Death of a 2-year-old boy in January 2014. Primary cause of death was bacterial pneumonia infection with secondary causes of dehydration, failure to thrive, norovirus and cerebral palsy. Following his death, mother received a police caution for cruelty against Child K contrary to Section 1 of the Children and Young Person's Act 1933. Child K and his sibling had been subject to a child protection plan for neglect for a month prior to the incident. Maternal history of: childhood abuse, time spent in the care of the local authority, offending, self harm and homelessness. Father was nine years older than mother and also had a history of childhood abuse and time spent in the care of the local authority. Child K was born 24-weeks prematurely, which affected his lung development causing chronic lung disease. Child K had additional complex needs resulting from a hole in his heart, concerns about his hearing and vision and a bleed in his brain resulting in him developing cerebral palsy. Analyses key themes, including: the impact of Child K's disabilities on assessment of risk and inconsistency in the level of professional concern; inconsistent perceptions of mother's understanding of Child K's needs or of her ability and commitment to meet them; pattern of concerns about Child K's weight being raised but not being seen as evidence of risk; lack of professional understanding of father's role; and lack of professional understanding of the interaction between Early Help, Early Support and Child in Need systems. Identifies lessons learnt, including: need for professionals to be clear about the purpose of letters and of the expectations of recipients. Makes various recommendations, including the provision of training on neglect and disability.
      
 Title:  Serious case review into the death of Child K: overview report. LSCB: Cambridgeshire Local Safeguarding Children Board Author: Jane Scannell Date of publication: 2015  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 INTO THE DEATH OF CHILD K  OVERVIEW REPORT                    Author: Jane Scannell        March 2015  2      Contents                 Page  1. Summary of findings         3  2. Introduction to SCR         3  3. Introduction to case         3  4. Family structure         4   5. Terms of Reference         4  6. Process          4  7. Background              5  8. Analysis of key practice events       6  9. Analysis  of themes                      16  10. Conclusions and lessons learned       28  11. Recommendations         30  12. References          32      Appendices  1. Genogram of family       33  2. Terms of Reference       34  3. Template for Agency Reports      36    3  SERIOUS CASE REVIEW INTO THE DEATH OF CHILD K  1. SUMMARY OF FINDINGS 1.1 The conclusion of this review is that Child K died from an overwhelming infection which he may have succumbed to regardless of the care he had received. However the underlying dehydration and malnutrition that the post mortem revealed contributed to his vulnerability to, and lack of resilience to recover from, the infection. Professionals, as well as his Mother had had concerns about his weight and nutrition during the last six months of his life.  1.2 This review has sought to identify any factors that either promoted or inhibited agencies and individuals to act effectively to ensure his safety.  Although professionals were aware of and were actively seeking to support this vulnerable mother and child, the review has identified a number of key lessons for agencies that would improve safeguarding arrangements.  2. INTRODUCTION TO THE REVIEW 2.1 Working Together (2013) states that where abuse or neglect of a child is known or  suspected and the child has died, then the Local Safeguarding Children Board (LSCB)  must initiate a Serious Case Review (SCR). The purpose of a SCR is to enable the  professionals and organisations involved with the child and their family to reflect on both  their own practice and that of others, to identify improvements that are needed and to  consolidate good practice.   2.2 Working Together (2013) also says that SCRs should be conducted in a way that  � recognises the complex circumstances in which professionals work together to  safeguard children; � seeks to understand the underlying reasons that led individuals and organisations to  act as they did; � tries to understand practice from the viewpoint of the individuals and organisations  involved at the time rather than using hindsight; � is transparent about the way data is collected and analysed; and � makes use of relevant research and case evidence to inform the findings.  This serious case review has been undertaken in a way that ensures these principles have been adhered to.  3. INTRODUCTION TO CASE  3.1 The child who is the subject of the review is referred to in this report as Child K. His parents  are called Mother and Father. Other family members are referred to by their relationship to  Child K e.g. Sibling.   3.2 Child K was born 24 weeks prematurely. As a result of his prematurity Child K had very  complex needs which made caring for him substantially more complicated than caring for  another child of a similar age. His prematurity affected his lung development causing  chronic lung disease. He had a hole in his heart and there were concerns about his hearing  4   and vision. He also suffered a bleed in his brain which resulted in him developing cerebral  palsy. 3.3 Child K was 2 years and 5 months old when he died unexpectedly at home in the early hours of the morning on January 1st 2014. At the time both he and Sibling, who had just had his first birthday, had been subject to a child protection plan for neglect for a month. The concerns which led to the children becoming subject to child protection plan included a failure to attend medical and other appointments, Child K's very low weight as well as the  domestic abuse that occurred between the parents. 3.4 Child K's death certificate identified that the primary cause for his death was a bacterial  pneumonia infection (with secondary causes of dehydration, failing to thrive, norovirus  and  cerebral palsy). The Coroner's report referred to his level of wasting as being severe and  associated with chronic malnutrition. No other underlying causes for the malnourishment  were found. Mother has subsequently been given a Police caution for the offence of cruelty  against Child K from his day of birth to the date of his death contrary to Section 1 of the  Children and Young Person’s Act 1933.  4. FAMILY STRUCTURE 4.1  Child K was the Mother's first child. Father, who is White British, has four older children. Mother is believed to have an Irish heritage. No information has been made available to the review about any religious affiliations the family has. A genogram is attached at appendix 1.   5. TERMS OF REFERENCE 5.1 The period of time of the review is from Child K's birth on 23rd July 2011 to his death on  January 1st 2014. Agencies who had been involved with the family were asked to complete  reports providing a summary of their involvement with Mother, Father, Child K and Sibling.  5.2 The Terms of Reference are attached at appendix 2 and detail the specific issues for  consideration the report authors were asked to consider. The format for agency reports  that the authors were given is attached at appendix 3. The LSCB's SCR sub-committee  subsequently realised that maternity services had been provided to Mother by another  health trust and information to inform the review was then requested from them.  6. PROCESS  6.1 The LSCB's SCR sub-committee group met on the 28th January 2014 and recommended that   a decision on whether to initiate a serious case review should be informed by the    conclusion of the post mortem. There was a delay until June in the post mortem results   being available and so this review was not initiated until the 1st July. Terms of Reference   were agreed on 9th September 2014 .  A meeting for authors of individual agency reports   was held on 30th October 2014 where the review process and expectations of the agency   reports were discussed.   6.2 On 28th November the agency report authors met with members of the SCR sub-committee  and the overview report writer to review the reports, to discuss emerging themes and to  5   identify further information needed to produce a final version of their reports. All  participants had view of all the reports prior to the meeting to ensure everyone attending  was able to fully understand the multi-agency context of the review.   6.3 A full day's Practitioners' Event  took place on 9th December 2014. All the agencies who had   submitted full reports were represented as well as some of those who had done only    background reports. Front-line staff and line managers who had been involved with the   family during the reviewed period were invited as were the agency report authors. The    Event was very well attended and enabled a “window on the system” and the discussions   and reflections that emerged informed this report.   6.4 The Overview Report Writer and a representative from LSCB met with Father and Maternal  Grandmother on 18th December 2014 to give them an opportunity to share their views  some of which have been integrated into this report.  Efforts to establish where  Mother is currently living so that she can be contacted to be offered the opportunity to participate in the review process have not been successful.  6.5 The Overview Report writer is an independent child protection social work manager and  consultant. Her previous operational experience includes managing a children's disability  team. She is the author of several Serious Case Review Overview reports.   7. BACKGROUND PRIOR TO CHILD K'S BIRTH  7.1  Mother had her 19th birthday two days before Child K's birth; Father was 28 at the time. Mother had had a troubled childhood and adolescence and Children's Social Care (CSC) were involved and she had spent some time in care and by the age of 16 was living  independently. When she was 17 years old she served a short custodial sentence. Staff   involved with the Mother at the time of Child K's birth were aware of the stress she appeared to be under due to being a witness in a court case in relation to abuse she had been subject to as a child. 7.2 Father also recalls a troubled and abusive childhood during which CSC were involved.  Whilst CSC have no records for him, they do have substantial records about his brothers  and family. Father has four other children besides Child K and Sibling. He has remained  involved with them all, even when living with Mother. He is now caring for Sibling  (under a Supervision Order) and is living with his partner (mother of three of his children),  their children and Father's Partner's two other children. 7.3  Maternity Service's notes record that Mother was homeless at the time that they met with  her. Because Child K was born so prematurely they had only met with her twice – once at  her “booking” at nine weeks and again for a 16 week's gestation appointment. They would  have met her again at her 24 week appointment but Child K's early birth superseded this ` and so they had very little contact with her prior to Child K's birth. The review noted that women generally have “hand held” records i.e. ones they keep themselves and it was indicative of some of the organisational issues that later became apparent in Mother's life that she mislaid hers.  This means that the Maternity Services' record of involvement is not complete.  The information that Maternity services rely on – in the absence of any other information  being brought to their attention – is self-reported by the pregnant woman.  6  In Mother's case a note was made that she was currently homeless, had limited support networks and that she “had difficulties” with reading and writing. Father and Maternal Grandmother were noted to be her next of kin. As a result of the vulnerabilities noted, the midwife made a referral to the teenage pregnancy worker.  8. ANALYSIS OF KEY PRACTICE EPISODES  8.1 In order to gain an understanding of the circumstances that led to Child K's death, the time  period under review has been divided into a series of key practice episodes. Key practice  episodes are episodes that are judged to be significant to understanding the way that the  case developed and was handled.  The term ‘key’ emphasises that they do not form a  complete history of the case but are a selection of the activity that occurred, and include  key information to inform the review. Crucially, not all the activity that was focussed on  Child K and his family on an ongoing basis is listed so it is important to keep in mind the  significant amount of professional activity/energy that was being concentrated on the  family beyond that which is explicitly mentioned.  Key Practice Episode 1: 23rd July 2011 - 5th December 2011 8.2  The first key practice episode covers the period from Child K's birth until his discharge home  from hospital on 5th December 2011.   8.3 Child K was born at 24.5 weeks' gestation at Hospital 1 and transferred when he was 10  hours old to the Neonatal Intensive Care Unit (NICU) at Hospital 2. At birth he weighed  790g (1lb 11.9oz). Medical staff confirmed that such prematurity means the baby's hold on  life is very tenuous and those professionals initially involved will be focussed on the baby's  medical needs. Child K's parents did not “stand out” to the staff at NICU from the other  families who were there with their very sick babies. The parents were appropriately  involved, Mother expressed milk for Child K and both parents visited most of the time.  When they were unable to do so, Mother would contact the ward for updates.  8.4 After about six weeks Child K's condition had stabilised enough for him to leave Intensive  Care. Because initially there was not a bed for him at Hospital 1 (the hospital local to the  parents' home address) he spent over three weeks in the Special Care Baby Unit (SCBU) at  Hospital 3 (some 25 miles from the parent's home address) before returning to Hospital 1  in October 2011. While he was in Hospital 3 staff noted that although Mother sometimes  stayed in the accommodation provided for parents, at other times she was unable to visit  because of financial problems. Once Child K was back at Hospital 1 professionals started to  note some concerns. These included more sporadic visiting by Mother and no other  visitors. Although Mother was noted to be able to meet Child K’s physical needs  appropriately, she appeared not to be very emotionally involved and, for example, did not  pick him up and cuddle him as much as would be expected. However, Child K made good  progress within the limitations of his prematurity, and plans were developed for his  discharge from hospital.   8.5 While Child K was an inpatient at Hospital 1 Mother told a member of staff that she was  involved in a court case as a witness and that she had self-harmed. Health Visitor (HV) 1  met with Mother and Child K while he was still in hospital and she was concerned enough  about Mother’s mental health and lack of support networks to refer her to the Perinatal  Mental Health Visitor. However, when the PMHV undertook a planned home visit on 14th  7   November, Mother told her that her visit was “inconvenient”.  No evidence has been  provided as to  what happened subsequently to follow this up .  8.6 A member of the Ward staff completed a Common Assessment Framework (CAF)  assessment, focussing on housing needs, but including other concerns and the need for  long term support for a child with complex health needs. At the Practitioners’ Event staff  confirmed that that the CAF was seen as a tool to pull together “niggling worries” about  Child K going home and was being used as a way of bringing all agencies’ concerns together  to form a robust plan for his discharge. Subsequently a referral was made to CSC (referral 1)  on 10th November resulting in the case being allocated for assessment.  8.7 A discharge planning meeting was held on 11th November and was attended by a range of  health professionals as well as the parents and a Young Parent Support Worker and a  Housing Officer.  Concerns about parents’ preparedness for caring for Child K at home and  their lack of contact led to a Professionals’ Meeting being convened on 22nd November.  This  meeting was attended by a social worker from CSC and, because of the number of concerns being raised, which included Mother’s parenting capabilities and ability to meet Child K’s complex health needs, her lack of family support and concerns about her mental health, it was agreed that the social worker would discuss the option of Child K being accommodated under s201 with parents.   8.8 The social worker completed an initial assessment on 23rd November, the possibility of s20 accommodation having been discussed with parents by the team Manager on the same day. There is no evidence as to the content and outcome of the discussion about s20 accommodation but the initial assessment concluded that a Child in Need (CiN) meeting should be held. This meeting took place on 28th November with the outcome that Child K would be discharged to his parents' care and would receive services as a child in need. The discrepancy between the level of concerns voiced at the meeting on 22nd November and the outcome of the CiN meeting a week later was  reflected on both in Agency Reports and at the Practitioner Event. In retrospect, staff concluded that Mother (agencies’ involvement with Father at this time was negligible) was  able to reassure staff - “to say the right thing” – about her commitment to working with professionals to meet Child K’s needs and this had been sufficient to allay concerns. Hospital staff remained very concerned with one nurse stating that she was “more worried about Child K than any other in her time on SCBU”. However there was no use made of the LSCB’s escalation procedure to address their concerns. There were two days in between the CiN meeting on November 28th and Child K's discharge home when Mother did not visit him. CSC were notified of this by both the HV and SCBU but no other concerns were raised with CSC about the discharge and on December 5th Child K was discharged to his Mother's care.  8.9 This is a key practice episode because there were early signs that Mother’s ability to give  Child K the intensive, consistent care a very premature baby needed was variable. Staff with concerns did not follow them through to conclusion. There was untested optimism about  Mother’s ability to cope and an emerging theme of Mother being able to calm professional nervousness by her responses.                                                   1 . S20 Children Act 1989 states Local Authorities' duty to provide accommodation for children in need.  8  Key Practice Episode 2: 5th December 2011 - 10th December 2012 8.10 This episode covers the period between Child K's discharge for Hospital up until the birth of  Sibling on 10th December 2012. If Child K's age is adjusted to take account of his prematurity he was four weeks old at discharge (although chronologically he was nearly 4½ months old). He weighed 4.79 kg (10lbs 9oz) and was being bottle fed. He had an ongoing need for oxygen (which was supplied to the home).  8.11 At this time Mother was living at Address 1. In the meeting with the LSCB Manager and  Reviewer, Father was clear that he lived with Mother and the children throughout the time  under review until October 2013 but this was not the perception of professionals who  attended the Practitioners' Event.  8.12 Some of the professionals who had been involved with Child K while he was in hospital   remained active in his care, affording a degree of continuity and in January he was referred  to Early Support.   Early Support is a model which aims to improve the delivery of services  for children who have complex  additional needs and their families. It is delivered through  services working together using the CAF and the Family Support Plan as tools for a single  holistic assessment and planning process with a lead professional taking a key worker role.  Despite Child K being referred to Early Support soon after he was discharged to a community setting, a Family Support Plan was not developed until July 2013. This was because for much of the intervening period Child K was receiving support (from CSC) and the subject of  child in need plans. The interplay between the various planning/support mechanisms which are considered further in the analysis section.  8.13 The case remained open to CSC and in January a core assessment was completed which  noted a “good bond” between Child K and Mother and was positive about the care Mother  was providing and noted that parents ensured he attended necessary appointments.   However, the assessment concluded that given Child K's complex needs the case would stay  open with a plan that CSC would ensure locality services were in place. Child in Need (CiN)  meetings were held in December, January and March although no detailed recording of  what was discussed in them was available on the CSC case record. CSC closed the case in  March. Health timeline notes that a CiN meeting took place at the beginning of March but  there is no other evidence to clarify whether this meeting was used to clarify the ongoing  involvement of the Early Support services.   8.14 Specialist professionals involved with the family at this time included the Physiotherapist,  the Occupational Therapist (OT), Portage2 and Consultant Paediatricians. All experienced  some difficulty in gaining access to Child K or in having him brought for appointments. At the Practitioner Event staff spoke of their frustration about how many appointments were  missed and were eloquent in speaking about the harm the lack of therapies could mean to  Child K. There was evidence that staff were not unsympathetic to the difficulties a young,  financially-challenged mother with little support would have in attending the numerous  appointments and that they did their best to ameliorate them by, for example agreeing to  come to the home rather than Mother bring Child K to them. However, the need to  reschedule missed appointments further added to the burden. Staff also reflected that                                                  2     Portage is home visiting educational service for pre-school children with additional support needs and their family    9   Mother appeared reluctant to accept offers of help with, for example transport, from  professionals, preferring to rely on friends who then sometimes let her down.   8.15 A Team Around the Child (TAC) meeting (referred to as Professionals' meeting in some  Agency Reports) held at the beginning of July resulted in another referral (referral 2) to CSC  with the identified concerns being that Child K was not receiving the occupational therapy  he needed and that Mother was 16 weeks pregnant. The referral was passed to the   Disabled Children' Team (DCT) for an initial assessment.  8.16 The assessment (which was  completed within time scales3) concluded that there was no  current role for CSC as Mother “could manage Child K's health care needs with the  support of professionals”. Mother's pregnancy, in so much as it impacted on her ability to  meet Child K's needs at the current time was given consideration but there was no  assessment of how Mother's ability to care  for him might be compromised by the birth of  another baby. There was no contact with Midwifery services as part of the assessment  process. Although the plan at the conclusion of the assessment was for health professionals  to “monitor Mother's attendance at health appointments” there is evidence that key  professionals were not told the case was closed on 24th July – 2 weeks after the referral had  been made . The OT, who later became Child K's lead professional under the Early Support  arrangements only found out in August when she contacted CSC to reiterate concerns  about missed appointments.  8.17 At the end of the month Child K and Mother moved to Address 2. Agency authors and staff  at the Practitioner's Event reflected that this move was to enable Mother to be closer to  her network of friends but felt that the hoped-for support did not materialise. During this  time the Vulnerable Women's Midwife (VWM)was involved. The Midwifery service had  recognised the additional impact Child K's care needs would have on Mother's pregnancy  and ability to cope with the newborn baby and so had involved the VWM. This midwife  visits pregnant women in their own homes rather than expecting to see them at clinics and  there is no evidence that Mother failed to be available for any of her appointments with  the VWM. The Midwifery service is now strongly promoting CAFs (Common  Assessment Framework) as a way of collating information and concerns about pregnant  women. In this case, the agency representative felt completion of a CAF would have been  “advisable” to inform whether the threshold for a pre-birth assessment was met.   8.18 In September 2012 CSC opened another referral (referral 3) from Consultant Paediatrician 1  expressing further concerns about Mother not bringing Child K to medical appointments and not engaging with professionals. The OT and the HV had both contacted CSC during August expressing similar concerns but these were considered to be the same referral as referral 2 (as they repeated the same information). As a result, CSC initially took no further action in relation to these contacts, considering that the assessment completed in July had  addressed these concerns.  However on receipt of Consultant Paediatrician 1's letter in  September, CSC decided that a core assessment was needed and  the case was allocated to  a social work unit.  At about this time a diagnosis that Child K had cerebral palsy was made  and discussed with parents by health professionals.                                                   3 At this time Cambridgeshire were working to the requirements of Working Together 2010 which required initial assessments to be completed within 10 working days from referral and core assessments within 35 working days.  10   8.19 The core assessment was completed in November with an outcome that ongoing support  under s174 was needed. Although the identified issues included that Mother needed to  keep health appointments the plan did not address how she would be supported in this  other than to say that if appointments were not kept, action under s475 may be taken.  However the plan also noted that CSC would explore what support Mother would need  once the new baby was born. The assessment was particularly concerned about the poor  housing the family were living in and identified that this would be addressed.  8.20 Sibling was born by Caesarean Section on 10th December 2012, 4 weeks early.   8.21 This is a key practice episode because the issues with Mother ensuring that Child K was  taken or made available for professional appointments became apparent, professionals  ceased to consider Father's role and his ongoing involvement in the care of Child K. Parents  were coping with the news of Child K's diagnosis and prognosis and Mother's pregnancy. CSC closed the case after five months' involvement but received two further referrals during this episode expressing very similar concerns and the Disabled Children's team became briefly involved.    Key Practice Episode 3: December 2012 – November 2013 8.22 This key practice episode covers the period from Sibling's birth in December 2012 up until  November 2013. During this time Mother was caring for two very dependent children –  Sibling was very young and Child K's complex needs meant that, despite his chronological  age – he would have been 16½ months at the start of this period – he would have needed  at least as much care as a newborn – and the care of two such dependent children would  have challenged the most organised and supported parent. Mother needed advice and  equipment to meet the demands Child K's special needs presented, especially around  eating which required patience, time, correct handling and positioning and a special chair.   It was noted that it was virtually impossible for Mother to use public transport with both  children's buggies.  8.23 CSC remained involved throughout the first three months of 2013 having transferred the  case to a CiN Unit shortly after Sibling's birth with the intention that the Unit would co- work with a social worker from the DCT. However, this arrangement was never activated,  neither was the plan, recorded in February 2013 for “Sibling to be closed. Child K to transfer  to DCT” (CSC Timeline). CSC records do not provide the reason why the plans to involve the  DCT were not implemented. CSC records are also sparse in the information they provide  about the focus of the social work intervention but the outcome was that Mother took  Child K to his appointments regularly. The CSC agency report author hypothesised that  Mother was aware that CSC could take statutory action and so complied. There was an  anomaly in that Mother was casual about keeping appointments with the social worker but  was more diligent in keeping the other appointments when social work was involved during  this period.                                                  4 S 17 Children Act 1989 states the duty of Local Authorities to safeguard and promote the welfare of children who are in need. 5 Under s47 Children Act 1989 an enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm.  11   8.24 In February the family moved again to Address 3 and some staff  commented that this was  positive time for the family.  Paternal grandfather helped decorate the house, more   support via Mother's friends was available and a Disabled Facilities Grant was agreed which  would have enabled the house to be adapted to meet Child K's needs and lessen the  physical demands - such as carrying him upstairs – on Mother. Practitioners recalled that  Mother seemed to have some health problems at this time. She was also observed to have  lost weight during the next few months and was often seen drinking energy drinks to “keep  herself going”.  8.25 In March 2013 CSC planned to close the case with the recorded intention that that it should  transfer to the  Short Breaks Team6 . Families who get high rate Disability Living Allowance  (care) and who don’t currently have an allocation of social care services have an automatic  entitlement of up to £2000 funding via this team and Child K qualified for this support.  However despite the team receiving a referral Mother did not respond to their efforts to  contact her.   8.26 Child K missed an appointment with both Consultant Paediatricians in March and April.  Consultant Paediatrician 1 is a hospital consultant and responsible for Child K's chronic  needs relating to prematurity. Consultant Paediatrician 2 is a community paediatrician to  whom responsibility for Child K's ongoing developmental progress would have transferred as his health stabilised. The Consultant Paediatricians tried to see Child K together at clinics to both save Mother bringing him to separate appointments and also as part of the process of transferring responsibility to community based services. However, because of missed  appointments, Consultant Paediatrician 2 had only met Child K in October 2012 when the  diagnosis of cerebral palsy was given to parents. In March the Portage Worker also  contacted the social work unit after becoming very concerned about how was Mother  coping with a variety of issues including her own health needs, Child K's constipation and  problems with her benefits.  A CiN meeting was held on 17th April where a plan was made  for the lead responsibility to transfer to Early Support Services. CSC closed the case on 29th  April with the instruction that further referrals were to be passed to the CDT.   8.27 Mother took Child K to an appointment with Paediatrician 1 in May and expressed concern  about Child K's weight. He was weighed as part of the consultation and his weight was 9.35  kgs (9th centile). This represented a deterioration from December 2012 when his weight  had been on the 50th centile. A referral to the Paediatric Dietician was made although this  appointment was not kept.  8.28 In June 2013 the Police were involved following Mother reporting an assault by Father  when both the children were present. Father was initially bailed not to have any contact  with Mother and was subsequently convicted for the assault and given a conditional  discharge. CSC were notified of the incident via the usual process (referral 4). The Police  notification included the information that Father made allegations about Mother's care of  the children. The Integrated Access Team (IAT) responded to the referral by completing a                                                  6  This team co-ordinates services to enable disabled children and young people to experience time away from their primary carers, contributing to their personal and social development and reducing social isolation; giving parents and families a break  and enabling families with disabled children to do more things together as a family.  12   threshold assessment7 which concluded that further assessment was needed. The  case was allocated to an Access Unit  - not the DCT - for assessment. The reason why it was  not allocated to the CDT, as had been stated when the case had been closed in April was  because the concerns were not seen as ones relating to Child K as a disabled child and were  therefore did not need the specialist lens provided by DCT.  8.29 The case was closed by the Unit six weeks later on 12th August 2013. There is no evidence  that an assessment was completed so no analysis of the risk to the children from exposure  to domestic abuse, exploration of the allegations about the quality of Mother's care  or any  agency checks with the multi-agency support network were made. Consultant Paediatrician   2 wrote to CSC in August expressing concern about the number of appointments Child K had not been taken to but there is no evidence of CSC's response.   8.30 On 16th July a meeting, attended by both parents drew up the first Family Support Plan (the  mechanism by which Early Support is coordinated). Although Child K had been referred to  Family Support back in January 2012, during most of the intervening time he had been  subject to, and his care needs coordinated by, a CiN plan. Although plans were recorded  when CSC closed the case in April 2013 that Early Support  would take over the  coordination of Child K's support needs, arranging a meeting with Mother had proved  difficult and was not achieved until July. As a result, during the time when the concerns  about  Child K's weight/failure to thrive were first becoming apparent, he was not subject to any planning/oversight mechanisms that would have pulled together the different agency perspectives.  8.31 Child K's identified needs in the Family Support Plan included that his “weight and height  need checking” as well as noting his constipation problems needed addressing. The plan  was reviewed in September where it was noted that Child K “is currently not eating, he is  suffering from diarrhoea and losing weight”. The action identified was a dietician's  appointment due the following month (to which Child K was not taken) and that his weight  and height would be “done regularly” by Health Visitor. There is no evidence that Child K  was weighed until he attended an appointment with Consultant Paediatricians 1 and 2 in  November.   8.32 In September 2013 the Locality Allocation and Review Meeting (LARM8) agreed a funded  pre-school placement should be offered to Child K and he started at pre-school at the  beginning of November. He was allocated 5 afternoons a week in response to Mother's  observation that she would find it easier to get him there in the afternoon. The interaction  between the LARM and the associated Early Help arrangements and the Cambridgeshire's  Early Support services (for disabled children under 5) is complex and is considered further  in the analysis section.  8.33 At the end of October there was another violent incident between the parents, allegedly  when both parents had been using drugs. Mother sustained injuries and  Father also caused                                                  7 The purpose of a threshold assessment is to avoid “undue escalation to statutory assessment” (IAT Manual) by gathering further information, which can include seeing the family, to inform decision-making. 8 LARMs are professional meetings used to identify appropriate resources and actions to help children and families with who have more complex additional needs but who do not require social work involvement.  13   criminal damage to home and furniture. Again, both children were present during part of  this incident. As a result of the injuries she sustained Mother went to the GP surgery the  next day (where she was seen by a nurse practitioner) but even though the GP practice had  been receiving “multiple letters, usually addressed to other health professionals but cc'd to  (the Practice)” about Child K, no consideration was given to whether any action needed to  be taken in relation to the children. This is considered further in the analysis section of this  report.  8.34 The Police notification of the incident resulted in CSC opening a referral (referral 5) on 31st  October and the completion of a threshold assessment by the IAT. The IAT spoke  with the HV who was recorded as confirming that there were no current concerns over  missed appointments and also with the Pre-school. Staff from the IAT undertook an  unannounced home visit where both children were seen and Mother was spoken to. She  reflected on her exposure to domestic abuse between her parents as a child and of her  determination to protect her children from similar experiences. An Independent Domestic  Violence Advisor (IDVA) had been allocated to her and Mother wanted to attend the  Freedom Programme. The conclusion was that no further involvement from CSC was  needed as mother had agreed to engage with DV services and had responded appropriately  to protect the children and the case was not opened to CSC. However, other professionals  who were involved with the family at the time commented that this incident had had a   discernible impact on the children with Child K showing he was unsettled/unhappy and  Sibling becoming “clingy.     8.35 This is a key practice episode because, although the concerns about missed appointments  reduced while CSC were involved, they started again after the case was close having been  open for a lengthy period (8 months). There were two further referrals to CSC in the period  both because of domestic abuse although only threshold assessments were completed.   Mother expressed concern to professionals about Child K's weight gain and it was noted  that he had not gained weight and had dropped down the centiles. This was responded to  by referral  to a Dietician and the Early Support Plan noting actions to be taken to monitor  but the cause and impact of his weight loss and non-engagement with services was not  explored.    Key Practice Episode 4: November and December 2013 8.36 This key practice episode covers November and December 2013.  8.37 When Child K attended a joint clinic with Paediatric Consultants 1 and 2 on 25th November it was the first time Paediatric Consultant 1 had seen him for 6 months (she had last seen him at the very end of May. Child K had missed appointments to attend clinics in June,   September and at the beginning of November). Paediatric Consultant 2 had only seen him  once before (in October of the previous year).  At the November appointment his weight  was 9.1 kgs (he had weighed 9.35 kgs (9th centile) when he had last  seen Consultant   Paediatrician 1 on 30th May). In the referral (referral 6) Consultant Paediatrician 1   subsequently made  to CSC by telephone that day, she described him as thin, dirty and cold  and “the worst she had seen him”. She had wanted to admit him into hospital but Mother  had taken him home. Consultant Paediatrician 2 confirmed the referral to CSC in a letter  that was received by CSC the next day.  14    8.38 Child K was seen the following day by the Paediatric Dietician who prescribed some high   calorie  drinks/fortified milk. This was the first time the Dietician had seen Child K despite   previous appointments having been offered since Mother had first raised concerns with   Consultant Paediatrician 1 about his weight in May.     8.39 CSC's response to the referral was that social work intervention was needed and the case   was allocated back to the Social Work Unit who had done the assessment June 2013.     Further information was sent to CSC the next day  (26th November) by the Police –    informing them of Mother's disengagement from the services dealing with the domestic   abuse and also by Health Visitor. The Health Visitor was concerned about the basic care of   both children and alluded to the family now having a puppy which could place Child K at   further risk of  infection. She informed CSC that she had arranged a Professionals' Meeting   for 4th December.   8.40 On 26th November (the day following Paediatric Consultants' referral) a strategy discussion   with the Police was undertaken by the Consultant Social Worker (CSW) (the senior member   of the Unit) which concluded that a single agency s47 enquiry should be undertaken by   CSC (i.e. no criminal investigation should be initiated). The next day (27th November) the   CSW and a social worker undertook an unannounced home visit to the family home. The   recorded purpose of this visit was to see the children and to assess the home conditions   and how Mother was responding to the children's needs.   8.41 In the meantime Child K went to pre-school on Thursday 28th November (having been absent the previous two days) and staff noted how unusually thirsty he was.  The pre-school discussed this with the HV and it was decided that because of the concerns a Professionals' Meeting would be held the following Wednesday (4th December)at the Pre-school. This meeting was attended by a social worker from the Unit and eight other professional staff involved with the family including Consultant Paediatrician 1, the HV, OT, Housing representative, Pre-school and Portage workers. The social worker recorded the concerns as including failure to attend appointments, poor engagement with some professionals, Child K's poor weight gain over the past year and Mother not following professional advice. There is no record of what actions were agreed at the meeting to  address these concerns and in the absence of any other evidence it appears that professionals were relying on CSC to progress a s47 investigation to an initial child protection case conference. (There are conflicting accounts as to whether professionals were given information that this was already agreed. Some attendees understood that, as the meeting included everyone from the Early Support network it was part of that process and its purpose was to gather information to see if concerns warranted a referral to CSC; others understood that the s47 had already been initiated.)  8.42 The following day (5th December) the CSW had a telephone discussion with a Local  Authority lawyer about the referral information from the Consultant Paediatrician. The  outcome of this discussion, referred to by both CSC and Legal Services as a Legal  Planning Meeting, was that CSC needed to obtain clarity from Consultant  Paediatrician 2 about whether Child K's health needs “merited the shortest possible  15   PLO9 period (4 weeks). Dependent on the response, managers should be approached for  immediate permission to issue or CAM10”.  8.43 There is no evidence on either agency's records  that Consultant Paediatrician 2 was  consulted. However, in interview, Consultant Paediatrician 2 recalled being telephoned on  her day off (probably Thursday 5th December) by someone from CSC asking for an opinion   about Child K's condition. Consultant Paediatrician 2 remembers telephoning CSC back and  saying that she felt he was at risk of significant harm. There is no record of these  conversations in either CSC or Health records.  8.44 The next day the Group Manager decided to progress the case via an initial child protection  conference and assessment. The assessment was to consider Mother's “ability to engage  with social care and address the concerns..... a really tight time scale …. and if no change  evidenced, progress to PLO/care proceedings”.   8.45 However, that weekend, on the Sunday evening, Child K was admitted to Hospital 1 as there were concerns he might have a chest infection. This proved not to be the case and he was discharged the next day having been seen while he was in Hospital by Consultant   Paediatrician 1. Consultant Paediatrician 1 spoke with the CSW and they had agreed there  was “no indication to change the current safeguarding plan”. The Reviewer has found the  decision to discharge Child K difficult to understand (especially in light of the fact there was  no obvious Safeguarding plan in existence) as his hospital admission could have been an opportunity to address the concerns about his weight and care that Consultant   Paediatrician1 had raised less than two weeks previously when she was so shocked by his  appearance that she had wanted to admit him. No evidence was presented to the review  that indicated that these concerns had alleviated – his weight was “stable”, i.e. it had neither/increased or decreased since he was weighed on 25th November. In discussion staff  reflected that, at the time, it had been felt that the planned initial child protection   conference was the route by which concerns would be addressed and that, in light of the  inherent risks of being in hospital (infection etc. which could be particularly dangerous to  Child K) they felt that he was appropriately discharged.  8.46 In the week between Child K's discharge from Hospital 1 on 9th December and the initial   child protection conference on 17th December, the only professional contact with the    family was a home visit by the HV on 11th December to do Sibling's 12 month assessment.   On the same day Child K attended pre-school (for the last time, it subsequently became   apparent) who logged a concern in their own records about his clothing (he was in a sleep   suit that smelt strongly of urine).  8.47 The Initial Child Protection Conference was held on 17th December. It was very well    attended by personnel from  a wide range of agencies including both Consultant                                                   9 Public Law Outline (PLO) is a system for case management which came into force in England and Wales in April 2008.It aims to reduce the need for care proceedings and to speed up those that are necessary. A key change to the system was that councils had do much more of the work before the case got to court, including kinship and residential assessments, the idea being that the case would then be dealt with more speedily once it was presented in court.  10 Cambridgeshire Allocation Meeting - the authorising meeting for decisions regarding care proceedings etc.  16    Paediatricians. Some of the professionals who attended the conference told the review that   the risk from domestic abuse had been the focus of the discussions rather than the    concerns about the quality of the care the children received and Child K's weight. From the   minutes of the meeting it is apparent that the risk of harm from domestic abuse was the   first concern discussed. Other issues, including the number of appointments Child K had   missed with professionals, his failure to gain weight and Mother's lack of engagement with   services were also considered.   8.48 The outcome of the conference was that Child K and Sibling would be subject to a child  protection plan because of neglect. The recorded reasons were : � “Mother had failed to consistently meet Child K's ongoing health needs; this has been evidenced by her missing numerous appointments with Child K's hospital, and community paediatrician and other health professionals. � Child K's weight has dropped 5 centiles and most recently Mother declined for Child K to be admitted on ward in order to enable his weight to be monitored. � Child K was noted by health on his most recent appointment to be unkempt and wearing inappropriate clothing for the cold weather”.   8.49 Three days later the Core group met and it was reported that Child K's weight had increased by 0.8 kgs to 9.9 kgs. Staff had made particular effort to ensure that the fortified milk prescribed by the dietician was delivered to the home and that Mother had enough to last over Christmas. The core group developed the detailed protection plan which addressed:  the keeping of appointments;  � practical care of the children (cleanliness, clothing etc) � ensuring Sibling's needs were not overlooked,  � the impact of the domestic abuse � debts to Housing and issues with benefits claims  � Mother's low mood � professionals' lack of knowledge about the support available from Mother's family  There was no specific mention of Child K's weight or nutritional requirements or of the  expected level of frequency of visits.  8.50 A Police Officer called on at the home on Christmas Eve in order to obtain further information about the domestic abuse incident in October and during her visit saw both  the children. Mother and the children spent the afternoon of Christmas Day with Mother's family. Maternal Grandmother Mother recalled that Child K had been tired and had been put to bed. The social worker made an unannounced visit on 31st December but no one was in.  In the early hours of 1st January 2014 Child K was found dead in his bed.   9. ANALYSIS OF THEMES 9.1 The key practice episodes identified a number of themes. These themes were explored  with Agency Report authors and at the Practitioner Event and are further considered in  this analysis.  The overarching themes are � the impact of Child K's disabilities on professional behaviours and assessment of risk  17  � professionals' relationship with Mother  � role of Father and other family members and agencies' understanding of it � systems and processes � information sharing � voice of the child  Impact of Child K's disabilities on professional behaviours and assessment of risk  Consistency in professional behaviour  9.2 Child K was born very prematurely - “at the edge of viability” - and so was very vulnerable  but the professionals who were involved with him in Hospital 2 (where Child K was cared for in the NICU) did not have any concerns about the parents interaction with themselves or Child K. Staff at Hospital 1, however, were alert to the increasing disparity between Child K's family involvement and that of other babies in their care and raised concerns appropriately.  However, it is difficult to reconcile a senior nurse's statement that she was more worried  about Child K than any other child she had cared for and the fact that a professionals'  meeting had agreed that parents' permission to accommodate should be explored with the acceptance by all involved that Child K should be discharged to his parents' care.  9.3 This dichotomy was explored at the Practitioners' Event with the conclusion that staff had  felt that, because CSC would remain involved, there was “a safety net” which would act if  Child K's care was not at an acceptable level. Whilst CSC does have the ultimate  responsibility for ensuring safety, in this case the assessment of risk very much needed to  be informed by the specialist knowledge of people accustomed to the care of very  vulnerable babies with complex needs and those people must remain vigilant to risk and  remain actively involved, working alongside the “child protection specialists” in CSC.   Similarly, when Paediatric Consultants raised concerns in November 2013 that were  responded to by CSC instituting a s47 enquiry, health professionals relaxed in the belief that  a child protection conference would be convened.  No discharge planning meeting was held  to inform the responsible CSC unit (who were not specialists in disability issues) of the  specific risks that Child K's condition imposed. A case conference does not protect children – it is a process. It is the robustness of the plan and the involvement of all agencies and the  family, which will ensure the needs of the children  are met and that they are kept safe.   9.4 The apparent lack of consistency, with professionals expressing a high level of concern and  then subsequently appearing to be less concerned, was a theme that ran through the key  practice events and was compounded by  a tendency to focus on “the concern of the  moment” rather than seeing the whole picture. The most extreme examples involved  Child K's initial discharge from hospital and Consultant Paediatricians' assessment that he  needed to be admitted in November 2013. On both occasions the high level concerns  seemed to dissipate in a relatively short time and, although in the review process  practitioners were able to explain rationales for the apparent diminishing of concerns these  were not robust. Additionally, thinking from a social learning theory perspective – which  acknowledges the impact that the social environment (other peoples' behaviour) has on an  individual's learning - Mother did not receive a consistent message about the level of  18   concerns professionals had.   Concerns about weight  9.5 Just before the second referral to CSC (in July 2012) Child K had undergone a heart  procedure, which, medical professionals informed the review, would have meant he would  have started to put on more weight. (While his heart was not functioning as it should, he  would have been using up more energy and would not have gained weight.) Initially  following the heart procedure his weight did improve but this progression stopped around  November/December 2012 and the  detailed dietary history taken by the Dietician in  November 2013 revealed that his weight had dropped from the 50th centile to the 0.4th  centile during  the course of the year. It is difficult to reconcile this with the fact that he was  being seen very regularly by a variety of professionals, for some of whom weight  monitoring is  core business,  and yet little action was taken.  9.6 In January 2012, at a consultation with the Consultant Neurosurgeon Child K's weight was  recorded as being on the 50th centile.  There is no record of his weight at the two  subsequent neurological appointments that he was taken to, one of which was in October  2013, by which time it can be assumed his weight was concerningly low. From the parents'  perspective (both were at this appointment) it must have seemed that medically, there was  no concern about his weight as from their experience, professionals were rigorous in  following up issues they were concerned about.   9.7 Mother had raised concerns about Child K's weight at an appointment with Consultant  Paediatrician 1 in May 2013 where he weighed 9.35 kgs (9th centile) and he had been  referred to a dietician, indicating that although it was thought that some expert input was  needed, there was not a level of concern about his care and feeding that indicated a  referral to CSC was needed. There is no evidence that  any particular measures such as  specific input from the HV was requested.  The Family Support Plan, developed in July 2013  and reviewed in September 2013 noted the need for Child K's growth (both his height and  weight) to be monitored and specified who should do this, but there is no evidence that  this was done.  9.8 Child K was not weighed by HVs on any systematic basis. The reason for this is two-fold:  firstly, the HV felt that as Child K had regular outpatient appointments at Hospital 1 he  would  be weighed then and secondly, it was felt that “disturbing” Child K by undressing him to be weighed (his stiffness meant that undressing him could be difficult) was intrusive.  However, it was well known to the professional system around Child K that attending  appointments was an issue and so the outpatient attendances could not be relied on and, if  it was felt inappropriate to undress Child K for regular weighing it would have been possible  to allow for the weight of his clothes and keep a record, albeit less accurate, of his failure to  gain weight. The HV team has a weight monitoring protocol which requires referral to  hospital if a child's weight drops more than two centiles. Had Mother's concerns been  listened to and Child K been weighed more regularly by the HV team and this protocol been  adhered to, the professional system would have been alerted to Child K's failure to gain  weight sooner.    19  Recognising risk  9.9 Health professionals explained to the review how, up until the age 2, a baby's  developmental milestones are adjusted to take account of their prematurity.  This means  that a baby like Child K, born 15.5 weeks prematurely, will have an adjusted age of 8 months when he is chronologically a year old. Potentially this influenced people's perception of what was appropriate behaviour in caring for Child K. Professionals noticed that Mother continued to treated him like a baby for example in the clothes he wore and how she carried him but it is less clear that they were rigorous in clarifying with her the need to adjust his feeding regime to make it age appropriate as he grew older. Practitioners  reflected that as Sibling grew older the contrast between him and Child K became more  obvious as Sibling passed milestones that Child K was yet to meet.  9.10 In their report of a thematic inspection of services to disabled children (2012) Ofsted noted  that  according to the child in need census of March 2011, 14.2% of the children in need in  England were recorded as having a disability and at the time only 3.8% of the children who  were subject to a child protection plan were disabled, suggesting there was an under  representation of disabled children being identified as at risk of significant harm. It is possible  that this was due to disabled children being better supported and therefore any risk identified  and addressed before they suffered or became at risk of significant harm. Earlier research  (Sullivan and Knutson 2000)  found that disabled children and young people were 3.4 times  more likely to be abused than their non-disabled peers, and neglect was the most common  type of abuse experienced by disabled children. Cambridgeshire figures suggest that they  follow the national trend with recent figures showing during 2014 the number of disabled  children subject to child protection plans ranged from 5% - 1%. (It is possible that the  figures do not accurately identify all  disabled children subject to plan but it is unlikely that  the unidentified cases would bring the numbers up to a level where there was a  proportionate representation of disabled children subject to child protection plans.)   9.11 Bearing this evidence in mind, the under identification of risk to disabled children is  irrefutable. Caring for a child with Child K's level of needs would challenge many parents.  Child K was the first child of a young and vulnerable mother and although there was a  degree of professional recognition of some of the risks their combined needs represented  there was not a consistent holistic oversight of it, with practitioners addressing their own  professional concerns and expecting others to address other aspects. For example, health  relaxing when they thought CSC would take care of child protection issues and CSC  expecting health professionals to “monitor”.  Professionals' relationship with Mother   Perception of Mother  9.12 At the Practitioner's Event it became apparent that professionals did not have a consistent  perception of Mother's understanding of Child K's needs, or of her ability and commitment  to meeting those needs. Staff reflected, possibly with the benefit of hindsight, that  Mother related to some professionals better than others and concluded that the ones she  got on well with were  people she viewed as being able to assist her in ways she  20   perceived as particularly useful i.e. over money, housing etc. but she was less engaged with  disability “specialists”. Staff from the Children's Centre noted that despite considerable  efforts on their part they were unable to ensure Mother brought Child K to playgroup  although she did engage with pre-school.   9.13 Without Mother's participation in this review it has not been possible to confirm whether  this selective engagement was due to the varying implications of the professionals'  involvement. Attending the playgroup and “specialist “activities required her active  involvement whereas the other professional involvement provided direct services to her or  did not require effort on her part. Viewed through a different lens it is possible to identify  this behaviour not as mercenary or callous on her part but as defence mechanisms against  facing up to the reality of Child K's disabilities. Nevertheless, there is also evidence that  Mother did relate better to some professionals than others in the same role suggesting  that  there were interpersonal issues at play not just a reluctance to engage with people in  certain professional roles.  9.14 Despite the review not having had direct input from Mother it is apparent that, in caring for  Child K with his significant and complex needs as well as a younger child, she was having to  cope with a situation that would have challenged many carers. She was a young parent,  with limited practical and emotional support, financially-challenged and who had had a  difficult personal history. It is unclear whether there was sufficient appreciation  amongst  the professionals involved, of the implications the combination of Mother's  vulnerabilities could have on her care Child K.  Balancing support and risk  9.15 At the Practice Event staff agreed that professional attention had been concentrated on  Mother and her needs rather than on Child K and his needs and reflected critically on  this. However, as noted in the analysis of service provision to disabled children and  their families (Ofsted 2012) “helping the parents (is) a prerequisite for ensuring that the  children (get) the support that they need”. Given Mother's situation and lack of   support networks, she was inevitably going to need more professional support than most.  What is critical is that the adult's needs are not allowed to divert professionals' awareness  of potential risk to the children. Research into disabled children and child protection  (Scottish Government 2014) found that some professionals considered that they “had  unwittingly been too sympathetic to the parent's situation and potentially underestimated  the risk posed to the child”. In this case there is evidence that although professionals were  appropriately concerned that Child K was deprived of opportunities to maximise his  potential, until November 2013, this was not being viewed as a safeguarding concern.  Disguised compliance 9.16  The review process has considered whether there was an element of “disguised compliance”  (Reder, Duncan and Gray 1993) in Mother's behaviour.  Disguised compliance involves a  parent or carer giving the appearance of co-operating with agencies to avoid raising  suspicions, to allay professional concerns and ultimately to diffuse professional  intervention. Although there was not an overall consensus, it was agreed that Mother's  behaviour, in general, was more consistent with a disorganised and distracted young parent  21   rather than with someone who was deliberately trying to mislead.  9.17   However staff reflected on the frustration they felt when Mother was not receptive to  suggestions and offers of support they made which could have eased the organisational  difficulties she was experiencing. The review has identified a dichotomy between  professionals' empathy with Mother and lack of curiosity about her history which was not  known to most in any detail. It is possible that had practitioners known more about   Mother's childhood and adolescence they would have been able to rationalise some of her  behaviours but it would have also alerted them to the additional risks.   Role of Father and agencies' understanding of it 9.18 Studies of SCRs (Brandon et al 2011) have consistently identified that professionals have  not sufficiently involved and taken account of men's roles in the lives  of children subject to  review. Other research has shown that, in the case of disabled children, professionals  side-line fathers by talking to mothers and ignoring the fathers (Tower and Swift 2006). In  this case there is evidence that Mother and Father were opaque about Father's  involvement as Mother was claiming benefit as a single parent and Father was in   employment at times during the scoped period. Nevertheless Father is explicit that, up  until the domestic abuse incident in October 2013, they were living (and parenting)  together.  It is difficult to reconcile this with professionals' perception that he was only  intermittently  involved and that he “sofa-surfed” between his children's mothers' homes  and was “never really” at Mother's home.   9.19 Given the amount of professional involvement, the concerns people had and the fact that  two core assessments as well as a number of other assessments were completed during  Child K's life time, a clearer understanding of the parents' relationship would be expected.  The first assessment completed by CSC (undertaken after Child K first went home from  hospital) included Father, but he is not visible in their subsequent assessments. He is  recorded as having been at the Early Support meeting in July 2013 when the first Family  Support Plan was drawn up. The plan itself does not identify a role for him although under  Wider Family/Environmental Needs  it is recorded that he “sees children regularly  supervised by a friend”. As this meeting was held within a few weeks of the June domestic  abuse incident it is likely that Father's bail conditions precluded him attending a meeting  where Mother would be present and the record of his presence is in error.   9.20 What is apparent is that Father continued to play a role in his other families' lives – he  attended a Triple P parenting course with the mother of three of his children in the autumn  of 2013. He is now living with this mother and the children and caring for Sibling. This  suggests he was not exclusively with Mother during Child K's life. It is apparent from meeting with Father that he considers himself as an active and committed parent to all his children.  The HV for his “other” family concurred with this, saying he “was wonderful and a good father”.  There was social work involvement with this “other” family – two of the children have additional needs. However there was little evidence of workers sharing information  and understanding the implications – for both families – of Father's duplicate families.   9.21 It is not clear what impact this situation had on Mother's sense of security and whether  22   professionals were sufficiently curious about the relationship and the effect it was having  on Mother's mental well-being. The Children's Centre staff felt that the fact that the  mother of the elder children was involved with the Children's Centre was a factor that  contributed to Mother's lack of engagement with them.  9.22 In the meeting with the reviewer Father was reflective about how he had struggled to  come to terms with Child K's diagnosis and the implications of long term disability but was  less prepared to acknowledge that Mother may have had the same experience. He was also  very critical of her practical parenting, repeating similar concerns he had made when he  was arrested following the domestic abuse in June 2013.   Systems and process  Interaction between Early Help, Early Support and CiN systems  9.23 There is evidence that at times, professionals were unclear about the role and function of  the various meetings that were convened. In addition the “step up” and “step down”  systems to and from CSC were not effective. From a systems perspective this confusion was  contributed to by the  interplay between the Early Help, Early Support and CiN processes in  operation. Having three systems through which the needs of a disabled child under the age  of 5 and their families can potentially be addressed seems unnecessarily complicated.  9.24 Early Support is a model which aims to improve the delivery of services for children who  have complex  additional needs such as they meet levels 3 or 4 of Cambridgeshire's Model  of Staged Intervention (MOSI)11  and their families. It is delivered through services working  together using the CAF and the Family Support Plan as tools for a single holistic assessment  and planning process with a lead professional taking a key worker role.  Early Help refers to  preventative and early intervention and support provided to families which is aimed at  stopping problems deepening, avoiding crises and ultimately  reducing the demand for  specialist and statutory services. Again the CAF is the tool which supports the identification  of need and preventative action and a lead professional, who has the experience and the  resources that are best able to meet the needs of the family, is identified. Children needing  Early Help will meet the MOSI levels 2 or 3. When a child is the subject of a CiN or a child  protection plan that plan “takes precedence” over Early Support's Family Support Plan and  the CAF's Support Plan.  9.25 The process for transferring responsibility from CSC to Early Support was described as  “work  in progress”. There are ‘step up’ and ‘step down’ processes between Locality Teams12 and Social Care which have been in place since early in 2012. Logically the same                                                  11 The MOSI provides a framework for developing a common understanding of children’s needs, a shared understanding of the roles and responsibilities of services and aids practitioners in understanding the thresholds of different services. Cases meet MOSI level 2 if there are additional needs which require a targeted approach from additional services on top of universal provision; Level 3 if they have complex needs and require professional intervention from more than one agency and level 4 if the needs are complex and enduring and cross many domains. 12  Locality Teams provide advice and support to families who need additional help with parenting including providing young people with information and advice on education, employment, training and personal development opportunities; working with students who have behavioural problems by supporting schools; helping ensure children attend school regularly and punctually;  23  process should be used when a child has needs that warrant Early Support involvement. It was suggested that, although systems work well between the Disabled Children Units and Early Support, there is less effective liaison between the Access and CiN Units and Early Support. The fact a child is subject to Early Support involvement is now flagged on the CSC  electronic system  and this should assist in ensuring a seamless transition between services.  Without a robust process there is a risk of either duplication or absence of a plan as a child   transitions between the systems. This is illustrated by the fact that once Child K's case was  closed  to CSC (in March 2012) after their first involvement, Child K was not subject to a  support plan or any form of care coordination plan until the case was reopened by CSC in  September 2012.  The  Guidance Notes on the Early Support Pathway (updated 2014) are  complex in themselves and are not likely to be a useful working document for busy  frontline professionals.   9.26 In Child Ks's case, in October 2013, when the IAT were undertaking a threshold assessment  they did not contact the Lead Professional for information about whether appointments  were being missed. There is now a system for flagging Early Support and Lead Professional  involvement on CSC's electronic record but no such system was in place at the time to  prompt IAT staff to consider whether a disabled child had a lead professional under the  Early Support arrangements.  The professional the IAT did contact for information  following the domestic abuse incident in October 2013 was able to provide some  information but also did not suggest the Lead Professional should be contacted. This  indicates there was not a confident understanding of the lead professional role embedded  among those professionals working in the Early Support system, or among non-specialist  workers such as those in the IAT.   9.27 Cambridgeshire's CAF Board is currently considering how the learning that has developed  about the Early Support Family Support Plans can be used in their development of a Family  CAF so that planning for children and their families following the Early Support pathway  and CAF pathway both use the same paperwork. This is a step in the right direction but  further consideration needs to be made as to whether two different processes are needed  and whether the needs of young disabled children and babies and their families who do  not need CSC involvement can be met using the existing early help mechanisms.  9.28 CSC were involved with Child K at six different times during his life. For two of these periods  (following referrals 1 and 3) the involvement was for quite a long time – five and eight  months respectively. The first of these was when Child K was first discharged from hospital  and the other following the referral from Consultant Paediatrician regarding missed  appointments in September 2012. Both times the ongoing CSC involvement was  precipitated by the completion of a core assessment. These assessments were “very  comprehensive in detail” (CSC agency report) and covered most of the expected areas of  the assessment framework very adequately.  It is the analysis, planning and resultant  intervention that was less effective.    9.29 When CSC were involved Mother was reported to better manage to keep the health  appointments although it is not apparent what CSC did to help her achieve this – or what  structures they ensured were in place to maintain this when the case was closed. The                                                                                                                                                                   providing specialist support for young people needing help in the transition to adulthood  24   professionals involved believed that Mother knew from her own childhood experiences the  powers CSC could exercise and so “toed the line” while social workers were involved  because she did not want to her children to be taken into care. However this does not  explain why she avoided appointments with CSC as often as she did with other  professionals when the case  was open or why, if she understood the system (and therefore  knew reverting to missing appointments would result in another referral to CSC) she did  not manage to maintain a good enough attendance.   9.30 The author of the CSC agency report noted that although the parents' history was a key risk  factor, the assessments that were completed did not consider how this would impact on  the their ability to care for a child with the significant needs Child K had. Similarly, there  seems to have been little curiosity about the extended families and their role. Given that  both parents had known troubled and possibly abusive experiences as children, a clear  understanding of their role – and any potential risk this indicated – would be  expected. It is  not clear whether the fact that Child K was a disabled child lessened anxiety about this.  9.31 The referral in September 2012 (referral 3) was made by Consultant Paediatrician 1.  Identical concerns had been raised the previous month by the OT and HV. The reason why  no action was taken in response to the earlier concerns was because they were seen to be  the same as those that had been raised in referral 2 (in July 2012) and it was considered  that the initial assessment completed in July had addressed them. This is a debatable  decision: it appears that no re-evaluation of the initial assessment was done to see if, in  light of the concerns being raised again, whether the assessment's conclusion remained  valid.   9.32  When CSC received the last referral in November 2013 the significance of the concerns were recognised to the extent it was immediately allocated to a Social Work Unit. However,  it was not allocated to the Disabled Children's Team despite Child K's needs being the  primary cause for concern and it had already been agreed that future referrals should go to  the DCT. Child K's complex needs meant that he clearly met the threshold for the DCT  involvement. The Unit to which the case was allocated was the same one as had been  involved both in June 2013 as well as when the case was open between September 2012  to April 2013. It is generally good practice for the same social workers to  be involved so  that they are able to build on their previous knowledge, relationships and experience of a  family when a case is re-referred to CSC.  However the Agency Author noted that the Social  Work Unit was under considerable pressure at this time –with the two social workers  both being newly qualified and coping with a high number of cases. There is no evidence  that this was considered in the decision to reallocate the case to the Social Work Unit or if there was active consideration given to allocating to the DCT.  9.33 The pressure the Social Work Unit was experiencing is a possible explanation why, given the  significant concern the Paediatric Consultant was expressing as well as the further issues  raised, there was no immediate response to the referral. Instead, the day following the  Paediatric Consultant's referral, a strategy discussion was undertaken by the Consultant  Social Worker (CSW) (the senior member of the Unit) and the Police. Cambridgeshire's  Safeguarding Children Procedures state that face to face strategy meetings should take  place when the child is disabled and that strategy meeting should include  member of the  25   medical team, ideally the medical consultant responsible for the child’s healthcare. In this  case, given that the concerns giving rise to the strategy discussion had been raised by a  Consultant Paediatrician this would have been particularly appropriate.    9.34 It was two days before a home visit was undertaken (on the 26th November) by the CSW  and a social worker. This is not a timely response and again is a possible reflection of the  pressure the Unit was under. The recorded purpose of this visit was to see the children and  to assess the home conditions and how Mother was responding to the children's needs.  This is quite a non-specific plan given that the overriding reason for the visit was  because a  Consultant Paediatrician thought a child was so underweight hospital admission was  indicated. The only reference to this concern in the CSC recording is a reference to the fact  Mother said that that she had been telling people that Child K was not putting weight on as  he should. The social worker attended the Professionals' Meeting on 4th December and the  fact that the discussion with Legal Service took place after this suggests that the  information heard there heightened CSC concerns.  9.35 There is no explanation why there is no CSC record of the conversation someone had with  Paediatric Consultant 2 following the Legal Planning Meeting. Similarly there is no record of  it in the health records either and Consultant Paediatrician 2 is unable to remember  whether she made any record but recalls that she was phoned on her day off and was not  back at work for a further three days which may account for why it was not on Child K's  hospital record. No explanation has been offered as to why it was Consultant Paediatrician  2 that  was contacted. The legal planning meeting notes stated that Consultant  Paediatrician 2's opinion should be sought but there is no evidence that there was any  consideration as to whether Consultant Paediatrician 2 was the most appropriate medical  opinion to seek. In light of the fact that Consultant Paediatrician 2 had only seen Child K on  very few occasions, and that Consultant Paediatrician 1 had had longer term involvement –  and was the Paediatrician who had made the statement “worse she'd ever seen him”– it  could be assumed that her opinion would have more validity.   CP conference  9.36 The conference was very well attended with all the agencies involved with Child K  represented. The only notable absence was that there was no legal advisor. The review  learnt that some years ago a decision was made in Cambridgeshire that although Legal  Services would be routinely notified of cases going to initial child protection conferences,  legal advisers would not attend conferences. The basis of this decision was that if legal  advice was needed it could be given to social work staff and/or the conference chair either  before or after the conference – depending on the circumstances and the urgency with  which the advice was needed. This approach means that legal advisers do not have the  opportunity to hear the detailed multi-agency discussions and decision making that  conferences allow and which could inform their advice.  9.37 The Police representative at the conference was from the Domestic Abuse Specialist Unit  rather than a from the Child Abuse Unit. This may account for why the primary focus (both  in staffs' recall and also reflected in the record of the meeting) was the domestic abuse. The  conference record does show that the weight/growth issues were explored but in the  26   context of missed appointments and Mother's failure to robustly undertake the therapeutic  activities that professionals recommended rather than the primary risk that Child K was  exposed to. Nevertheless the stated reasons for making the children subject to child  protection plans are clearly around issues of neglect rather than the risk of harm from  exposure to domestic abuse. However the child protection plan that was subsequently  developed is not focussed on risk and contains no reference to Child K's weight or feeding.  Agencies' context  9.38 During the autumn of 2013 CSC were experiencing an unprecedented increase in referrals  with the consequent impact on all services. The Unit that the case was allocated to was  acknowledged to have been under particular pressure with a high number of cases  allocated to it. In addition, the two social workers in the Unit were both newly qualified  which would have placed an additional burden on the CSW. In this period, in one month  alone, 91 children were made the subjects of a child protection plan (approximately four  times more than the average monthly number in Cambridgeshire at the time) indicating  that the child protection conference service would also have been under pressure.   9.39 This increase in volume of cases inevitably impacted on Legal Services' capacity as well  although this was not the reason why there was no follow up by the solicitor to find out  about the outcome of the discussion they had advised the CSW should be undertaken with  Consultant Paediatrician 2. The Legal Services' report identified that it is not usual practice  for Legal Services to do this because of capacity issues.   9.40 The Health Visiting Service noted that although capacity per se was not an issue for them  nevertheless many of their staff were newly qualified putting an additional burden on  experienced staff such as those involved with Child K. The review noted a general issues  that, becoming the  Lead Professional under Early Support arrangements is a considerable  commitment and that  capacity issues will affect staffs' ability and willingness to take on,  and be effective in this role. There was no evidence that this was an issue in this case.  Role of  Disabled Children's Service 9.41 In between the two episodes of Child K being subject to a CiN plan (between November  2011 and March 2012 and then again September 2012 to April 2013) the case was briefly  open to the Disabled Children's Team, in July 2012. The CSC timeline records that this was  despite the case being “not appropriate for DCT as Child K does not have a diagnosed  disability yet”. When the manager signed off the assessment that was completed by the  DCT, a comment that the case did not meet the criteria for Disability Services was added.  Both these statements imply that Child K, a child with profound and long term disabilities  but who did not yet have a formal diagnosis should have their social work needs addressed  by generic child care social workers. It is recognised there is a need to define the role of  DCTs  to ensure their specialist skills are utilised in the most efficient and effective way but  it is questionable if using whether a child has a medical diagnosis or not is the most  appropriate criteria and does not seem to be in keeping with a social model of disability.   9.42 The review has been told that the Disabled Children's Service was redesigned and re-launched in April 2012 and that the practice described above, although it was after the  27   new service had been set up, is more indicative of the earlier model than current practice.  The review was told that under the new arrangements the Disabled Children's Units  undertake the full range of social work tasks for disabled including undertaking s47  enquiries and undertaking responsibility for looked after children as well as providing the  specialist support that disabled children and their families require. The criteria for the  Disabled Children's Service to become involved with a child is defined as  “the needs of the  disabled child or young person are beyond those of a non-disabled child of the same age  and means they are likely to require lifelong support in the future from statutory services”.  It is clear that Child K would have met this criterion.   9.43 However, when a referral was made to CSC in June 2013 following the first domestic abuse  incident and the Threshold Assessment completed by the IAT concluded that a CiN  assessment was needed, the case was allocated to a mainstream social work unit and not  to a Disabled Children's Unit. The reason why it was not allocated to the Disabled Children's  Service, as had been stated it should be when next referred, was because the concerns  were not seen as ones relating to Child K as a disabled child and therefore did not need the  specialist lens provided by Disabled Children's Service. Had a social worker with an  enhanced level of understanding about the impact of disability and prematurity on child  development become involved in June 2013, a better understanding of the concerns  (besides the domestic abuse) that were emerging at this time might have been obtained.   Recording and information sharing 9.44 Some of the agency reports identified shortcomings in recording and it was also apparent  from comparing timelines and discussing agencies' activities, that there was missing and  contradictory information about events e.g. the letter about Child K's diagnosis of cerebral  palsy did not get attached to his social care record and the SEN service understood that  some of the meetings they were attending were CiN meetings although the case had been  closed to CSC. The titles of meetings were described on several occasions differently by  various agencies. What a meeting is called is more than a semantic issue. The title of the  meeting clarifies who should be there, the function and expected outcomes. Parents would  be expected to attend TAC,  CiN and Family Support Meetings but not  a professionals'  meeting. A strategy meeting has a specific function in agreeing whether the threshold for a  s47 investigation is met and whether the investigation will be undertaken jointly by the  Police and CSC or by one or other agency alone.  9.45 There were some deficits in information sharing between agencies (although staff felt that   information sharing within agencies had been strong and there was no evidence to  contradict this view.) The Lead Professional cited a number of instances when she had not  been made aware of significant information by CSC including the closure of the case in July  2012. The fact that the CSC electronic system did not then alert social workers to the Early  Support involvement was a possible reason for this. She had also not been aware of the  domestic abuse in October 2013. There is an agreed system by which CSC disseminate the  Police incident reports to Health partners and how they are entered on to Systemone (the  health electronic record) so that HVs and school nurses have access to the information.  However, the review has identified that although Allied Health Professionals also use  Systemone they  do not necessarily have access to this information (due to the system  having been set up differently for different disciplines).      28   9.46 However, notwithstanding this, it is difficult to understand how CSC  concluded  their  assessments without speaking to and clarifying with Child K's lead professional her  perception of the situation. This was particularly relevant considering one of the rationales  for not allocating the case for assessment in November 2013 was that there were currently  no concerns about missed appointments. The reviewer considers that the complexities of  the Early Help, Early Support and CiN systems (discussed earlier in this analysis) led to  confusion and affected practitioners' understanding of who was currently involved and  therefore, who needed to be included in any information sharing.   9.47 The medical staff were diligent in copying CSC into letters although the agency report  identified that they did this without an awareness of whether the case was currently open  and without any clear intention i.e. were they sending the letter as a referral, for  “information only” or for another reason? However there was evidence that these letters  did not consistently get entered on to Child K's social care record. At the time CSC were  transitioning from one type of electronic case record to another and this may have  impacted on the system for entering documents on to the case file.  9.48 Child K's GP practice - who only saw him twice in his life – also received numerous letters,  usually addressed to other health professionals but cc'd to them. The GP practice  therefore potentially had an overview of the total of the missed appointments but did not  have a robust system for identifying whether there was any action they needed to take.  The Practice  has recognised  there were deficits in how these letters were dealt with and  have taken subsequent action to improve processes. However both these examples  illustrate that information sharing is about more than delivering a piece of information –  context, expectations about actions  and outcomes are all essential activities that need to  be integral to make the process robust and effective. These letters illustrates the need  to  take professional responsibility for both the sending and receiving of information  Voice of the child 9.49 It is appropriate to consider how Child K's voice was heard and responded to during the  course of agencies' involvement with him. There are examples, quoted in the agency  reports, of  workers identifying his mood via his responses to them and to Mother. It is also  apparent from the discussion at the Practitioners' Event that his individuality and  personality were recognised and responded to by those professionals who knew him best.  Nevertheless it is salutary to reflect that despite this, those professionals were not able to  recognise that Child K was not receiving sufficient nourishment.  9.50 The core assessments both make reference to Child K's positive responses to his mother and how he indicated that he could differentiate her from other people from a very young age. Professionals refer to examples of Mother playing with him, getting down on the floor with him or enjoying his reaction to a stimulus. As he grew older Mother found if difficult to  respond to Child K in a way that was age appropriate. It is likely that she the way she did care for him did not assist his development. For example, not establishing routines such as  washing and getting dressed in the morning which would help him to start learning the  difference between day and night.   29   10. CONCLUSIONS AND LESSONS LEARNT Conclusions 10.1 This review has sought to establish whether those involved with Child K were aware of the risks that he was exposed to. It also sought to identify any factors that either promoted or inhibited agencies and individuals to act to ensure his safety. The conclusion is that although Child K died from an infection which was possibly not preventable, the underlying dehydration and malnutrition that the post mortem revealed and which contributed to his vulnerability to, and lack of resilience to recover from infection, was potentially avoidable. A criminal investigation concluded that Mother had neglected Child K but process of this review has shown that professionals, as well as Mother and to some extent Father, were aware of and concerned about Child K's nutrition but effective action to address the concerns was not taken.  10.2 With hindsight a pattern of concerns about Child K’s weight being raised but not being seen as evidence of risk of harm has been identified.  This review has concluded that despite the involvement of committed, experienced and concerned professionals, there was a lack of focus on risk.  10.3 Caring for Child K with his complex needs would have challenged the most supported and well-resourced parent, especially once Sibling was born. Mother was a vulnerable young woman with little informal support, living in poor housing, with financial difficulties and an ambiguous relationship with the children's father. It was inevitable that she would struggle with his day to day care. Whilst Mother clearly loved Child K and wanted the best for him, her own childhood and adolescent experiences were also likely to impact on her receptiveness to formal support and professional intervention.  Lessons learnt 10.4 While some of the professionals involved were sympathetic to Mother's situation, it is not clear that they were sufficiently curious about her history and life experiences and therefore did not recognise the significance of her vulnerabilities and the consequent impact on her care of the children. The support that was provided to her was focussed on her compliance with professional advice. There was not sufficient focus on risk. Risk is more difficult to identify when it has a chronic component and when practitioners are seeing the child regularly there is a risk of them becoming desensitised to it. A recent study into neglect has also identified that practitioners become de-sensitised to children’s difficulties through habituation when undertaking medium- to long-term work (Farmer and Lutman 2012). Risk from neglect is also more difficult to identify and focus on when there is ambiguity about how much the child's disability is a factor.  10.5 The review has considered whether Child K's situation should have prompted a response under s47 sooner than it did. The conclusion is that it is not the designation that counts - child protection  ‘rarely comes labelled as such’ (Laming 2009) - but it is the action and intervention that matters. Decision making must be based on an assessment of cumulative risk and harm as well as need. CSC's responses to referrals need to take account of the repetition of previous concerns and the cumulative impact on the children. Child protection processes and CSC involvement of themselves do not protect children. In addition the right people need to be involved . Whilst CSC have the ultimate responsibility for the assessment of risk and ensuring  30  safeguarding the expertise and knowledge of health professionals was needed to inform the multi-agency assessment of risk. Professionals need to take responsibility for addressing concerns through their own safeguarding systems and escalate their concerns if they feel that they are not being responded to appropriately. 10.6 The lives of children with disabilities and their families are complicated enough as it is. Systems that are there to support them need to be transparent and easily accessed and understood as possible. Despite individual practitioners' best efforts there was not a seamless transfer of plans of how Child K's and the family's needs were to be met between CSC and Early Support. The specialist knowledge of the social workers in the Disabled Children's Service could have provided a clearer understanding of the risks Child K was exposed to but despite the redesign of the Disabled Children's Service, and Child K clearly meeting the threshold for allocation to their services, their involvement with him was limited and the system for co-working and offering support to mainstream services was not effective. 10.7 The review identified learning about the need for professionals to be clear about the  purpose of letters they send and of their expectations of the recipients, especially when  copying others in. Similarly, agencies need to have robust systems for the receipt and  consideration of the content of letters sent. Another learning point relating to  communication practice was identified in relation to the need to make a record of  conversations and advice given when a professional is contacted outside working hours. Good practice 10.8 The review also identified examples of strong practice by individuals and agencies. It was noted that the HV met Mother and Child K while he was still in hospital and visited “over and above” the usual amount. A good handover between HVs when the family moved house ensured continuity of professional involvement.  There was good communication within agencies (if not always between them) for example between the Physiotherapist and the Occupational Therapist.  10.9 Some professionals formed respectful and trusting relationships with the family. Father said of the OT “she was the first person who made me feel Child K was a person not just a case”. In general, staff showed a willingness “to go the extra mile” when they felt it was needed e.g. HV accompanying Mother and Child K to Great Ormond Street Hospital and the Consultant Paediatricians seeing Child K opportunistically when he attended other appointments. The core group went to the family home when Mother was unable to get to the Children's Centre for the meeting.  10.10The pre-school were flexible in their provision of placement for Child K and admitted him  without waiting for funding and responded to Mother's asserted difficulties in the morning with provision of an afternoon placement.  11. RECOMMENDATIONS  It is recognised that actions have already been taken in relation to some of the individual agency's identified learning. In addition agency reports included a number of  recommendations which this review endorses. The purpose of providing additional  31  recommendations is to ensure that all professionals in the partner agencies of the LSCB are confident that the areas identified as of concern in this review are addressed.   Recommendation 1  Cambridgeshire Community Services NHS Trust review and then re-launch the Health Visitors' weighing protocol.    Recommendation 2  Arrangements should be reviewed to ensure that there is sufficient streamlining between with Early Help, Early Support and CSC services so that plans can seamlessly transfer between the various MOSI levels    Recommendation 3  The LSCB should assure itself that the role of lead professional in Early Support arrangements is clearly defined, understood and supported   Recommendation 4  CSC ensure that the changed remit of the Disabled Children's Service is embedded and that the system for sharing their specialist knowledge to support social workers across CSC is defined and understood.    Recommendation 5  The CSC  reviews the current systems for the provision of legal advice.   Recommendation 6  LSCB assures itself that it can be confident that it has robust data about the  safeguarding of disabled children   Recommendation 7 LSCB reviews the training provided on neglect and disability to assure itself that it provides sufficient focus on identifying risk when a child has a chronic health condition and that all relevant staff have received recent training.      32   References  Disabled Children and Child Protection in Scotland: An investigation into the relationship between professional practice, child protection and disability. The Scottish Government 2014  Protecting disabled children: thematic inspection  Ofsted 2012  Jones, L., Bellis, M.A., Wood, S., Hughes, K., McCoy, E., Eckley, L., Bates, G., Mikton, C., Shakespeare, T. and Officer, A. (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies Lancet 380 (9845), 899-907.    Sullivan P. M. & Knutson, J. F. (2000) Maltreatment and disabilities: a population-based epidemiological study. Child Abuse and Neglect, 24(10): 1257-1273.   A study of recommendations arising from serious case reviews 2009-2010A Marian Brandon,Peter Sidebotham ,Sue Bailey ,Pippa Belderson DfE 2011  Reder P., Duncan S. and Gray M  Beyond blame: child abuse tragedies revisited (1993)  Working with Neglected Children and their Families: Linking Interventions with Long-term Outcomes Farmer and Lutman 2012  Cambridgeshire LSCB Disability Task and Finish group action plan Jan 2015 v2 Jan 9th 2015  Laming H. The Protection of Children in England: a progress report. London, The Stationary Office  2009  The Cambridgeshire Early Support Pathway updated Guidance Notes September 2014  Munro review of child protection: final report - a child-centred system DfE 2011 Behind Human Error Woods D et al  Farnham Ashgate (2010) quoted in  Munro review of child protection: final report - a child-centred system DfE 2011   