent on the availability of these final versions. Although this process has delayed the completion of the SCR, it was felt that the learning from this case, which appeared to raise some fundamental questions of capability, professional challenge, missed opportunities and failures or gaps in process, was of sufficient importance that it was appropriate to ensure that a thorough and comprehensive review was undertaken.    8. Agencies have already considered some of the action points established from their IMRs and taken appropriate and prompt management action to address obvious shortfalls in process and operational capacity. This is positive and appropriate to ensure that learning and improvement does not wait on the completion of the formal serious care review process.  Actions already taken include  • an audit in Children’s Social Care to examine the recording and risk analysis at Strategy Meetings and a resulting action plan;  • the establishment of an annual CSC programme of Action Learning Sets for supervisors and chairs of Child Protection Conference, to develop skills to probe, evaluate and seek evidence to challenge biased thinking and ‘over optimism’ • a review of FAST teams by CSC (December 2011 to February 2012) to look at practice and decision making lessons illustrated by this case;  • changes to CSC guidance to clarify the aims set for Child Protection Plans; • an audit by the LSCB of Child Protection Plans which has led to the review of interagency training and the continued audit of CP Plans; • a requirement for the Resource Panel of senior managers in CSC which reviews high risk and complex cases, to consider all cases involving parent(s) with previous involvement in proceedings or with a conviction for harm of a child;   • where a person is investigated for possible offences against children a requirement for police to liaise with the investigating officer(s) or at least consult the crime files, for any previous investigation.  9. There has also been learning from the Unannounced Inspection of Contact, Referral and Assessment arrangements conducted by Ofsted in February 2011, which found areas of strength and no priority actions requiring urgent attention, but which did identify the need to strengthen arrangements for multi-agency Strategy discussions in child protection cases.   10. It was recognised by the SCR Panel that one of the issues raised through this SCR is the process of debriefing and support provided for staff when a serious injury or death of a child occurs.  As this is a more general issue that does not arise directly from the circumstances of the children in this case, but arises after the event, it has been agreed to review this separately from the SCR process. Version 06/13  3   11. Since the SCR was recommissioned the Panel has met on  • 9th February – to review key themes and lines of enquiry, and to consider what outstanding work was required through IMRs • 25th May – to review the evidence and emerging conclusions from the Social Care IMR, and also the background information about A2 contained in the Leicestershire IMR • 6th August – to review the completed IMRs, draft recommendations and to consider the main analysis, evaluation and conclusions of the draft Overview Report  • 17th September – to review the Overview Report prior to approval by the LSCB and to confirm the recommendations and action plan The Final Overview Report was presented to a meeting of the LSCB Senior Management Group on 4 October and approved following discussion and consideration of the key learning points identified from this Serious Case Review.  12. Management oversight of the SCR process has been retained by the LSCB Business Manager, although she moved to a new role as Head of Service, Children with Disabilities with Lincolnshire County Council Children’s Services in June 2012. The LSCB office has continued to provide administrative support for the SCR process.  13. The SCR Panel has representation from all the partner agencies involved with this case, and membership is set out in the Terms of Reference.  The Panel has provided constructive and reflective criticism of the SCR reports as they have been presented, and has maintained a clear focus on establishing the learning from this case.  This has been important, as the case has raised issues of individual professional actions, errors of judgment and omissions, as well as wider systemic questions about the climate and ‘custom and practice’ across organisations and amongst professionals in discharging safeguarding responsibilities. Although it was recognised at an early stage that some of the decision-making by individual workers and the supporting processes had been flawed in working with A1, this recognition does not itself explain why this occurred nor does it identify the extent to which either individual judgements may have been optimistic or partial or that there were wider cultural or organisational issues which allowed mistakes to be made.  The Panel and this Overview Report also note that there are examples of good practice in aspects of this case.  14. The Panel and the LSCB chair have monitored the timescale for this SCR throughout its process.  Ofsted retained a formal responsibility for the oversight and evaluation of the SCR when it was started and they agreed the necessary extension to the original timescale.  There is now no longer a requirement (from July 2012) to submit SCR reports for evaluation to Ofsted, and copies are now supplied to the Department for Education (DfE).  DfE does not evaluate SCRs, but Ofsted will ask for evidence of learning from them at the start of unannounced inspections of arrangements to protect children.  Version 06/13  4   Terms of Reference  15. Terms of Reference for the SCR were set when the original Review was commissioned and were subsequently in revised in March 2012.  These are attached as Appendix 1.  These set out the purpose, subjects, scope and governance for the Review and identify those agencies requested to provide Internal Management Reviews (IMRs).  This Overview Report addresses the areas identified in the Terms of Reference, but has adopted a more analytical and comprehensive structure in order to draw out clearly the learning from the case and to examine and evaluate the extent to which issues were the result of individual professional practice, or were influenced by organisational culture, processes and systems within and between agencies.  Where IMRs contain detailed narrative of events and appropriate analysis this has not been repeated in the Overview Report in order to avoid duplication and to ensure that the Overview Report remains concentrated on the wider learning from the case and retains a true overview perspective.  16. The objectives of the SCR are set out in the Terms of Reference as follows: • What lessons are there for decision-making and risk assessment in cases where there is a previous parental history of neglect/abuse either as a victim or perpetrator? • What lessons are there for the type of risk assessment and interventions that should be used to work with families with new-born babies in need of protection?  • What lessons are there about how agencies develop and monitor Child Protection Plans? • Are there specific diversity considerations? • What lessons are there for agencies in fulfilling their duty of care to employees who are involved in serious incidents?  • Are there lessons that would enable the improvement of information management systems both on an inter- and intra-agency basis?  17. The purpose of this Serious Case Review is to identify what can be learned from the case about the way professionals and agencies work together in order to improve inter-agency working and to better safeguard and promote the well-being of children.  It is not an inquiry into how a child was injured, or who was culpable which is a matter for the criminal courts.  A criminal prosecution was initiated and those charged were acquitted in May 2013.  18. It was agreed at the SCR Panel on 25th May that the consideration of lessons for agencies in fulfilling their duty of care to employees would be dealt with as a separate piece of work and was not a part of the learning directly arising from the circumstances of this case.  Version 06/13  5  19. The timeframe for the SCR is in relation to the case of C5 and C6, and therefore focuses on the period from 23 August 2010 (when A1 consulted her GP about pregnancy) to 23 May 2011 (when the Police confirmed to the LSCB that the injuries to the children were considered to be non-accidental).  20. However, the SCR Panel considered that the history of previous involvement for A1 and her children with Lincolnshire agencies provided critical information and this needed to be evaluated in order to understand how this history informed assessment, decision-making and the management of risk for C5 and C6. It was also clear that the care history of A2 and his involvement with Leicestershire County Council Children’s Services was significant. All agencies were therefore asked to consider all records relating to A1 and A2, and those for A1’s previous children (C1, C2, C3 and C4).  The Genogram attached as Appendix 2 provides details of the subjects, their immediate family and other significant adults.  These are summarised below. SCR Index DoB Relationship A1 28.3.1984 Mother A2 15.11.1990 Father A3 21.5.1959 PGM and carer to C1, C2, C3  A4 5.4.1960 PGF and carer to C1, C2, C3 A5  MGA and carer to C4 A6  MGU and carer to C4 A7 3.6.1982 Father to C1, C2, C3 A8 27.3.1986 Father to C4 A9 Unknown Partner to A1 C1 15.8.2003 Half sibling C2 23.6.2005 Half sibling C3 5.5.2006 Half sibling C4 26.12.2007 Half sibling C5 23.3.2011 Subject C6 23.3.2011 Subject  Version 06/13  6  21. A large number of staff have been involved with this case.  For the Overview Report the following are the most significant professionals involved and the following index codes are used to identify personnel in this report.  SCR Index Role/title Agency Principal involvement SW1 Social worker. North Kesteven FAST Children’s Social Care Case responsibility for C5/6 from 13/12/10  PP4 Principal Practitioner FAST  Children’s Social Care Supervisor to SW1 LCSW Leaving Care Social Worker Leicestershire CC Leaving care support for A2 2007 to 2011 MW1 Midwife ULHT Maternity care for A1 HV2 Health Visitor LCHS Allocated HV for family TM1 FAST team manager Children’s Social Care Manager for FAST teams IDVA1 Independent Domestic Violence Advisor LIDAS Worker with A1  Independence  22. David Ashcroft was appointed as the Independent Overview Author of this Serious Case Review in February 2012.  He has worked at a senior level in children’s services for the past 20 years, including operational responsibility for all aspects of safeguarding and children’s social care in a number of local authorities.  He is an accredited C4EO Sector Specialist in child protection, and a member of the British Association of Social Workers, The College of Social Work and an associate member of the Association of Directors of Children’s Services.  23. Mr Ashcroft has conducted a number of SCR, IMR, inspection and investigation assignments in children’s services, covering social care, education and health responsibilities as an independent chair and/or author.  He has worked with Safeguarding Boards, cross-sector partnerships and health and third sector agencies to identify and resolve performance issues and to improve services.   He has no managerial or other connection with the agencies involved in this case.  24. The Independent Chair of the SCR Panel had no previous knowledge or involvement with this case. He is also the Independent Chair of the LSCB, and this reflects relevant government guidance that “The Panel Chair can be the Version 06/13  7  Independent LSCB Chair”. All the IMRs have appropriately identified that their authors were independent of the case and have commented on the involvement of staff members where this affected different aspects or periods of the case history.   Summary of key events  25. A full integrated chronology of the case has been compiled from the details supplied by each agency.  This section highlights the key events that are commented on in the following sections.  This illustrates also how there was parallel contact between A1 and different agencies and that much of the contact was concurrent.  This highlights the missed opportunity to draw these strands together into a comprehensive assessment of the situation until a late point in A1’s pregnancy.  26. During 2003 and 2004 there was evidence of injuries caused to C1, which culminated in his accommodation in foster care from November 2004 and care proceedings.  A1 was convicted in January 2006 of willful neglect and Grievous Bodily Harm to her son and sentenced to 2 years imprisonment.  A7 received an 18-month custodial sentence.  C2 was born in June 2005 and placed in the care of her paternal grandparents, A3/4.  In December 2005 she contracted pneumococcal meningitis that resulted in significant disabilities.  27. In September 2005 a specialist psychological assessment of A1 concluded that the risk of physical abusive parenting was significant without therapeutic work and that considerable parenting support would be required to offset the continuing potential risk to children.  28. Whilst in prison A1 gave birth to C3 in May 2006 who was immediately placed in foster care.   C1, C2 and C3 are now all cared for by their paternal grandparents, A3 and A4.  29. A1 was released from prison in January 2007 and formed a new relationship with A8. No work had taken place with A1 on her offending behavior in prison.   30. A strategy discussion and S47 enquiries resulted in an ICPC in September 2007 where professionals agreed that C4 (unborn) was likely to suffer physical harm.  A pre-birth assessment was completed, together with a further specialist psychological report and legal advice sought.   A review CPC in November agreed that the threshold for care proceeding had been reached, C4 was born in December 2007, and was placed in the long term care of his maternal great aunt and uncle.  31. The 2007 Psychologist’s report concluded ‘the level of risks in this case are significant and I would have great concerns were A1 to be in a position of caring to Version 06/13  8  care for a new born child’.  32. A1 had a relationship with A8 from early 2007 until early 2010, and with A9 from early 2010.  Both relationships involved domestic violence and A1 was referred to MARAC in April 2009 and April 2010. Her relationship with A2 appears to have started in mid 2010.   33. The domestic violence and continuing depression and anxiety are recorded in her contacts with her GPs through 2008 and 2009. Whilst the GP continued to prescribe antidepressants, A1 was also referred for counseling to LPFT’s Improving Access to Psychological Therapies service “for work on past abuse” in September 2009 although she is discharged in February 2010, and referred to a psychological wellbeing practitioner for anxiety management (5 sessions to November 2010).  34. A1 presented to her GP and her pregnancy was confirmed on 23rd August 2010.  35. At this time A1 was concerned about threats from her ex-partner A9, and was in contact with Women’s Aid and the police in respect of these.  She was also staying with a same-sex couple who appeared controlling of her movements and contacts, and cancelled some of her appointments.  One of this couple had a conviction for child cruelty.  36. A1 attended her booking appointment with the midwife on 9th September, and subsequent antenatal appointments.  Her pregnancy was confirmed as twin on 13th October.  As a result of disclosing that none of her previous children reside with her MW1 completed a CAF on 9th November, with A2. There is no record of this CAF form faxed to the FAST team.  A1 continued to attend her antenatal appointments to March 2011 and there appeared to be no serious concerns about her pregnancy,  37. A1 alleged that A9 raped her and told the Independent DV Advisor that she was staying with friends as she was too frightened to remain at her own flat, and that she was suffering from depression and panic attacks. A MARAC meeting on 18th November considered A1 as a high-risk individual as a result of her previous relationship with A9.    38. On 29th October and 1st November respectively A3/4 and A5/6 contacted CSC to advise that A1 is pregnant as they have concerns about this, and the implications for future care of the children.  39. On 13th December the case was allocated to SW1 for Initial Assessment after the midwife followed up on previous contact on which no action had been apparent.  Previous files are secured and the IA was completed on 21st December.     40. On 20th December the case was referred by Maternity to Health Visiting and Version 06/13  9  arrangements made for an antenatal visit at 32 weeks (February 2011).  41. On 6th January the IDVA and SW1 assisted A1 in moving back to her own flat from the house of the couple she had been staying with.  42. On 9th February SW1 and PP4 discussed the case briefly with TM1, initially proposing that it should be dealt with as a Child in Need case and a support plan prepared for A1/A2 to parent the twins.  TM1 concluded that the case should proceed to a Child Protection Conference.  On the same day a phone conversation took place between PP4 and the police.  This confirmed that the case will proceed to ICPC, but was not a multi-agency strategy discussion to share the information now known to several agencies.  43. SW1 discussed a request for support with the Strengthening Families Service, although this is not recorded.  It appears from interviews with staff that this raised concerns about the plan for the twins to remain in the care of A1 given the history and severity of previous abuse of C1.  44. An Initial Child Protection Conference (ICPC) was held on 25th February.  The professionals did not reach a clear consensus on whether the twins were at risk of significant harm and the chair made the decision that a Child Protection Plan was required.  The Child Protection Plan (CPP) included a community based assessment; a high level of visits to monitor parenting; engagement by parents with health visits and clinics; continued work with A1 from Women’s Aid, and work to address depression and anxiety – A1 to consider continuing counseling and therapy ‘when she is ready’.  45. C5 and C6 were born on 22 March 2011, twenty days prior to the expected date of delivery.  A1 had had a Caesarean and subsequently her wound became infected requiring additional treatment.  46. Thirty-five day time visits were undertaken by a team of social workers and Strengthening Families workers – on four occasions no one was at home.  A proposal to reduce the number and frequency of visits to three visits a week was agreed at a core group meeting on 4th April.  47. There is a gap of recording visits between 18th and 25th April when it is not clear any visits by CSC took place.  48. On 8th May East Midlands Ambulance Service attended in response to a 999 call and C6 was admitted to hospital with injuries.     Version 06/13  10  Internal Management Reviews (IMRs)  49. IMRs were requested from and completed by the following agencies: Lincolnshire County Council, Children’s Social Care (CSC) Leicestershire County Council, Children’s Services Lincolnshire Police Lincolnshire Partnership Foundation Trust (LPFT) United Lincolnshire Hospital Trust (ULHT) Lincolnshire Community Health Services (LCHS) NHS Lincolnshire (General Practice) Health Overview Report City of Lincoln Council East Midlands Ambulance Service (EMAS) NACRO Lincoln Integrated Domestic Abuse Services (LIDAS) MARAC: Domestic Abuse Management  50. In addition, a summary report for information was requested from Queen’s Medical Centre, Nottingham, relating to the investigations and treatment of C6 in May 2011.  51. The following sections provide a brief summary of the coverage and findings of each IMR, and identify, with the benefit of hindsight and an overview perspective, any issues arising from the IMR accounts that contribute to the learning from this case.  52. Lincolnshire County Council, Children’s Social Care 52.1. The Lincolnshire Children’s Social Care IMR is the most extensive and detailed account from any agency of the contacts and engagement with this family, and includes considerable evidence and analysis.  The IMR author, a qualified social worker with extensive relevant experience, was commissioned to undertake the Review in March 2012, following the conclusion that the previous draft IMR did not provide sufficient analysis and was not clearly independent of the operational responsibilities for the service.  Interviews with relevant staff were conducted between 18th April and 3 July 2012 and a first draft of the report was presented verbally to the SCR Panel on 25th May to indicate the main lines of enquiry and to allow these issues to be dealt with in other IMRs where appropriate. 52.2. The author consulted and has drawn upon in the IMR a wide range of written records and information relating to the past history of A1 and her children. A total of 16 staff were interviewed or spoken to in preparing the IMR.  The IMR also provides important contextual information about the management, structure and reorganization of social work teams in Lincolnshire.   52.3. The IMR reviews seven episodes of service provision or contact.  These provide an important context for the dealings with A1 and A2 during the scoping Version 06/13  11  period of the SCR, which is the last episode. This starts in 29th October 2010 when the A3 contacted LCC Customer Services to notify Children’s Services that A1 was pregnant and is considered in detail within the IMR.  This was already two months after A1’s pregnancy had been confirmed. The IMR provides a detailed account of the contacts and provides analysis and comment on the practice recorded.   This has been effectively combined with the evidence collated from interviews to examine the practice and performance of both practitioners and the procedures and processes that applied to this case. 52.4. The IMR identifies a series of points that indicate the weakness of the social care response to this case.  These include: • Lack of consistency in dealing with, and assessing, the safeguarding issues for unborn babies; • Failure to contact the extended family as part of the assessment process; • Failure to record or act on the Common Assessment Framework (CAF) from midwife – this information was apparently lost or not received; • No involvement from Children’s Social Care in the MARAC (Multi-agency Risk Assessment Conference); • Failure to draw upon extensive available historic information through the assessment process, especially the previous psychological reports on A1 from 2005 and 2007 and the assessment of risks, legal advice and decisions on removal, made for C4 in 2007; • Inaccurate and partial information incorporated into the initial and core assessments (IA/CA), resulting a inadequate and contradictory conclusions on the risks posed to the twins • Premature and inappropriate assumption that A1 and A2 could parent the twins • A lack of effective supervision and challenge of SW1 and PP4 • A failure to recognize that the thresholds for a strategy discussion had been reached in December 2010 as a result of the information gathered for the Initial Assessment • An acceptance of information and opinion at face value from A1 and A2 without corroboration or probing • A failure to hold an effective multi-agency strategy discussion on 9 February • A failure to recognize and appreciate the reservations about the validity of the support plan presented by the Strengthening Family team • Failure to undertake Section 47 enquiries following the Strategy Discussion that were compliant with procedure (LSCB and Working Together) • An Initial Child Protection Conference that started from an assumption that A1/A2 would parent the twins; did not challenge or test the information before it; and where there was inadequate challenge from partner agencies • A child protection plan that was flawed in a number of ways – lacking specific responsibilities allocated clearly between agencies and Version 06/13  12  professionals; not addressing the demands likely to be made on A1 and A2 in their parenting; unclear about the expectations or sanctions against which progress was to be judged • A reduction in visit frequency that was not justified by any identifiable reduction in risk  52.5. The IMR draws on a range of research and provides appropriate references to relevant information.  The IMR comments critically on the practice in this case and relates that to recent research on safeguarding practice, and particularly the importance of ‘respectful uncertainty’ in assessment and analysis. 52.6. The IMR makes appropriate recommendations and also indicates work to investigate and address operational performance in the intervening period between early 2011 and the conclusion of this SCR.  53. Leicestershire County Council, Children’s Services 53.1. The IMR provides a detailed history for A2 who had a disturbed and violent family background, and was in foster care from 1999 to 2008.  The author has reviewed case records and interviewed the Leaving Care Social Worker (LCSW1) who held case responsibility for A2 from April 2007 to May 2011.  The IMR illustrates the difficult relationship A2 had with his mother, and also covers the caring responsibilities for his paternal grandfather that A2 had assumed from mid 2010. The IMR identifies the involvement of LCSW1 in the ICPC and subsequent child protection planning.  53.2. The IMR provides evidence of the mix of relationships and responsibilities that A2 was managing during 2010 and the first part of 2011 – with changing and distinct relationships with each of his own parents, caring responsibilities for his grandfather, and his new relationship with A1 and the prospect of becoming the father and carer of twins.  The view recorded by LCSW1 is that A2 was showing some maturity and insight into these potentially conflicting pressures, but she was also clear that considerable support would be needed to assist him.   The IMR also provides evidence of the LCSW’s concerns about the influence and reliability of A2’s mother as a potential carer/support for C5 and C6, and subsequently as a reliable witness in the investigations into their injuries.  53.3. An analysis of A2’s care history might suggest that he could be subject to manipulation by powerful females and that he had an extremely mixed experience of childcare, parenting and family relationships through both his birth and foster families.   The IMR provides a balanced account of this.  This strengthens the concerns about the level and nature of the support required to sustain his high expectations of himself as a partner and father.  It appears that A2 welcomed the potential support offered by the child protection plan – it is less clear that the expectations and practical implications of this were sufficiently explored with him and A1.  The picture of A2 that is presented from the evidence in this IMR contrasts with the picture (of near invisibility) seen Version 06/13  13  through the midwifery service; it is not clear that despite the child protection process these contrasts were ever robustly tested and resolved. 53.4. The IMR notes the historic failures of communication between Leicestershire and Lincolnshire County Council Children’s Services in respect of the placements of A2, and his siblings.  It also identifies the concern that the LCSW was not kept promptly informed of the birth of the twins or of their subsequent removal.  53.5. The IMR identifies that the LCSW1 recommended at the ICPC that a Child Protection Plan was required.  It is not clear however that she presented any challenge to the prevailing optimistic picture at the conference, despite her impression that A2 and A1 had a transient relationship and that A2 was relying on the benefits he was claiming for caring for his grandfather.  LCSW1 was not asked to contribute prior to the ICPC to any strategy discussion and S47 enquiries that should have taken place.  54. Lincolnshire Police 54.1. The Lincolnshire Police IMR has been prepared by a dedicated IMR author with over 30 years police experience who is entirely independent of operational management.  The IMR provides contextual information about the organization of the force, in particular the Public Protection Unit (PPU) and Central Referral Unit (CRU).  The IMR also provides a summary of police involvement in respect of injuries to C1 in 2003 and 2004, including the investigation leading to A1’s conviction for offences of GBH and neglect. 54.2. Between November 2007 and February 2010 A1 came to police attention 35 times, the majority in relation to domestic incidents with various partners.  The historic information is cited in the IMR to show the circumstances of the previous conviction and to illustrate the chaotic lifestyle of A1. 54.3. The first contact within the scoping period of the SCR was a request for police information on A1 and A2 from SW1 on 7th February 2011.  The IMR details this and the subsequent involvement in the strategy discussion on 9th February and the ICPC on 25th February.    54.4. The IMR correctly identifies the gaps in information and evaluation supplied to the ICPC, and that this was inadequate given the serious offences committed against C1, and that the views of the investigating officer were not sought. The IMR also identifies the lack of experience and relevant safeguarding knowledge of the Case Conference Co-ordinator who attended the ICPC.  Even given his lack of experience and understanding of conference procedures, if he had been aware that A1 was not permitted unsupervised contact with her other four children, it is possible that he would have challenged the assumption that A1 and A2 should parent the twins even with a Child Protection plan in place.  54.5. The IMR recommended that where individuals have previously been investigated for offences against children, the investigating officer should be consulted, or at least the crime file reviewed.  This recommendation has been implemented, together with additional training for the Case Conference Co-ordinator. Version 06/13  14  55. Lincolnshire Partnership Foundation Trust 55.1. The LPFT IMR covers three periods when A1 was in contact with various mental health services provided by the Trust; July 2007 to April 2008 for counseling; September 2009 to February 2010 for counseling and April 2010 to May 2011 when A1 was seen for cognitive behavioural therapy work.  The author of the IMR was the LPFT Deputy Director of Nursing with no managerial responsibility for the delivery of the services accessed by A1. 55.2. Although there were a total of 18 contacts made or attempted during the third period of treatment, A1 was seen face to face on only four occasions. In July and August 2010 A1 disclosed concerns about domestic violence from her ex-partner (A9). A representative from LPFT attended the MARAC on 18 November, but had not been able to speak to the practitioner working with A1 prior to the meeting.  On two occasions the Psychological Well Being Practitioner (PWP3) sought to refer A1 to the Mother and Baby Specialist nurse, but this was not seen as an appropriate referral as A1 did not have severe mental illness.  Discharge from LPFT services was agreed and it was understood that the appropriate agencies were involved in relation to safeguarding issues of domestic abuse and child protection.  Contact was made with midwifery and children’ services. 55.3. The IMR records that appropriate advice, support and guidance was sought by PWP3 and that contact was maintained both with A1, as far as possible, and with other agencies.  55.4. While the IMR demonstrates that contact with A1 was handled appropriately by LPFT, it is not clear that there was a comprehensive and multi-agency assessment made of the mixture of mental health, anxiety and depressive issues (including prescribed medication) which can be traced for A1 over a long period, or of how these connected to the therapeutic recommendations of the psychology reports from 2005 and 2007.  This wider picture was not available to LPFT at the time and therefore their response was to the presenting issues with A1 and her engagement with their services. With more effective input to the MARAC discussion in November, and certainly with a more thorough core assessment completed prior to the ICPC in February, it might have been clearer what risks were posed by A1’s mental health and the episodic treatment and contacts she had over 2007-2010, together with the significant changes and pressures of her life (uncertainty about housing, domestic violence, changes of partner, pregnancy, controlling friends, involvement with several agencies, child protection and assessment process).    56. United Lincolnshire Hospitals Trust 56.1. This IMR covers the maternity care provided to A1 between August 2010 and April 2011; the midwifery involvement in CAF and Child Protection processes from November 2010; and the emergency admission and treatment of the twins in May 2011.  The author is a registered midwife and supervisor with safeguarding experience who has no operational or managerial responsibility for the services and practitioners covered by the IMR. Version 06/13  15   56.2. A1 attended for antenatal appointments through September to December 2010, and made a partial disclosure of social care involvement with her previous children.  As a result MW1 arranged to complete a Common Assessment Framework, which was done on 9th November with both A1 and A2 present.   This was good practice and an appropriate response to possible concerns.  The IMR suggests that although well completed the CAF does not reflect the level of professional curiosity concerning the background for A1 and A2 and the possible risk factors for the twins, and that information was accepted at face value. The CAF was passed to Children’s Social Care but cannot be traced as a referral, but a core assessment was not started until December and the social worker (SW1) did not meet A1 until 26th January.  Other agencies involved with A1 (including LPFT, the IDVA, MARAC partners and subsequently the health visitor) were aware of the CAF referral, but there was a significant failure to link these concerns and co-ordinate the information known about A1 and A2 and the potential risks for their unborn children for almost three and a half months (9th November to 25th February).  56.3. The IMR examines the antenatal, intra partum and postnatal care provided to A1 and raises no issues concerning the clinical service provided. Similarly, there are no significant issues arising from the care provided to C6 and C5 on admission in May 2011.  Given the multiple birth the IMR author suggests that more frequent postnatal visits might have been advantageous. If so, these should have been co-ordinated with the multi-agency visiting and support plan agreed at the Child Protection Conference.   As will be noted elsewhere, this plan lacked clarity and specific outcomes and there was not clear accountability allocated between agencies.  The assumption that community midwives could make twice-daily visits was unrealistic. 56.4. Midwifery staff attended the MARAC and ICPC meetings on 18 November and 25 February.  It was clear from these discussions, and other information, that there was a complex network of issues affecting A1, which should have prompted constructive challenge between professionals and a more rigorous testing of the presenting picture each agency was seeing, and the development of a more comprehensive and holistic evaluation of the situation. In particular the ULHT IMR notes that A1’s history of depressive episodes and the parenting capacity of A1 and A2 should have been more actively assessed as part of the midwifery engagement with the family. 56.5. In reviewing the lessons learnt the IMR notes the importance of testing safeguarding assumptions across the wider picture. “…a more holistic approach to care could have highlighted not only parenting capacity but emotional well being and bonding.  This would have contributed to the wider assessment of risk…The completion of this review has highlighted that the continual reassessment of the information known regarding A1, A2 and their past history, combined with an assessment of the present circumstances, was lacking in this case.”  Version 06/13  16  56.6. Key issues identified by this IMR are: 56.6.1. The ULHT pathway for Mongolian blue spot was not followed, with a referral to the GP for examination of C5 despite both the midwife and health visitor being aware from the home visit on 4th April.  56.6.2. There was no follow-up on A1’s history of mental health difficulties and depressive illness. 56.6.3. There could have been greater professional challenge at the ICPC to the assumption that A1 and A2 could parent the twins, although the midwife was clear that a Child Protection plan was required.  The outcomes and accountability for this plan were not robustly specified or agreed. 56.6.4. Although present for the CAF meeting in November A2 is not visible through the antenatal period.   He is not recorded as present intra partum or in visiting.  Given both his previous care history, and the mitigating factor he is presented as providing, it is surprising that there is no documentation that A2’s contribution to the care of C5/6 was discussed or assessed.  This should have been an integral part of the maternity care.   57. Lincolnshire Community Health Services 57.1. A specialist nurse independent of the operational management of this case has completed the IMR.  The IMR covers the involvement of health visiting services from 20th December 2010 when the health visiting team was informed of A1’s pregnancy at 32 weeks through to May 2011. 57.2. The IMR notes that the existing pre-birth protocol between NHS Lincolnshire and ULHT was not followed and that this would have identified the pregnancy as a medium to high level of concern and would have triggered earlier health visitor contact and liaison with children’s social care during the 1st trimester.  However the first visit to A1 was in February 2011 at 32 weeks. However, it is clear from the IMR that the severity of the offences committed by A1, her mental health issues and history of post natal depression were known to the health visiting team, and through the content of the CAF completed by the midwife in November 2010.  There is no evidence that the health visitor was asked to contribute to a strategy discussion antenatally, nor is there evidence of the receipt of the child protection plan or of the health visitor’s role in implementing it.  There was no representation from the health visitors at the ICPC.   There is no record of continuing liaison with the midwife, or of liaison with the GP or the mental health team.  57.3. The IMR presents a picture of limited assessment and analysis, and of poor communication between professionals, with partial information shared.  The IMR appropriately recommends that the LSCB should develop an integrated multi-agency pre-birth protocol, but does not examine why, even in the face of poor communication and information sharing, there was not a more rigorous questioning of the circumstances surrounding the family.    Version 06/13  17  58. NHS Lincolnshire (General Practice) 58.1. The IMR for General Practice has been prepared by an experienced public health consultant, who is managerially independent of the primary care services involved. Appropriate records were consulted and the general practitioner who saw A1 when she presented as pregnant on 23 August 2011 was interviewed. The IMR provides relevant contextual information about the provision of GP services in Lincolnshire and about the information systems and record keeping used in general practice.  58.2. Evidence is provided of the history of antidepressants prescribed to A1 by her GPs from October 2005 to June 2010.  There are also referrals made to community psychiatric services made in 2005, 2007 and 2009.  When seen by her GP on 23 August 2010 the use of a filter on the SystmOne records meant the that the GP was not aware of this long history or that her four previous children had been removed.  He now acknowledges that he would have considered making a referral to social care if he had been aware of this history.  It is also clear that a referral at such an early stage of pregnancy would, by custom and practice, not normally have been accepted by CSC as it would not have been considered as a viable baby.  However, a referral at this very early point in the pregnancy, if acted upon, and in the context of A1’s previous history and the risk assessed for her previous children, would have allowed greater assessment of the potential risks to the unborn children and might have enabled better co-ordination of the available knowledge about A1 and A2 held across several agencies in the following months.  It could have served as a trigger point for information sharing and risk assessment. 58.3. There are a number of points where outcomes might have been different noted in the IMR.   58.3.1. A1 intended to have a depo contraceptive but did not attend her appointment on 12th July 2010.  With hindsight it is unlikely that she would have become pregnant with C5 and C6 if she had had this. 58.3.2. The antenatal booking letter following the 23rd August consultation does not mention A1’s past history of violence towards her own child, or that four children had been removed from her care, although this information was known and had been recorded on SystmOne by health visitors.   58.3.3. The practice did not send a report to the February 2011 Child Protection Conference and there is no record of the resulting Child Protection plans in the notes for A1, C5 or C6.   58.3.4. When the health visitor noted a small mark on C5 on home visit on 4 April 2011 (‘could be bruise or could be Mongolian blue spot’) this was not directly brought to the GP’s attention and there was a missed opportunity for C5 to be examined.  58.3.5. When A1 was seen on 26 April 2011 following the birth of C5 and C6, despite a past history of postnatal depression and recent treatment with antidepressants, there is no record that she was assessed for postnatal depression when she ought to have been.    Version 06/13  18  58.4. There are several examples of good practice noted in the IMR in the liaison, recording and prompt communication between the practice and other services, including the notification to primary care of the suspected NAIs to C5 and C6 in May 2011. 58.5. The IMR reinforces what we already know about the potential for primary care to act as a key repository for detailed and long-term information about patients.  Extensive information is built up over a long period that can provide a context for more transient engagement with other agencies and services. This makes it especially important that indicators that may have a bearing on safeguarding risks are robustly flagged and identified, and that General Practitioners are alert to the possible safeguarding implications of their contact with patients.  As a community and universal service, general practice can be a vital point to identify early indicators of risk, the significance of which may only be clear when placed alongside information with other services.  This reinforces the conclusion of the IMR that GPs should always seek to contribute to Child Protection conferences through attendance or a written report, and that Child Protection plans should be clearly recorded in patients’ records. 58.6. The recommendations contained in the IMR are all endorsed by this Overview report and should be taken forward under the auspices of the LSCB for action.  59. Health Overview Report 59.1. The Health Overview Report has been completed by a consultant nurse and LSCB member who has no management responsibilities for the services covered.  The Report provides relevant context for health services in Lincolnshire, and references wider learning, such as the recognition from previous SCRs that highly mobile families have increased safeguarding risk factors.  The Overview Report comments helpfully on information that has come to light during the SCR process, such as the involvement of MW2 in previous proceedings involving C4 and links this to the lack of professional curiosity seen across all agencies.  59.2. The Report identifies a number of themes across the evidence from the health IMRs.  These include: 59.2.1.  the inconsistent contact between A1 and health services, with frequent failed appointments and DNAs through maternity, primary care and mental health services, and the missed opportunity to link information across the teams working with C4 as well as the unborn twins 59.2.2. the lack of early liaison between midwifery and mental health services in October 2010; 59.2.3. the custom and practice that discouraged an early referral to social care before the foetus had reached a ‘viable gestational age’, despite the decision taken to remove C4 at birth and the known history of A1 59.2.4. difficulties in communication between teams and agencies, particularly as experienced by the PWP who sought to ensure that other agencies were aware of the situation with A1 Version 06/13  19  59.2.5. the question of how information disclosure in the context of safeguarding risk is handled with apparently compliant or ‘open’ families rather than those who are resistant or difficult to engage.  A1’s engagement was seen as positive in itself rather than evaluated in the light of previous known behaviours.  This encouraged a more positive evaluation of the potential risk she might pose to C5 and C6. 59.3. The Report concludes that overall clinical services were provided appropriately and to meet current guidelines and standards, with the exception of the referral of possible Mongolian blue spot. However, it is clear that there were weaknesses in the effectiveness of inter-agency co-operation. ‘Professional curiosity and decision making could have been strengthened through consistent use and sharing of the assessment framework that illustrated risk and protective factors regarding both parents and a twin birth.  There appears to have been a passive acceptance of information by each practitioner involved and a continued delivery by each of the services as would be expected on a day-to-day basis…Despite the formulation of the children’s protection plans there is no evidence that the plans were central to each practitioner’s programme of care for the family, or that a cohesive model was in operation. “  60. City of Lincoln Council 60.1. The IMR records the contact between A1 and City of Lincoln Housing functions, which were largely in respect of rent arrears, benefit and possible rehousing.  Taken together they indicate an unsettled and uncertain picture of housing for A1, which might have been considered as a risk factor as she started a new relationship with A2, and was expecting, twins.  In December 2010 the IDVA advised housing that A1 was living with two females, one of whom had a conviction for child cruelty. The housing officer, together with the IDVA and SW1 advised A1 to return to her own tenancy, which she did in early January.  A referral was made for NACRO floating support and it appeared that A1 was seeking a move away from Lincoln. Both Brighton and Leicester are noted as possible destinations. This was the last contact with housing before the twins were born. 60.2. On 4th and 6th May A1, A2 and the twins called at City Hall to sort out claims for Housing Benefit.  The IMR records that the failure to process and claim this so could have resulted in eviction.  Although the twins were described as immaculate and there was nothing in the behaviours of A1 and A2 that gave any cause for concern this episode might suggest some of the practical pressures affecting the family in respect of housing and finance.     61. East Midlands Ambulance Service 61.1. The Ambulance Service IMR has been prepared by a Clinical Quality manager with appropriate experience and with no managerial or operational responsibility for this case. Version 06/13  20  61.2. The Ambulance Service attended on three occasions; to take A1 to Lincoln County Hospital on 22 March 2011; to bring C6 to A&E on 8th May 2011 and to transfer C6 to Queens Medical Centre, Nottingham the following day. 61.3. The attendances and transfers appear to have been carried out in line with appropriate policy and procedures, and the cases accorded the appropriate level of priority based on the information available. 61.4. The IMR notes that the attendance on 8th May was in response to a 999 call from C6’s grandmother.  The identity of this person is not clarified, but is presumed to be A2’s mother.  It is also not clear who accompanied C6 to hospital.  Given the existence of a Child Protection Plan and the known parenting risks, it might have been appropriate for the address to be flagged on the EMAS Dispatch System, although it is unlikely that the presenting symptoms on C6 would have led the crew to consider a non-accidental injury when they attended.  The IMR points out that this could lead to many additional records being held.  However, this might usefully have been considered by the agencies involved in implementing the CPP as a specific rather than a routine requirement in the circumstances of this case.  62. NACRO 62.1. The involvement of NACRO relates to A1’s tenancy in the organization’s supporting housing in 2007-2008 (following her release from prison), and contact regarding floating housing support in 2010.   The IMR has been prepared by an independent manager in NACRO with safeguarding experience and provides an account and analysis of the limited contact with A1. 62.2. The extent of contact was limited in 2010 as A1 did not attend appointments or take up the service support offered.  The IMR states that ‘it was decided that the non-engagement with our service posed an increased risk factor which is why we kept the social worker informed of failed appointments and lack of response to correspondence’. It is not clear that this increased risk was recognized or informed decision-making by other agencies. Had the service been taken up there would have been an opportunity for up to 3 hours of direct contact per week and the chance to observe and prepare a detailed assessment based on the home environment.   This would have supplemented the inadequate assessment undertaken by social care, and might have highlighted some of its weaknesses and contradictions. 62.3.  A NACRO representative attended the ICPC on 25th February 2011. When discussing the conference outcome the two workers involved identified a clear set of risk factors, but it is not clear that these were reflected in the contribution made at conference.  There is no discussion of NACRO’s role within the housing section of the conference minutes, even to note the lack of engagement.   63. Lincoln Integrated Domestic Abuse Services (LIDAS) 63.1. The IMR was prepared by the manager of LIDAS who took over the task from the IDVA Project Manager who was directly involved in the case.  Given the size of the organization this was an appropriate allocation of responsibility.  Version 06/13  21  The IMR provides relevant contextual information and identifies recent constitutional and organizational changes. Managerial actions have been taken to strengthen the safeguarding capacity of LIDAS, and to streamline the referral and co-ordination of its areas of work.  The service provides services and support to women and children experiencing domestic abuse and has extended its remit from December 2011 to also support male victims. Referral pathways at the time were confusing and it was possible, as was the case with A1, for parallel work with IDVA and the outreach workers to be taking place with the same client.  63.2. A1 was referred in February 2008 concerning her relationship with A8. There is no record of the outcome of this intervention. On 20th October 2010 A1 was referred to the Outreach worker (LWA1) in respect of abuse from her ex-partner, A9.  At this time it was known A1 was pregnant with twins. A home visit was arranged for 10 November 2010 but did not take place; A1 said she just needed help with housing.  63.3. Following the MARAC meeting an Independent Domestic Violence Advisor (IDVA2) picked up the contact with A1.  She attended the ICPC on 25th February, and the IMR records her view that the decision regarding the children remaining with parents had been made prior to the conference, and that she did not feel sufficiently experienced to challenge this view.   64. MARAC: Domestic Abuse Management 64.1. This IMR provides an account of the contact with A1 in respect of her referral to the MARAC (Multi-Agency Risk Assessment Conference).   MARAC is not an organization, and therefore commissioning an IMR of this engagement was unusual, but provided a useful insight into how safeguarding arrangements meshed with those addressing the protection for victims of violence and abuse. 64.2. A1 was referred on 28th October 2010 as a result of threats to kill her and the unborn children from her ex-partner, A9.  She had previously been considered at MARAC in April 2009 and April 2010. The case was presented to a MARAC meeting on 18th November 2010 attended by police, LPFT, LCHS, ULHT, probation, IDVA, Fire & Rescue, and chaired by the Domestic Abuse Manager.  Children’s social care from Lincoln and North Kesteven were not represented (although there was a representative of Children’s Services) and an action from the meeting was to contact CSC.   64.3. The IMR does not indicate what information was shared (although this can be partially pieced together from the accounts of attending agencies and minutes have subsequently been made available to the Overview author) or what actions were agreed in order to protect A1 or to address any safeguarding issues that were then apparent.  64.4. Information shared at the MARAC (and not detailed in the IMR) included details that are at odds with other information and do not seem to have been challenged or checked.  It is implied that her current partner (A2) was abusive (‘already having another abusive partner who was referred to MARAC’, although this probably referred to A1’s previous partner, A8); that the CAF completed on Version 06/13  22  9th November was ‘with the social worker involved’ (the CAF was never received by CSC); that she was looking to move to Brighton (rather than Leicester with A2).    64.5. The MARAC meeting occurred at a critical point with a number of parallel processes identifying a range of issues for A1, A2 and the potential risks for their parenting of the unborn twins. The MARAC is primarily an information sharing meeting focused on the risks to victims of domestic abuse. This review has identified that MARAC could have had a wider role in providing a trigger for collating and assessing the emerging safeguarding risks to the unborn twins. These risks were already known as separate elements to the agencies that attended the MARAC, but they were not taken up in a comprehensive way. LSCB needs to establish a formal process for ensuring that risks shared at MARAC are considered within multi agency safeguarding meetings.  The domestic violence focus of MARAC does not override the safeguarding issues that may come to light through the information shared.  The MARAC discussion might have prompted the need for a comprehensive evaluation of the information that was emerging about A1 and her situation. This information did not emerge in a multi-agency forum until the Initial Child Protection Conference on 25th February 2011, when there was insufficient challenge and testing of the plan for A1 and A2 to parent the twins with support. MARAC is not a safeguarding forum in its own right, but all partner agencies need to ensure that information shared through MARAC that may have a safeguarding implication is promptly brought to the appropriate forum for evaluation and action.  This did not happen in this case.   Parallel Processes 65. On 8th May 2011 C6 was brought to Accident and Emergency at Lincoln Hospital by ambulance following a 999 call from the child’s grandmother (unidentified but assumed to be A2’s mother).    As a result on the suspicion of non-accidental injuries at A&E, C5 was also subsequently admitted for investigation.  A healing fracture of left clavicle was confirmed on 11 May, and C5 was discharged to foster care on 13 May.  The details of the investigations and care provided for both C6 and C5 are set out in detail in the ULHT IMR, and indicate an appropriate, urgent and enquiring response to the injuries and their possible cause with a clear focus on the safeguarding implications.    66. Following a severe deterioration in C6’s condition after admission, she was transferred to Queen’s Medical Centre, Nottingham, by ambulance the following day (9th May) and underwent a series of neurological investigations and treatments.  She was transferred back to Lincoln County Hospital on 22 May and was discharged on 24 May to foster care.   The likelihood that the injuries to both children were non-accidental was confirmed on 23 May 2011.  Version 06/13  23  67. C5 and C6 have been in local authority care since May 2011 and care proceedings have been concluded.  The Court agreed an adoption plan and the twins moved to their permanent home in October.   68. In terms of their progress both are doing very well.  They remained with the same foster carers from October 2011 until they moved to their adoptive placement.  C5 is walking and has lots of words.  C6 is doing well in terms of her development although her gross motor development is still delayed. She is continuing to have physiotherapy at home.  She is articulating some basic words and can wave goodbye.  There are no concerns about her hearing.  69. Criminal proceedings were initiated and came to trial in May 2013 when those charged were acquitted.   70. A request from the police for the release of information from the Internal Management Review was received in July.  The SCR Panel agreed that access to the IMRs could be provided to the investigating officer, and individual permission for the release of information agreed with each responsible agency.  71. Expert opinion and legal advice.  No specific expert opinion has been deemed necessary and legal advice has been available to the Panel through the attendance and involvement of the legal advisor to the LSCB.  The Legal Advisor has played an important role in quality assuring the draft IMRs, providing feedback to authors and ensuring that they address the prime issues of this case.  This has been a positive and effective example of partnership working and a concern for consistent and high quality of analysis.  72. There are no related current reviews.  Involvement of Family  73. A1 and A2 were the subjects of a criminal investigation and prosecution, and therefore any involvement with the SCR needed to be guided by that evidence-gathering and investigation process.  They were informed at an early stage that the Serious Case Review was being undertaken and offered the opportunity to meet with the Overview Author to answer a number of questions and to make any observations that they wish.  There has been no response to this offer.  74. The Independent Overview Author met with A3/4 and A5/6 in order to ask for their comments on the case, to put specific questions to them and to identify any observations as learning for the Serious Case Review process.  A3 and A4 care for the three children of A1 and A7, and A5 and A6 care for C4.   Version 06/13  24  75. Both couples contacted social care separately on 29th October and 1st November 2010 to alert agencies to the fact that A1 was again pregnant. Both couples expressed at interview their surprise that C5 and C6 were not removed at birth, as had happened with C2, C3 and C4, and confirmed that they had strong fears that A1 might harm the twins.  It was because of these concerns that they felt a clear obligation to notify children’s services of what they saw as a continuing and real risk. They felt that A1’s past history raised risks for any child in her care.  Neither couple had been asked subsequently to contribute to any assessment or involved in exploring the wider family support and contact.   They all agreed that they would have voiced these concerns clearly at the time if they had been approached. A5 pointed out that when she offered to provide mother and baby care for A1 and C4 together in 2007, this was rejected as it would be impossible to provide 24 hour supervision for A1 and this would not have been sufficient to mitigate the risk.  She did not understand why the same evaluation of risk had not applied to the care of C5 and C6.  76. A1 has only been permitted contact with her older children through supervised contact.  A5 stated that she would not trust C4 with A1 on her own.  She also observed that A1 could present as a very attentive and caring mother, but that this was in contrast with the known injuries she had caused to C1.    77. At contact with C4 in December 2010 A1 said to A5 that social care were ‘going to support her to bring them [C5/6] up’.  This suggests that at this early stage in the assessment of risk a presumption had already been made that A1 would parent the twins.  78. A3 and A4 felt strongly that the fact that A1 was expecting twins rather than just a single baby increased the pressures on her and made it even more likely that she might struggle to cope with their care and protection.    79. The involvement of these family members in the Serious Case Review has been valuable, and raised challenging questions about the decision-making that occurred during November 2010 to May 2011.   Analysis and evaluation  80. Operational context and organisational issues 80.1. Reorganisation of FAST.  The Social Care IMR outlines the changes to the management and organisation of the Family Assessment and Support Teams  (FAST) in 2010.  It concludes that these changes were not a direct factor in the conduct and outcome of this case.  An audit conducted between December 2011 and February 2012 confirmed that the practice and decision-making were specific to this case, and not a systemic failure of the service.  However, it is clear that the changes were an important part of the context in which the case Version 06/13  25  was managed, and workers supervised.  Throughout the case there is a reliance on process to identify and manage risks rather than a critical examination of the substantive evidence and information available. There was also reliance by PP4, and to a lesser extent TM1, on their confidence in SW1 as an experienced worker, which allowed her false picture and presentation of the case to persist as principally focussed on domestic violence, and viewed as a Child in Need rather than a Child Protection case. While specific breakdowns of individual judgment undoubtedly apply to this case these weaknesses did not happen in a vacuum – and the failure to probe evidence, provide challenging supervision, test assumptions and query what was significantly different in 2011 with the twins, from the position when C4 was removed for protection in 2007, all suggest a wider context that did not sufficiently counter the individual failures in judgment and decision making.  It is not possible to identify a specific reason for this, but this report concludes that the LSCB should consider the climate of partnership working that allowed flawed and partial judgements to persist without significant challenge.  80.2. Supervision.   PP4 did not receive effective supervision through the critical scoping period, which the Social Care IMR identifies as a missed opportunity for the case to be discussed and the evidence of risk tested.  The supervision of SW1 lacked challenge and rigour in questioning the assumptions made about A1 and the potential risks to C5 and C6.  As noted in the Social Care IMR the supervision record does not evidence that PP4 tested and interrogated the assumptions or lines of enquiry on SW1.  This contrasts with evidence of supervision with other practitioners in social care teams that was more challenging and evidence based. 80.3. There are several instances in the CSC IMR where there are no written records of supervision and no record of the discussion, challenge or decisions between practitioners and supervisors/managers in the case file.  It is critically important that these should be recorded, even in the event of no action being agreed, so that there is a clear evidence trail of the questioning and analysis that has taken place in reaching complex and difficult decisions. 80.4. At the case supervision on 17th January between SW1 and PP4 it was recorded (amongst other details) that A1 was  • An historic victim of domestic violence • Has a conviction for child neglect • Ex partner was convicted of causing an injury to a child • Having weekly contact with previous children This record contains some significant errors. • A1 had had violent relationships with A8 and A9, but there is no evidence of violence in her relationship with A7 or with A2. • Her conviction was for GBH and child neglect, a more serious offence than A7’s conviction • Her contact was monthly with C1, C2 and C3 and quarterly with C4, and only on a supervised basis. Version 06/13  26  This illustrates the degree to which partial or inaccurate information created a narrative that repeatedly underplayed the potential risks, and concentrated on perceived changes to A1 and her situation, rather than examined the risks from the perspective of protecting the unborn babies.  80.5. Organisational context.  This case highlights the importance of middle management setting performance/professional expectations within which professionals exercise individual judgement, and of challenging and probing the practice and assessments of even the most high regarded of practitioners.  The Social Care IMR provides evidence of different approaches to management and supervision in the two FAST teams.   It is of concern that it was possible to have a case discussion on 9 February to decide whether to proceed to a child protection conference on a complex case of this nature almost as a matter in passing, and without seeking legal advice or drawing together the range of multi-agency perspectives through a full strategy meeting. This was followed by a strategy discussion by telephone with the police, as a procedural requirement in order to progress the case to ICPC, rather than as a full multi-agency pooling of knowledge about the case, and S47 enquiries were not undertaken as required by procedure.  Poor and internally contradictory assessment reports were not robustly challenged, and the Team Manager appears to have been given a misleading impression of the case, although she appropriately recommended proceeding to an ICPC rather than a Child in Need plan as advocated by SW1 and PP4.   80.6. It is unclear how the inadequate enquiry, supervision, recording and decision-making evidenced in this case were able to persist over a period of several months.  The practice of the FAST teams was audited later in 2011, and subsequent to the completion of the Social Care IMR which highlighted issues with the case work and supervision of this case, a review of the practice of PP4 and SW1 was undertaken. It is difficult to assess whether this case represents a single and exceptional failure of judgement and challenge, or whether it reflects a wider pattern.  What is clear is that throughout the case there was low curiosity and little professional challenge not only within CSC, but also from other partners and professionals.   There are clearly failures of individual judgement, and mistakes made by practitioners and managers, but it is worrying that these could continue without challenge.  It is possible there was a climate that assumed that clear and robust processes would mitigate any failures in practice, particularly from a well-regarded worker.  When these processes were then not followed or did not draw out all the evidence, it was possible for mistakes to persist without challenge, or without the consequences of decisions being fully worked through.  81. Failures in due process 81.1. The MARAC discussion and the information shared did not serve as a trigger for agencies to pick up safeguarding concerns, despite the fact that Version 06/13  27  several professionals in different agencies were already aware of the very mixed and contrasting information available about A1. 81.2. There were several points during A1’s pregnancy that could have acted as a trigger for a more comprehensive evaluation of the risks to the twins and for bringing together a more cohesive plan for working with A1 and A2 and making a considered decision about their parenting capacity and whether there were grounds for the removal of the twins.  Each agency followed its own procedure, but did not actively question or seek out what was known by others to provide a more comprehensive assessment.  This allowed a flawed estimate of risk from SW1, based on A1 as a victim of domestic violence, and presenting as compliant and positive in her attitude to her pregnancy, to create a narrative that an intensive Child in Need plan was likely to be sufficient to protect C5 and C6. 81.3. Although each agency followed its own procedures and timing these did not combine to bring together an early evaluation of the risks.  The GP would, in retrospect, have referred to social care when A1 presented as pregnant if he had been aware of the full history; the midwife completed a CAF in early November, but this was not received by social care; the MARAC meeting on 18th November brought together a range of information about A1; health visitors and midwives did not follow the agreed birth protocol which would have highlighted risks at an earlier stage; and there was uncertainty about whether an early referral to social care would have initiated action before the foetus had reached a viable gestational age.  These were significant missed opportunities in the light of A1’s previous history.  It does not suggest a clear focus on the wellbeing and protection of the unborn babies.  81.4. There were significant gaps in the Initial and Core Assessments completed by SW1, with a failure to draw on history and available information and a reliance of a partial reading of the files.  The details of the enquiries made, and the significant omissions in drawing upon the historic file evidence, particularly the 2007 Psychology report, or to speak to other practitioners involved with A1, are identified in detail in the Social Care IMR.  SW1 relied on the case files for C1, without fully appreciating the severity and extent of the injuries caused by A1 to this child, and did not correlate this picture with the files relating to the removal of C4. The recommendations that A1 needed to undertake significant therapeutic work before she would be safe to parent a child were not tested against the fact that she had not undertaken such work, and that the stress factors involved in parenting twins would be greater than with her previous pregnancies and were not the only pressure on her.  81.5. The Social Care IMR also identifies in some detail the information that was and was not included in the SW1’s report to the ICPC.  There is no evidence of testing the information against the likelihood of significant harm. ‘The information available in the initial assessment should have identified that there was reasonable cause to suspect that the twins were likely to suffer significant harm and a Strategy Discussion should have been held at that point (Social Care IMR 7.36).’  Both the Initial and Core Assessment came to a premature conclusion of supporting the parents to care for the twins, although there were Version 06/13  28  no significant differences from the information in 2007 when a decision had been reached to remove C4 at birth. 81.6. At no point during the assessment period and the decisions to proceed to an ICPC was legal advice sought on the question or option of removal, or to examine the grounds for decisions made in 2007 concerning the care of C4 and whether there had been any material change in the circumstances affecting A1’s capacity to care safely for a child, let alone twins.   81.7. Nor was the case referred to the Resource Panel of senior managers.  This was a panel held once a week and chaired by a Head of Service to ‘ensure that all possible resources are provided to children and families to ensure that children are supported at home and within their family, including wider family and friendship groups whenever possible and appropriate. It endorses the plan for a legal planning meeting, or request for placement for planned accommodation of a child. It provides senior managers with an oversight of cases deemed to be ‘high risk and where care planning needs to be discussed in detail to further support the worker and manager’ (Terms of Reference 2011).  It is clear in hindsight that this case would have fallen within this category.  81.8. SW1 intervened with the IDVA in January to help A1 move from the house of a same-sex couple who had established a dominating and controlling relationship over A1.  The theme of vulnerability in relationships of domestic abuse was pursued by SW1 and became central as an external factor that caused the removal of A1’s children.  The care records show that C1, C2 and C3 were not removed because of domestic violence, but due to the physical abuse of C1, the conviction and sentence of A1, and the length of time required to implement the recommended rehabilitation package recommended by the psychologist. 81.9. The strategy discussion held on 9 February was a telephone conversation between PP4 and the police, not with any other agencies involved, and was undertaken as a necessary step in proceeding to an ICPC, not for the value and insight to be gained from sharing information and planning further enquiries and assessment – as set out in Working Together.  In a complex case involving several agencies, the opportunity to establish the grounds for concern and therefore ensure that the conference discussion is fully informed is critical.  The Strategy Discussion should have been an opportunity to test evidence and consult with other agencies more widely. This is one of the key lessons that is identified in the Social Care IMR, particularly when the likelihood of significant harm has been identified independently from a precipitating incident, as will almost always be the case pre-birth. This conclusion corroborates the findings of the January 2011 Ofsted inspection and a subsequent audit that generally Strategy Discussions only involved the police and social care, that there was limited evidence that other agencies were involved and there was a general failure to circulate the record of discussion and action to other agencies.  This practice meant that where an assessment was flawed or partial a critical opportunity to test its assumptions was minimised.  An Action Plan to address Version 06/13  29  standards and maintain procedure, together with revised guidance and further audits have been undertaken to address this weakness. 81.10. Neither the Strategy discussion nor S47 enquiries were carried out as set out in procedures, so the case ‘shortcut’ from Child in Need to ICPC.  Furthermore legal advice was not sought at any point and there was no consideration of whether a legal planning meeting was required to review the case for intervention.  This led to a face value assessment and perspectives on risk persisting, both between professionals and between the parents and professionals, with a lack of connecting information.  There was an assumption that the ICPC would resolve this, and when the Conference reached the conclusion that a Child Protection Plan was required rather than a CiN Plan this was without any challenge as to whether the A1 should retain care of the twins, despite the fact that this went against the clear conclusions in 2007. 81.11. Initial Child Protection Conference  81.11.1. Without an effective Strategy Discussion, or S47 enquiries, the ICPC on 25th February was starting from a partial and incomplete view of the case.  This was compounded by the presumption of the outcome that was evidenced in the invitation which stated: “The plan is for A1 to parent UBB C5 and C6 however this needs to be placed before conference for a decision to be made if UBB C5 and C6 need to be subject to a Child Protection Plan.” This was an unacceptable form for the invitation to be issued.  It is clear that the expectation from SW1 was that the protection of the twins could be delivered through a Child in Need plan.  Her comments to A1 in December and February had led A1 to have that expectation.  This was to undermine the role of the conference to test the risks for the twins and to encourage all agencies to share their knowledge of the case and to challenge each other and the parents about how protection for the twins was to be secured.  The debate was about whether and with what support A1 (and her partner) could parent the twins at home, not about the risks to the twins and therefore the question was never examined of whether it was safe for them to be cared for by someone who had four children removed from her care, had not undertaken any remedial work since then to address these issues, who was still subject to pressures, anxiety and some level of depression, and who had been convicted of serious crimes of child cruelty. 81.11.2. However, the chair did use her role to steer those leaning towards a CiN plan back to the view that a Child Protection plan was required. 81.11.3. There was a failure to invite/inform all relevant parties.  The absence of health visitors and Strengthen Families staff was critical when these were expected to play a major part on any subsequent plan, whether that had been CiN or CPP. The health visitor was invited but did not attend, as it was understood that the midwife represented health, and the Strengthening Families Staff were not invited. There was no invitation or representation from mental health, despite the recent contact that A1 had with services from LPFT.  Probation was invited but neither attended or Version 06/13  30  sent a report, as their involvement was historic. This was in line with usual policy and practice. However, although not currently involved with A1, their contribution might have given the severity of A1’s conviction more resonance with other professionals and highlighted the lack of therapeutic work during and since her sentence.  Probation had attended the MARAC and shared relevant information about A1 at that point. 81.11.4. There was a lack of constructive challenge from agencies to the assumptions presented at the Conference, and a lack of correlation with the information known to each agency. 81.11.5. Some of the participants in the Conference lacked experience/training in contributing to child protection decisions, and were uncertain of the challenge they could make or the options and choices open to the conference.  Again, the focus of the conference was on how to support the parents rather than on critically assessing the risks to the unborn babies.  81.11.6. The Conference did not consider why no legal advice has been obtained, or whether such advice and a legal planning meeting was required. 81.11.7. Uncertainty in SW1’s expectations and recommendations.  The CA, and the report to Conference based on it, and subsequent interview evidence, all suggest uncertainty and doubt in SW1’s views.  The evidence presented, although itself not complete, did not match with the conclusions in favour of supporting A1/2 to parent the twins.  However it was presented to colleagues as a foregone conclusion that A1 and A2 would parent with support.   SW1 does not appear to have reflected on the complexities and contradictions of the case or her approach to it, and was not supported by probing and challenging supervision in order to establish decisions that were better focused on the risks to the twins.  82. Confused picture of and from A1  82.1. It is a conclusion of this report that there was too great a focus on A1 to the detriment of a focus on the twins, both prior to their birth and then during their care at home. However, having said that, the picture that emerges of A1 through the evidence is a confused and contrasting one. What was lacking was a robust and shared evaluation of this picture that would have allowed a more consistent and co-ordinated approach between practitioners and agencies in dealing with her, assessing her support needs and evaluating what risks she posed and whether or how these could be mitigated.  The picture that is evidenced through the IMRs is of separate engagement by each agency in offering the service or support for which they were responsible, but a failure to establish a safeguarding framework, focussed on the twins, that added up to more than the sum of the parts.  A1 is variously seen as victim and/or perpetrator and there is a failure to analyse this with reference to the risks to the twins.  Version 06/13  31  82.2. There are several pieces of evidence that indicate that A1 was able to disguise her behaviour and present in ways that minimised risk.  She was able to disguise from family and professionals the extent and length of abuse to C1. The psychological reports in 2005 and 2007 both indicate that A1 had some insight into the extent that she disguised her abusive behaviour. A5 described that “you’d never know there had been a problem”.  A5 and A6 described being very conscious of the ‘gap’ between what they know A1 had done and that she can seem to be a very caring and responsive mum.  They assumed that social workers are trained to see through her ‘nice’ side. The statement from the SW1 that she believed that A1 and the circumstances had changed because she was able to give eye contact, talk about C1 and had not concealed the pregnancy is a flawed and perhaps naive judgment with no evidential basis.  SW1 subsequently acknowledged in interview that she had misjudged A1.  SW1 has not appreciated the extent and seriousness of the injuries caused to C4, and the association of the triggers to the twins’ circumstances.  The descriptions of A1 suggest that her presentation may have had a disarming effect on SW1.  A1 remained in control of the assessment process, so that when the case came to ICPC the theme dominating discussion was the vulnerability of A1, and the minutes reflect a conference that had developed empathy for her.  Professionals’ focus had shifted away from the twins and their need for safeguarding. The Police investigating officer in the case of C1 would have wished to contribute to the picture of risk had her views been sought prior to the ICPC.  She records that in her opinion A1 presented as a devious and manipulative individual during the original investigation.  It appears that A1 could adopt different strategies in engaging with different agencies – so she concealed her pregnancy with C4 as this could have jeopardised her release on license, but had no reason to disguise her pregnancy with the twins in July to November 2010 when her prime contact with agencies was as a victim of domestic violence, and when she was seeking assistance for her own safety, to secure housing support and possibly to establish the prospect of retaining care for the twins when this might have seemed unlikely in view of  her past history. 82.3. There was a lack of challenge and respectful uncertainty from SW1 towards A1.  At the assessment visit on 10 February SW1 reassured A1 that ICPC is not about removal – which possibility should not have been ruled out given the previous decision on C4. A5 also reported as early as 6th December 2010 that A1 was expecting for social care to allow her to parent the twins. Not only were professional expectations of ICPC compromised, so were the expectations of A1. 82.4. There was an important but fragmented mental health dimension to this case that never satisfactorily informed the assessment of A1’s capacity as a parent.   A1 did not have a diagnosis of mental illness, but she had a mixed pattern of prescribed medication, depressive episodes, referrals for mental health services, anxiety and serious psychological issues affecting her capacity to parent as assessed in the specialist reports from 2005 and 2007.  As different agencies were involved with these different aspects at different times, there Version 06/13  32  was never a comprehensive assessment of how these issues added up and what impact this might have on the safeguarding of the twins. 82.5. Due to the presenting issues when agencies first become aware of A1’s pregnancy the domestic violence narrative became dominant as a result of her relationships with A8 and A9 and the abuse and threats she was subject to from them.   This perspective had a distorting effect on the view of the risks for the twins.  It is important to note that A1’s relationships A7 and A2 were not violent.  A1 interactions with other significant adults/friends/partners were a more complex mix and should have been an equal part of the assessment of risk.  The social care IMR summarises this: ‘Having lost sight of the themes, triggers and evidenced low level of tolerance that led to A1 abusing C1, the professionals did not consider how the convergence of themes would affect the parenting style that led to the abuse of the twins.’  82.6. There is evidence of concealment and premeditated action in the extent and seriousness of the injuries to C1.  This was part of the assessment made in 2007 in considering the risks to C4, and is a conclusion from the 2005 and 2007 Psychological Reports.  The Health Overview report (12.35; 12.38) notes the extent to which information from A1 was accepted at face value at critical points. There is a clear contrast between the assessment of the risks to C4 and the much more optimistic conclusions reached for C5/6.  It is not clear that anything significant had changed so that there was a reduction in risk. Deception and denial were not assessed as risks, or the possible risks to children when A1 was alone/under pressure. It was known that A2 was seeking to continue his care responsibilities for his grandfather in Leicester and therefore, however supportive, was unlikely to be available full-time to help with the twins.   83. Invisibility of A2 83.1. The relationship between A1 and A2 was a new one and carried a number of uncertainties. The pregnancy was recorded as unplanned; A2 admitted to finding it difficult to come to terms with it; A1 was subject to threats from her previous partner (A9); their housing arrangements were uncertain.  There does not seem to have been any examination with either parent of the particular challenges of coping with twins. There is a differing picture from the Leicestershire and Lincolnshire agencies of A2’s commitment and role.  Apart from his presence at the CAF meeting in November, A2 is largely invisible through the maternity, housing, LIDAS and MARAC and social care interactions from October 2010 to March 2011, although he attended the ICPC.  In contrast, his contact with the Leicestershire LCSW1 suggests a gradual but positive acceptance of his prospective fatherhood.  However, this brought challenges in combining with his other relationships and caring role.  There was no robust assessment of these contrasting elements in order to more accurate assess what protective role A2 might play, yet there was a view that because his relationship with A1 was not violent, this was itself a positive and protective factor. Version 06/13  33  83.2. A2’s background and capacity were not adequately evaluated. A lack of evidence of any history of harm to children does not mean that A2 was effectively prepared to be a proactive factor in protecting against risks from A1 toward children.  The Leicestershire IMR identifies a series of factors that might have impacted on A2’s capacity and behaviour as a parent and partner, which were not adequately assessed as part of the preparation for the ICPC.  84. Failure of curiosity 84.1. There was failure to probe and test known and available information.  All was not as it seemed – so information gathered in good faith was not seen in the wider context.  Good practice was noted in the midwife completing CAF early, separately from antenatal appointment and with A2.  However the CAF was completed as home of ‘friends’ where A1 was residing, this was the couple who A1 later regarded as controlling, and from whom she moved, with support from IDVA and SW, in January, and who had a conviction for child cruelty.  84.2. A point subsequently raised through discussion at SCR Panel was whether appropriate weight in terms of maternity and obstetric risk has been given to the fact that this was A1’s sixth pregnancy, and was twins.  It is not clear that the prospect of lasting full term, possible complications and the practical care demands of two babies had been factored into the case in either health or social terms. 84.3. There does not appear to have been any curiosity about the motives or intentions of controlling individuals such as the couple with whom A1 was staying in December 2010 or A2’s mother, in establishing a strong relationship over A1, or of the possible implications for the protection of the twins that this might raise.  Indeed, when a case discussion did take place between SW1 and PP4 around these risks, it was agreed that there were no safeguarding risks as the twins were unborn.  This was to take a limited view and a reluctance to think through possible motives, or the prospects for protection in anything other than the shortest time period.  Equally the wider family context of those caring for A1’s older children was never explored.  84.4. There was a failure to use available information or to recognise it.  SW1 formed the view that circumstances for A1 had changed, but this view was formed in isolation from any evidence.  In interview SW1 stated that she believed circumstances had changed because A1 was able to maintain eye contact, talk about the injuries to C1 and had not concealed pregnancy.  But there was evidence from a variety of professionals that A1 could appear calm and talk about previous history, and she had no motive to conceal her pregnancy, unlike with C4 when this could have compromised her release on license.  If anything this suggests that A1 was able to manipulate her account to meet the expectations of the process she was in. 84.5. The wider family context and other relationships were not analysed for either A1 or A2.   Both relatives with care of A1’s children contacted social care to notify that she was pregnant and did so in the context of the harm she had perpetrated previously.  A4 followed this up in December with a further prompt Version 06/13  34  to the social worker for C2 about their concerns.  However, there was no follow-up to these enquiries.  Both sets of relatives assumed that further checks were being made, and that there was some basis for the plan for A1 to keep the twins that was sufficient to outweigh the evidence of the earlier decisions.  They were concerned about the inconsistency of only allowing the children they cared for supervised contact with A1, while C5 and C6 were to be in her care.  85. Failure of implementation 85.1. The Child Protection Plan of regular and frequent visits was flawed, as it could not militate against the demands place on A1 and A2 by twins rather than a single baby, or during the night and at other times when they were alone.  85.2. The assessment component of the CPP focussed on assisting parents ‘in managing difficult and challenging situations, realistic expectations and looking at stimulation and engaging with the children’.  When explored in interview it is not clear that practitioners visiting were able to describe how this would be done or what events from past parenting or childhood experience needed to be taken into consideration. 85.3. Practical support.  A high number and frequency of visits was put in place, but this in itself was not protective – more clarity was needed about the practical support and on-going assessment of risk that needed to be co-ordinated between the different professionals engaged with the family. Social Care IMR states this clearly: ‘The protection plan of regular and frequent visits was flawed as it could not mitigate against the demands that are placed upon parents of twins during the night and at other times when they were alone.’ It is not clear that information was consistently shared between the professionals visiting from different agencies, or that there was a common set of risk or protective factors that were being consistently assessed. 85.4. The expectations of and by A1 and A2 were unclear, and did not address their lack of parenting experience.  They declined practical support from the Strengthening Families Service, and it is not clear whether there were clear sanctions of consequences established for sustaining effective parenting and protection. 85.5. The reduction in visits was precipitated by reported anxiety from A1, when this should have been identified as one of the possible contributing factors to her previous abusive behaviour.  As the Health Overview report notes: “There is no evidence of any risk assessment having been undertaken, notification to relevant professional working with the family or process of escalation should the reduction in support present challenges for the family.”  Anxiety is established as a risk factor in A1’s ability to parent safely, but when she raises that she is anxious, visits are reduced.      Version 06/13  35  Conclusions and Lessons to be learnt  86. There are a number of conclusions that can be drawn from this Serious Case Review. Throughout the case the focus of professional attention remained on A1, and to a certain extent A2, rather than on the safeguarding of the twins, C5 and C6.   At at least one point safeguarding concerns are dismissed because the twins are as yet unborn.  A stronger focus of the twins as the subjects of the safeguarding process was required.  Effective safeguarding needs to be proactive in the interests of the child(ren) concerned.  A proper professional scepticism and robust evaluation of the evidence available needs to be deployed particularly when there are no precipitating incidents.  87. A1 had never provided safe, long-term care to any child. She had been convicted of serious child cruelty offences, and was not allowed unsupervised access to her older children. The carers of her children had contacted children’s services because of their anxieties about her caring for new babies, particularly the pressures and demands of twins. She had contact with others with a history of offences against children.  She had experienced a number of relationships, some of them involving violence. She had placed herself and the unborn babies in a dominated and controlling relationship with others. Her pregnancy was unplanned and her new partner said that it had taken three months to come to terms with it.  The relationship with A2 was recent, and there were disputed claims for paternity of the twins from A9.  A thorough assessment in 2007 had reached the conclusion that C4 should be removed from her care, and this had been supported through the courts.   Her three older children had been removed from her care as a result of her actions as a perpetrator of abuse, not as a victim.  Her continuing contact with all four children was limited and supervised.  88. It is remarkable that it was assumed that, even with a robust and closely monitored support plan, she was likely to find it easy to provide safe care for the twins. The focus in most assessments from the agencies she was in touch with is on her separate presenting issues or on her relationships with partners rather than examining her parenting capacity.  The acknowledged pressures that she had found difficult to deal with when caring for C1, and which had been accepted as risk factors against her care for C4, were undoubtedly increased in looking after twin babies. The specific therapeutic work to address her parenting capacity, identified in 2005 and 2007 by the specialist psychological reports as required before she could be considered as safe to parent, had never been undertaken.  Her mental health support had been patchy and no specific programme of work had been completed.  She was also recovering from her labour and Caesarean, with a wound requiring continuing treatment; still establishing her relationship with A2, who also had caring responsibilities for his grandfather; and was dealing with housing and benefit issues which must have increased the pressures on her.  There is little evidence of a strong and supportive family or community support network on which she could draw.  She had little practical experience of childcare, and had Version 06/13  36  admitted in the care of C1 that she had controlled her behaviour towards C1 in public and in front of family and partner, but could ‘lash out’ and lose her temper.  The evidence of the injuries to C1 demonstrates a sustained period of cruelty and premeditated and controlled previous abuse.  Even if there had been secure evidence of therapeutic intervention there was little foundation in 2010/early 2011 on which to establish safe and secure parenting for C5 and C6.     89. It is clear from the evidence in the IMRs that A2 had conflicting care responsibilities. Although these are retrospectively acknowledged in the evidence collected in the IMRs, these were never properly assessed at the time nor the tensions and demands that arose addressed.  The evidence of his Leicestershire LCSW suggests that A2 sincerely wished to support his new partner and the twins – but he was also committed to continue caring for his grandfather.  The ICPC records that he had taken three months to come to terms with the pregnancy.  The ULHT IMR highlights that A2 was ‘not visible’ during the antenatal period. There were complex benefit and housing implications for him and his new family that are not satisfactorily addressed during November 2010 to March 2011.    In November, when A2’s role was already becoming established as a protective factor, A1 was in fact living in a controlling relationship with a same sex couple with convictions for child cruelty, and was thinking of moving to Brighton as well as to Leicester. She was presenting herself to LIDAS and to the MARAC process as principally a victim of domestic violence. All this suggests that the protective role of A2 should have been evaluated more critically.  90. The practical experience of child care of both A1 and A2 was limited and expectations of parenting on them were not clear.  The core assessment records that the focus of work with them should be ‘to educate’ them in managing difficult and challenging situations as the twins develop; to provide engaging and stimulating activities; and to sustain realistic expectations of children, but it not clear how this was to be achieved, nor what expectations of parenting behaviours and practical competencies they were expected to demonstrate.  The visits set out in the Child Protection Plan were largely to monitor, rather than to provide practical assistance.   91. The social worker formed a view of this case at an early stage of her involvement in December 2010.  This carried through into the core assessment.  This perspective minimised the severity and length of the injuries to C1, failed to recognise the extent to which these were hidden by A1, and read back the context of domestic violence that was prevalent in 2010 to correlate this to the harm done to C1. Despite the ample evidence available in the files, the availability of colleagues who had worked on the case before, the concerns flagged by family members, and the complex engagement with other professionals that suggested a number of different presentations and scenarios to be examined, this was not adequately evaluated or analysed in preparing the case for conference.  This view suggested Version 06/13  37  that ‘things had changed’ and that the parents could be supported to look after the twins.  It did not examine critically the triggers that were known and recorded as contributing to A1’s previous behaviour.  This was the wrong judgement, and was not effectively probed and challenged by supervision or process.  The lack of an effective strategy discussion, or multi-agency S47 enquiries, meant that the discussion at ICPC was inhibited by the missed opportunity to link and share information and to test apparently contrasting evidence.  92.  There is a series of missed opportunities highlighted through the IMRs.  These include: 92.1.1. GP did not refer at 5 weeks, when in hindsight if he had been aware of A1’s history he said would have done so 92.1.2. The CAF in November completed by midwife was not acted upon by CSC and may not have been received 92.1.3. The opportunity to share information provided by the MARAC process remained focussed on the domestic abuse and threats to A1, which was its proper purpose, but could have triggered that there might also be safeguarding concerns for the twins.  Agencies should ensure that any risks to children identified at MARAC result in specific and timely interventions and that the risks and actions are recorded in the minutes and action log.  92.1.4. Poor quality IA and CA – including a lack of wider family involvement and lacking in evaluation 92.1.5. Inadequate case discussion with TM1 to probe the complexities of case on 9 February 92.1.6. Formulaic strategy discussion in order to progress case through stages rather than to test evidence 92.1.7. A failure to seek legal advice given the complexity of the issues and the previous decisions made for removal of the older children  92.1.8. Assumption of a CiN plan as being adequate to protect 92.1.9. Poorly defined Child Protection Plan – setting a high frequency of visits, but which could not provide the 24/7 supervision and support that might have mitigated risks.  92.1.10. A reduction in visits without critical examination of reasons and effectiveness and without a clear process for escalation.  93. My conclusion on this case is that there was a failure by the Social Worker responsible to assess and evaluate fully the information available, both from the history of C1 and the decision-making concerning C2, C3 and C4; and from the multi-agency involvement with A1 and A2 from August 2010 to May 2011. This occurred in a context where there was a lack of curiosity and challenge from other professionals and agencies. Key opportunities to inform a more comprehensive picture of the situation were missed across all agencies, and A1 rather than the twins became the focus for attention.  At critical points there was a failure to provide challenge and evidence was too readily accepted at face value.  Each agency had a different picture and this was never brought together to allow the Version 06/13  38  contrasting evidence to be tested and assessed.  Each agency involved was focussed on delivering the service for which it was responsible, rather than asking the critical questions that might have safeguarded the twins.  The accounts of professional involvement in this case are not complacent or unconcerned, but appear to trust in the process and do not seek to safeguard or extend responsibility beyond the remit of the given agency or service.  This is seen most clearly in the absence of robust challenge to the presumptions presented at the Child Protection Conference.   94. In the light of what is known about A1’s history and behaviour, and taking into account the varying extent to which she engaged with agencies on different issues during the period of this SCR, I believe that there were strong grounds to suspect possible harm to the twins, and that therefore the outcome of significant harm was predictable.  This could have been assessed at a much earlier stage.    95. It is not clear that any level of intensive support would have been sufficient to offset these risks, and therefore it is not certain that any action would have made the injuries to C5 and C6 preventable. A decision to seek the removal and protection of C5 and C6 should have been sought. It is clear that there was sufficient evidence available, although a failure to collate and assess it, for the decision to have been reached at a much earlier point than late February.  96. As identified in paragraph 8 above, there have been prompt and appropriate management actions to review the issues raised by this case, and to strengthen the management and oversight of key processes.  An Action Plan (Appendix 4) has been prepared to take forward the recommendations identified in each IMR.  This Overview Report confirms that the LSCB should take responsibility for two specific actions that have cross-partnership relevance.  96.1. The LSCB to consider developing and implementing an integrated multi-agency pre birth protocol which includes arrangements for Child Protection Conferences for unborn babies 96.2. LSCB to develop a Lincolnshire-wide protocol for the management of suspected Mongolian blue spot and possible indications of bruising.  Appendix 1 Terms of Reference  Appendix 2 Genogram  Appendix 3 Action Plan for Recommendations  David Ashcroft Independent Author 12 October 2012 Version 06/13  39 Appendix 1    TERMS OF REFERENCE  SCR – Family T/S  Reason for Serious Case Review:  C6 was admitted to hospital on 8th May 2011 with life-threatening head injuries. Her twin brother, C5, was subsequently found to have a healing fracture to the left clavicle. The babies were 7 weeks old and both the subjects of Child Protection Plans.  Mother, A1, has previously had four children removed from her care and received a two year custodial sentence in 2005 for wilful assault and Grievous Bodily Harm on her son, C1.  Father, A2, is a Care Leaver from Leicestershire.   Subjects:  Birth Mother: A1  DOB 28.02.84  Birth Father:  A2  DOB 15.11.90   Children:  C6  DOB 22.03.11                   C5 DOB 22.03.11           Home address: Confidential  Purpose of a Serious Case Review:  • To establish what lessons are to be learned from the case about the way in which local professionals and organisations worked 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 upon and what is expected to change as a result. • To improve intra-and inter-agency working and better safeguard and promote the welfare of children.   SD/LSCB Terms of Reference Redacted Version November 2012 1 Appendix 1 Scope: At a meeting of the Lincolnshire Safeguarding Children Board’s (LSCB) Serious Case Review Sub-Group, on the 23rd May 2011, the panel agreed unanimously that this case meets the criteria to undertake a Serious Case Review (SCR). The Independent Chair of the LSCB, Chris Cook, also confirmed his decision, on the same day, that this case will be subject to SCR.   The SCR Sub-Group recognised that there is a great deal of history pertaining to A1’s involvement with Lincolnshire agencies in respect of her previous children and her conviction in 2005. However, key to this SCR is an understanding of the decisions taken in relation to C6 and C5 and how that history informed assessment, decision-making and management of risk.  The Scope of this review is therefore relatively short but will require agencies to consider all records held in relation to A1 and A2 plus those held in respect of A1’s previous children. It is essential that the review determines how the historical information informed the recent involvement with C6 and C5.  Agencies should therefore consider all records held in respect of the twins’ half-siblings. These are:  C1   DOB 15.08.03    C2   DOB 26.06.05     C3   DOB 05.05.06     These three children live with their paternal grandparents, A3 and A4. Address: Confidential.  C4   DOB 26.12.07    C4 lives with his maternal Great-Aunt and Uncle, A5 and A6.  Address: Confidential.  Other significant adults are the former partners of A1. These are:  A7      DOB 03.06.82      A8      DOB 27.03.96         A9      DOB Not Known     The SCR should therefore consider all historical information, and how this informed recent involvement in respect of C6 and C5, whilst the detail of the SCR should focus on agencies’ involvement between 23rd August 2010 and 23rd May 2011 (the date A1 consulted GP in respect of pregnancy and the date on which Police confirmed to LSCB that medical opinion was that injuries were non-accidental).   The SCR process must not undermine any other inquiry that takes precedence over the SCR. Both A1 and A2 are the subjects of criminal investigation. SD/LSCB Terms of Reference Redacted Version November 2012 2 Appendix 1 Serious Case Review Panel:  Chair:   Chris Cook, Independent Chair of Lincolnshire Safeguarding Children                       Board (LSCB) Lincolnshire County Council:                                    Debbie Barnes Lincolnshire Police:                                                  Guy Leach Lincolnshire Partnership Foundation Trust:              Liz Bainbridge United Lincolnshire Hospital Trust:                           Sue Barnitt NHS Lincolnshire:                                                     Jan Gunter Lincolnshire Community Health Services:                Joy Gilbert Lincoln City Council:                                                 John Latham Domestic Violence Co-ordinator:                              Sara Barry Lincolnshire Integrated Domestic Abuse Services:  Julie Rimington East Midlands Ambulance Service:                          Danielle Burnett Leicestershire County Council:                                 Chris Nerini  Advisers: Legal:                                                                      Toni Geraghty LSCB Business Manager:                                       Sheridan Dodsworth   Designated Doctor (as required)                             Dr Margaret Crawford Objectives of the Serious Case Review:  • What lessons are there for decision-making and risk assessment in cases where there is a previous parental history of neglect/abuse either as a victim or perpetrator? • What lessons are there for the type of risk assessment and interventions that should be used to work with families with newborn babies in need of protection?  • What lessons are there about how agencies develop and monitor Child Protection Plans? • Are there specific diversity considerations? • What lessons are there for agencies in fulfilling their duty of care to employees who are involved in serious incidents?  • Are there lessons which would enable the improvement of information management systems both on an inter and intra-agency basis?   Individual Management Reviews:  On the 15th May 2011 all partner agencies of the LSCB were asked to check their records and indicate whether their agency had been involved with Adults A1 and A2 or twins C6 and C5. Additionally they were asked to indicate any involvement with the half-siblings of C6 and C5. Agencies were asked to submit a ‘nil’ return if their agency had not had involvement.  The following agencies are those that had involvement that is relevant to this SCR  and are therefore requested to provide an Individual Management Review (IMR): Agency                                                           IMR Author  Lincolnshire County Council:                        Jane Mason SD/LSCB Terms of Reference Redacted Version November 2012 3 Appendix 1 Lincolnshire Police:                                       Russ Greaves Lincolnshire Partnership Foundation Trust:  Andy Skelton United Lincolnshire Hospital Trust:               Joan Petterson NHS Lincolnshire:                                         Dr Robert Wilson Lincolnshire Community Health Services:    Kay Crome Lincoln City Council:                                     Kevin Scott Domestic Violence Co-ordinator:                  Sara Barry Independent Domestic Violence Advisors:   Julie Rimington East Midlands Ambulance Service:              Matthew Cooper Leicestershire County Council:                     Rob Wade NACRO:                                                        Jude Wilkinson Queen’s Medical Centre, Nottingham:          Carol Arme  (Brief Report not IMR) Health Overview Report:                               Jan Gunter     The following agencies have confirmed a ‘nil’ return:  East Lindsey District Council West Lindsey District Council South Holland District Council North Kesteven District Council Youth Offending Service AddAction Drugs and Alcohol Services Lincolnshire Adult Social Care NSPCC/ChildLine Lincolnshire Probation Trust (no involvement within SCR Scope period) NHS Direct HomeStart  Each agency commissioning an IMR should provide the following using the IMR template:  1. Contextual Information 2. Methodology 3. Genogram (to be provided through LSCB to ensure consistency).  4. Summary of agency involvement   The following areas are to be addressed both in the IMRs and the subsequent Overview Report:  Resources, Policies and Procedures: • To examine the referral and assessment mechanism and the decision making framework to establish if it was sufficiently resourced and robust enough to meet the needs of the children. • To examine the methodologies used to establish if they were effectively delivered and resulted in desired outcomes in line with the Child’s/Care Plan.  Risk Management: • To examine the risk management process to establish whether reliable SD/LSCB Terms of Reference Redacted Version November 2012 4 Appendix 1 risk assessment tools were used.   Information Gathering and Defensible Decisions: • To ensure that decisions made were informed by information available, grounded in the evidence and that risk and protective features were        appropriately balanced.   Competencies, Training and Development: • To identify whether the practitioners in this case had the proper competencies and confidence to carry out their role and to determine any relevant training or development need which may improve future practice?   Line-Management, Advice and Guidance: • To establish whether the practitioners in this case sought, and were given, appropriate levels of supervision, advice and guidance during the decision making process.   Information Management Systems: • To identify information systems utilised in this process to establish whether they can be improved/upgraded to support practitioners in cases such as this one.   Diversity: • To determine whether any diversity issues had an impact on the decision making process  Communication: • To establish if the inter- agency communication process in this case was efficient and effective.   Other inter-agency input: • To establish whether there has been any other multi-agency involvement with this family and examine the scope and effectiveness of such intervention and evaluate its outcomes.   5. Analysis of involvement     This should consider the events that occurred, the decisions made and the          actions taken or not taken. Where judgements were made, or actions taken, which indicate that practice or management could be improved, try to get an understanding not only of what happened but why something either did or did not happen.     Consider specifically:   Were practitioners sensitive to the needs of the child(ren) in their work, knowledgeable about potential indicators of abuse or neglect, and about what to do if they had concerns about a child?  Did the organisation have in place policies and procedures for SD/LSCB Terms of Reference Redacted Version November 2012 5 Appendix 1 safeguarding and promoting the welfare of children and acting on concerns about their welfare?  What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family?  Do assessments and decisions appear to have been reached in an informed and professional way?  Did actions accord with assessments and decisions made?  Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments?  Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with?  When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making revisions about children’s services?  Was this information recorded?  Was practice sensitive to the racial, cultural, linguistic and religious identity of the child and family?  Were more senior managers, or other organisations and professionals involved at points where they should have been?  Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and wider professional standards?  6. Detailed Factual Chronology (using template provided)   7. What do we learn from this case?      Answer the following questions:   Are there lessons from this case for the way in which this organisation works to safeguard and promote the welfare of children?  Is there good practice to highlight as well as ways in which practice can be improved?  Are there implications for ways of working; training (single and inter-agency); management and supervision; working in partnership with other organisations; resources?  8. Recommendations (also to be completed on template provided)       These should state what action should be taken, by whom and when. They should include what outcomes these actions will bring, and in what timescales, as well as details of how the organisation will evaluate whether they have been achieved.  Please do not make recommendations about practice that has already changed. Recommendations should be Specific, Measurable, Achievable, Realistic and Timely (SMART). Avoid recommendations that are in fact aspirations.    SD/LSCB Terms of Reference Redacted Version November 2012 6 Appendix 1 Please note that as agencies prepare their IMR reports it may be necessary to revise the terms of reference as information comes to light.  If anyone feels this is necessary, they should refer in the first instance to Sheridan Dodsworth. IMRs may be reviewed and further drafts written; agencies are asked not to keep multiple drafts of reports. Please date IMRs and include the Version Number. All Agencies will be required to have the final versions of their IMRs signed off by Senior Managers within their own organisation. Anonymity of individuals involved with Family T/S: All agencies should give staff/practitioners referred to within their reports a code e.g. General Practitioner 1 or Doctor P. To each IMR an Appendix will be added to enable identification of those involved in this case. The Overview Report and Executive Summary will only refer to those involved by their code. Recognising that one agency making reference to another agency staff member will not know the coding for the other agency we will ensure that, once all the IMR reports are received, the correct coding is applied throughout in order to maintain consistency.     Involvement of family members: The SCR Panel recognises its responsibility to consider the involvement of family members in this SCR. The involvement of family members should be to add to the overall purpose of the SCR; that is to establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work individually and together to safeguard children. SCRs are not inquiries into how a child was injured or who is culpable. That is a matter for criminal courts to determine as appropriate.  The SCR Panel will seek to determine which family members might usefully contribute to the learning in this case, bearing in mind the on-going criminal investigation.      In any event the Panel will determine how and when information regarding this SCR will be shared with appropriate family members. SD/LSCB Terms of Reference Redacted Version November 2012 7 Appendix 2 Genogram  Maternal Grandmother Partner 04.04.1964 Maternal Grandfather 25.09.1960 A4 21.05.1959 A3 05.04.1960 Sibling 08.08.1991 A7 03.06.1982 A1 28.03.1984 A8 27.03.1986 A2 15.11.1990 C4 26.12.2007 C5 22.03.2011 C6 22.03.2011 C3 05.05.2006 C2 23.06.05 C1 15.08.2003 Sibling (LAC) 21.04.2002 Paternal Grandfather 16.10.1964 Paternal Grandmother 02.06.1964 Sibling 26.09.1994 Sibling 02.11.1992 Sibling 30.10.1993 KEY: Female Male Married to Partner of Child of     Maternal Great aunt &      Uncle A5 A6 