Ingestion of a potentially fatal amount of methadone by a 20-month-old boy in 2018. Both parents were arrested on suspicion of child neglect. Liam is the youngest of 3 children to the same mother and father. Prior to Liam's birth parents had only been known to universal services and substance misuse services, as both parents were known to have misused heroin. Liam was in the care of the local authority, placed with his mother. Enquiries subsequently revealed that Liam's father had been staying at the family home, without the local authority's agreement, and that, despite suspecting that Liam had consumed methadone, parents had delayed seeking medical help for him. Ethnicity or nationality not stated. Learning and recommendations focus on the following: professionals having a better understanding of the impact of substance misuse (including methadone); placement with parent's procedure needs to be reviewed; professionals must balance optimism with objective evidence; fathers should be included be included in relevant assessments.
      
 Title:  Serious case review: executive summary report: Liam. LSCB: Wirral Safeguarding Children Partnership Author: Wirral Safeguarding Children Partnership Date of publication: 2020  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 Executive Summary Report _____________________________  LIAM                        In order to preserve the anonymity of the children in this family, Wirral Safeguarding Partnership has taken steps to disguise the children’s identities and circumstances.  It has: • represented the children by names chosen at random and which do not necessarily reflect the children’s true gender; • used initials for key family members, indicating their relationship with the child;  • avoided the use of exact dates; and, • removed details about local services which could lead to the recognition of the children and family.    1  Wirral Safeguarding Children Partnership February 2020 Summary of Case  Liam was admitted to hospital in the autumn of 2018, at the age of 20 months, having ingested a potentially fatal amount of methadone. At the time Liam was in the care of the local authority, placed with his mother.  Enquiries subsequently revealed that Liam’s father had been staying at the family home, without the local authority’s agreement, and that, despite suspecting that Liam had consumed methadone, parents had delayed seeking medical help for him. Both parents were later arrested on suspicion of child neglect. This was the second time that Liam had come to the attention of services. Whilst in hospital just after his birth, Liam was found to have suffered two skull fractures, with no explanation as to how they could have occurred. Care proceedings were initiated by the local authority, and during the course of those proceedings, mother revealed that she had dropped Liam. Within a month of the second event, Wirral Safeguarding Children Board (WSCB) undertook a rapid review of the information readily available to agencies, in accordance with the still current requirements of Working Together to Safeguard Children 2015, and concluded that the criteria had been met for a Serious Case Review.  This decision was endorsed by the national Child Safeguarding Practice Review Panel.  Family History Liam is the youngest of 3 children to the same mother and father. He has 2 older brothers, George and Alexander. Prior to Liam’s birth his parents had only been known to universal services and substance misuse services, as both parents were known to have misused heroin.  During the pregnancy and after Liam was born, professionals understood that his mother and father had ended their relationship. Fathers living arrangements were not known to professionals.  Whilst still in hospital, Liam was found to have swellings on his head. A CT scan revealed fractures of the skull with underlying bleeding. With no explanation for Liam’s injuries and his mother denying having dropped the baby, child protection procedures were initiated. A week later, before Liam was discharged from hospital, Liam and his brothers were made subject to interim care orders.  Twelve weeks into care proceedings, their mother admitted to professionals that she had accidentally dropped Liam while they were in hospital.  Childrens Social Care and the Children’s Guardian accepted that Liam’s injuries were the result of an accident and so supervision arrangements were lifted. It was agreed that the children could return to mother’s care prior to the final hearing. There was still uncertainty about Liam’s father’s role in the children’s lives and he was not recognised during the care proceedings.  Throughout this time, specifically on three separate occasions in three months; Liam was seen to have either a fading bruise or a cut to his head which his mother explained as having resulted from a fall against a glass TV cabinet.    2  Wirral Safeguarding Children Partnership February 2020 The following month, Liam’s mother and the children moved out of area to the rehabilitation facility for 12 weeks. At the end of the 12 week period, his mother was drug-free. During this period his father’s engagement with the substance misuse service had been poor: he had not attended planned medicals. In the same month, Liam’s mother spoke to CSC about a plan for both parents to take the children on holiday. This suggested that there was a change in family dynamics and that his parents may have been back in a relationship, but this was not explored.  A week after the last looked after child review Liam was taken by ambulance to hospital following a 999 call from house.  Ambulance staff found him to be unresponsive, grey and not breathing on his own.  On admission to hospital, Liam was very close to death and it was identified there had been some delay before an ambulance had been called. Key Learning For the review, a combined chronology of significant events was completed and a learning review for practitioners and managers was held in September 2019. The principal lessons and recommendations focused on the following practice issues:  Professionals having a better understanding of the impact of substance misuse (including methadone) The review identified that there should have been a much more effective multi-agency approach to recognising and responding to the risks of parental drugs misuse. The practitioner learning event revealed that most practitioners had significant gaps in their knowledge about both the potential effects of opioid use on parents’ capacity to provide care for their children, and how their impact would be measured in any individual case.  Liam’s mother was recognised to be the children’s primary carer, and yet no comprehensive assessment was ever completed of her substance use or its impact on her care of the children. Also, it was generally understood by professionals that the children were having some contact with their father although this had never been formally agreed. Their fathers inconsistent engagement with the substance misuse service, meant that there was only a partial understanding of his drugs use.  There were clear misunderstandings of the purpose and effectiveness of routine drugs testing as an indicator of illicit drugs use, and non-specialist practitioners were overly reassured by negative results. Due to the combined work by the service and by CSC, ‘the case wasn’t viewed as high risk’. As the substance misuse learning summary indicates: ‘It is reasonable to believe that father spent more time at mothers house than the service or children’s social care were aware of at the time. Because the service wasn’t aware of fathers methadone being in the children’s home environment, the risk could not be adequately, or safely managed’.      3  Wirral Safeguarding Children Partnership February 2020 Placement with parent’s procedure needs to be reviewed After the incident in the hospital practitioners suspected that his mother had hurt Liam accidentally but that she did not want to say so. Her insistence on not being responsible caused more doubt amongst practitioners. There seems to be no evidence that there was any discussion as to whether there were avoidable factors on his mothers part which could have contributed Liam’s fall. Instead at the point that care proceedings began, all parties had agreed that this was a ‘single issue case’ focussing on determining the cause of Liam’s injuries, rather than the implications of his mothers drug use.  The CSC learning summary indicated there was little information on file in respect of the decision to return the children to their mother’s care. It appears the NSPCC framework for reunification was not followed meaning the decision taken was ‘overly optimistic’ of their mothers ability to care for Liam and his brothers. The CSC learning summary also showed no record of formal supervision being provided to the allocated social worker from the start of care proceedings until after the children had returned home. This absence of supervision and management oversight would clearly impede and effective risk analysis and case planning.  Professionals must balance optimism with objective evidence. Liam’s mother admitted to her drugs worker that during the care proceedings she had been able to evade urine testing reviews by attributing opioid positive results to co-codamol.   She also admitted that she had stored surplus methadone while she was pregnant and taken this into hospital to reduce heroin withdrawal symptoms. Practitioners at the learning event considered the significance of the likely impact of taking this whilst taking what she was also being prescribed and acknowledged it could have had an impact on her ability to care for Liam, as it would have likely caused drowsiness.  However, it seems practitioners were not aware of his mothers illegal use and hadn’t questioned it.  Participants at the learning event talked about how well his mother presented at all times.  She had been described by some as ‘middle class’. This combined with professionals considering his mother as ‘a protective factor’ after leaving rehabilitation, led to an over-optimism in her parenting ability.  Father’s should be included be included in relevant assessments During the pregnancy and after Liam was born, professionals understood that Liam’s mother and father had ended their relationship. His fathers living arrangements were not known and the nature and frequency of the children’s contact with their father was unclear. Liam’s health visitor had worked with the family since Liam’s older brother, George, was six weeks old. Their father was never seen during this time and his details were not recorded on the health visitor file.  Police and CSC held information about their fathers history of domestic violence in a previous relationship which included an incident in which two of his children were directly harmed. Within CSC, however, no link had been made between the children of Liam’s fathers first family, and Liam and his brothers.  Police also had details of a violent incident some years ago where their father had been implicated in a case where a man had died.    4  Wirral Safeguarding Children Partnership February 2020 During care proceedings, Liam’s father stated that he did not want to be considered as an alternative carer and so he was not the subject of a parenting assessment. There was little consideration of the role that he played in their mothers life, and any future contact with the children did not form part of the final analysis of risk.  This suggests that standard agency checks, including with police records, were not undertaken.      8 recommendations were made for the Partnership focusing on ensuring a shared understanding of processes and protocols with regards to substance misuse, understanding the implications of placements with parents and increased staff confidence working with substance users.    This case raises the following key questions for agencies: • Do staff fully understand the impact of substance misuse on the children in the family, and the risks this presents? • Are staff able to challenge parents use of substances and confidently question the resolve of any parents who are reducing/abstaining? • Do staff monitor family dynamics, particularly where relationships between parents are unstable and change frequently, and does any assessment take into account the role of the father in the family?  