Death of a 4-month-old girl in October 2013, suspected to be caused by malnutrition. Mother was charged with causing or allowing the death of a child and the neglect of Jamilla and her two older siblings; she pleaded guilty to manslaughter and cruelty. Mother was born in the UK to a Somali mother and white British father. Mother was taken to live in Somaliland at 12-years-old where it is understood that she was forced into marriage at 13-years-old and experienced domestic abuse and rape. Mother returned to UK with the help of the Forced Marriage Unit (FMU) and her father when she was nearly 18-years-old and pregnant with Jamilla. Mother's care of Jamilla and siblings was assessed as good, despite her age and vulnerabilities. Identifies themes, including: the rapid deterioration of home circumstances, highlighting that neglect can lead to risk within a very short period of time for babies and young children; and the impact and potential addictive features of social network use on parenting capacity. Uses a locally developed systems approach, based on the Social Care Institute for Excellence (SCIE) model, to present findings, including: focus of assessments on current levels of functioning within families, with insufficient consideration of the potential risks of ongoing vulnerabilities; practitioners not obtaining an understanding of the implications for mother of being dual heritage and lack of knowledge of family's views to mother having escaped a forced marriage; and the need for challenging the myth of persistence in neglect. Makes recommendations covering agencies including the FMU and housing services.
      
 Title:  ‘Jamilla’: serious case review. LSCB: Tower Hamlets Safeguarding Children Board Author: Edi Carmi Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                ‘Jamilla’ Serious Case Review            Report Author Edi Carmi 08.11.14      1  Contents 1 EXECUTIVE SUMMARY 3 1.1 Context 3 1.2 Summary of Case 3 1.3 Summary of Main Findings 5 1.4 Could it happen again? 9 1.5 What will the LSCB do in response to this? 9 2 INTRODUCTION 10 2.1 Initiation of Serious Case Review 10 2.2 Methodology 10 2.3 Structure of the report 13 3 CONTEXT 14 3.1 Family composition 14 3.2 Knowledge of family by professionals prior to period under review 15 3.3 Additional information of the history prior to 2012 from family members 17 4 APPRAISAL OF PROFESSIONAL PRACTICE 18 4.1 Introduction 18 4.2 Key events 18 4.3 13th – 30th October 2012: Mother returns to the UK 19 4.4 Provision of temporary accommodation in Tower Hamlets: 30th – 31st October 2012 20 4.5 Temporary accommodation in Tower Hamlets: 31.10.12 – February 2013 21 4.6 New home prior to birth of Jamilla: March – mid May 2013 26 4.7 Birth of Jamilla: May 2013 28 4.8 Post natal period: mid-May – end of July 2013 29 4.9 August to October 2013 32  2  5 THEMATIC ANALYSIS 35 5.1 Introduction 35 5.2 Neglect 35 5.3 Threshold responses & assessments of need 38 5.4 Thresholds for children’s social care involvement 39 5.5 Use of history in determining agency responses 41 5.6 Health visiting service provision 41 5.7 Mother’s co-operation with health services 43 5.8 Lack of co-ordinated multi-agency provision 45 5.9 Health practitioners knowledge of police notifications 47 5.10 Task centred versus relationship based provision of support 48 5.11 Social isolation: family contact with extended family and community 49 5.12 Shortage of housing resources 52 5.13 Culture 54 5.14 Financial Problems 55 5.15 Addiction to social networking sites? 56 6 FINDINGS & RECOMMENDATIONS 58 6.1 Introduction 58 6.2 Findings and Recommendations 58 GLOSSARY OF TERMS & ABBREVIATIONS 68 APPENDIX 1: PANEL MEMBERS 69 APPENDIX 2: PRACTITIONERS INVOLVED IN THE SCR PROCESS 70    3  1 EXECUTIVE SUMMARY  1.1 Context 1.1.1 This serious case review was initiated by Tower Hamlets Local Safeguarding Children Board (LSCB) following notification that a four month old baby (referred to as Jamilla) had died in October 2013, following cardiac arrest, suspected to be caused by malnutrition.  Her two older siblings were exhibiting signs of neglect and the family home was described by police as being in a poor condition. 1.1.2 This tragedy took professionals by surprise, as despite the mother’s youth and traumatic earlier experiences, the care of the children had always been assessed as being good, and she had presented as positive about the future and about the support she was understood to be receiving from family members.  1.1.3 Due to the lack of identified concerns about the children’s welfare the family was not in receipt of services from Children’s Social Care. At the time of Jamilla’s death, they had universal health services (GP and health visitor), as well as being an open case to the Gateway midwifery team1. There had previously been children’s centre involvement, but  mother ceased to have her own allocated worker in March 2013 and had stopped attending any sessions shortly after Jamilla’s birth. 1.1.4 In the weeks prior to Jamilla’s death, a sibling had been registered at pre-school, but had only attended twice, both times in the company of his mother and siblings. The only concern identified at that stage was the smell of urine apparently coming from the children’s double buggy.   1.2 Summary of Case 1.2.1 Jamilla’s mother was born in the UK to a Somali mother and a white British father; her father had converted to Islam. She lived in London until the age of twelve2, when she and her younger siblings were taken by Jamilla’s maternal grandmother (MGM) to live in Somaliland3, the country from which the maternal family originated.                                                             1 The Gateway midwifery team provide ante and post natal services for vulnerable women 2 The age is calculated from agency records of when Jamilla’s mother last attended school; but the mother herself understood she moved when she was aged eleven years old. 3 Somaliland is a former British protectorate which declared independence from Somalia (a former Italian colony) in 1991. Though not internationally recognised, Somaliland has a working political system, government institutions, a police force and its own currency. The territory has lobbied hard to win support for its claim to be a sovereign state.  4  1.2.2 Whilst in Somaliland it is understood that the mother of Jamilla was forced into a marriage at the age of 13 and suffered domestic violence and rape. She gave birth to two children whilst in Somaliland before managing to escape and return to the UK in 2012, with the help of the Forced Marriage Unit4 (FMU) and her own father. By this time Jamilla’s mother was nearly eighteen years old and pregnant with Jamilla. 1.2.3 In London, Jamilla’s mother and her two children stayed for a short period with mother’s father (MGF) and members of his family, before staying briefly with extended maternal family in Tower Hamlets. She was provided with housing in the borough and accessed local services for support. She also reported to practitioners from local agencies that her extended family were providing her with support.  1.2.4 In professional contacts with the family staff were impressed with the mother’s care of her children despite her youth. She received routine midwifery and health visiting appointments, and would have been provided with additional support had she requested. She did not however ask for more help. 1.2.5 Professional contact decreased after the birth of Jamilla as the mother was assessed to be coping well and (according to the midwife) chose not to attend the last midwifery post natal appointments (Mother though understood that the midwife would visit her). Mother ceased attending a Young Parents Group at the Children’s Centre: she had attended this regularly until the birth of Jamilla and subsequently on a few occasions.  There was no health visitor or GP contact after early July, although the health visitor was planning to make contact in October.  1.2.6 In September 2013 the eldest child was registered at a local pre-school, but prior to the death of his sister he had not yet started to attend regularly. In the three pre-school contacts with the family in the days and weeks prior to Jamilla’s death, observations of the home, the children and their relationship with their mother did not give rise to specific concerns, other than a smell of urine from the children’s buggy.  1.2.7 In response to this concern, and the early indications of a lack of regular attendance, the pre-school were considering what support mother may need, whilst also trying to engage her to enable the son to attend. The manager involved mother’s previous family support worker (FSW), about who mother spoke positively. The FSW had provided support during the early months of mother’s return to the UK, when mother attended a children’s centre. Following contact with the pre-school manager, the FSW was attempting to make contact with mother.                                                             4 The Forced Marriage Unit (FMU) is a joint Foreign and Commonwealth Office and Home Office unit which was set up in January 2005 to lead on the Government’s forced marriage policy, outreach and casework. It operates both inside the UK, where support is provided to any individual, and overseas, where consular assistance is provided to British nationals, including dual nationals.  5  1.2.8 Before the previous FSW had succeeded in getting a response from Jamilla’s mother, an ambulance was called to the family home and Jamilla was found to be in cardiac arrest. Jamilla’s siblings were found to be in a state of neglect and the conditions in their home were poor.  1.3 Summary of Main Findings  Predictability 1.3.1 The death of Jamilla and the severe neglect of her siblings were not predictable. Professional contact with the family identified the mother’s vulnerability, due to her earlier life experiences, but led to consistent observations of a resilient young woman who was managing to provide her children with the love and care they needed.  Preventability 1.3.2 It would have been difficult for professionals to have prevented the tragedy, due to the rapid deterioration in the home circumstances, mother not opening the door to callers in late September and her ability at pre-school, to project the appearance that she was still coping well with parenting her children, just four days prior to Jamilla’s death. The following sections suggest changes in service provision that may reduce the likelihood of similar tragedies in the future. Children’s health and welfare system does not routinely monitor pre-school children in the absence of identified needs 1.3.3 To have been able to prevent this unexpected and sudden tragedy, we would require a universal service with frequent family contacts, which is able to identify changes in the home circumstances and in mother’s parenting capacity, such as happened here. Current systems nationally do not by their nature intend to routinely monitor the health and/or welfare of children after they are 6 weeks old other than through voluntary developmental checks at subsequent points. When children reach school age they will be monitored when they attend school, with unexplained absences followed up. When children are younger and more vulnerable, their health and/or welfare will be monitored only if there are identified concerns, or if parent/s choose to bring the children to clinic appointments and/or to sessions at children’s centres, nurseries or pre-school.  6  1.3.4 In the case of this family, there were no concerns identified about the care of the children. The family had ceased to attend voluntary sessions at the children’s centre and although registered at the local pre-school, the eldest sibling had not yet begun to attend regularly. In the absence of babies and young children being seen regularly at community settings, we rely on family and neighbours to alert services if there are concerns. This did not happen in this case, partly because extended family, like professionals, thought mother was coping well and had themselves decreased contact and partly because of the family’s general social isolation. Focus of multi-agency assessment is on current levels of functioning 1.3.5 The focus of multi-agency assessment and subsequent response is based on current levels of functioning within families, with insufficient consideration of the potential risks arising from underlying vulnerabilities. The local Family Wellbeing Model (in line with the National Framework of Assessment) does not include such vulnerabilities in the trigger to undertake a multi-agency assessment, have a lead professional or team around the family. Local enhanced health visiting service does not provide criteria for level of service provision 1.3.6 The family were correctly assessed as needing both an enhanced health visiting service and the Gateway midwifery service, in recognition of mother’s vulnerability. However, the local arrangements for an enhanced health visiting service, whilst providing definitions of vulnerability, does not specify the minimum contact level with families  or criteria to trigger follow up / additional visits: this is left to individual professional judgment. In this case a universal service was provided, with the added proviso that mother was able to request additional help. Given mother’s underlying vulnerability, such reliance on her to be able to understand she could request and then ask for help should her circumstances change may be over optimistic.   Is there a role for a lead professional in the absence of current concerns, but where there are underlying vulnerabilities? 1.3.7 Because there were no identified concerns about the children, there was a lack of co-ordinated multi-agency input, so no one lead professional understood that mother had not brought her son for his developmental check, had not brought the children for their immunisations, had not attended her last two midwifery appointments and had ceased to attend the children’s centre. Whilst these are all voluntary activities and attendances, the pattern when taken together, was indicative of possible changes or even withdrawal from activities and contacts.   7  1.3.8 Given mother’s youth (18 years old) and vulnerability (and the difficulties for any single parent coping with three children under the age of 4 years old), such a pattern, if identified, should have led to follow up. The health visitor was planning to do this in October, on the basis of the missed developmental check and immunisations. This urgency is likely to have been greater had the health visitor also been aware that the family were no longer being seen at the children’s centre and had not attended the last two midwifery appointments. 1.3.9 Mother explained to the review author, that without a consistent relationship with any one professional she was unable to develop a trusting relationship and feel able to speak openly. An identified lead professional may have made a consistent relationship more likely. National Health Service: contrast between professional contact before the birth of baby, and after the baby is 6 weeks old 1.3.10 One of the features of the National Health Service is frequent contact with a pregnant woman during pregnancy, but then a marked decrease after the birth, unless the post birth visit by the health visitor assesses any additional needs. In this case whilst mother’s underlying vulnerability was identified, the assessment did not indicate any additional needs.  1.3.11 However, for some parents, the difficulties only become apparent later. This was the case for this family, with an 18 year old single parent with three children aged under 4 years old.  The mother described to the author how soon after the birth of Jamilla the support she had from her family decreased and at the same time contact with professionals stopped. The rationale for this is that following the 6 week review, in the absence of identified concerns, it is left to parents to request help or to attend the clinic.  It was though at this point when the responsibilities of caring for her new baby and two other young children seemed most onerous for this mother and she described feeling constantly tired.  Potential weaknesses in identifying the presence of children arriving in the UK 1.3.12 This was not a problem in this case, but the circumstances have highlighted a potential weakness when families move to the UK from abroad, as there is no automatic information provided to universal services about the arrival of families and it is possible for the children’s existence to remain unknown.  1.3.13 In this case, the FMU were involved and informed Brent Children’s Social Care, who spoke to MGF, but did not inform health colleagues. Fortunately the family followed the advice provided and registered with a GP, so ensuring the children’s presence in the UK was identified. In Tower Hamlets, Children’s Social Care ensured the children’s presence was known and that the family was assessed for services.  8   Task centred versus relationship based provision of support 1.3.14 A challenge for practitioners nationally when undertaking assessments is the focus on achieving tasks as opposed to developing relationships. Moreover in the absence of identified concerns, contact normally takes place outside of the home, at clinics, children’s centres and schools. This contrasts with a generation ago when the universal health provision involved home visits by health visitors to households with pre-school children and midwives visiting the home for 10 consecutive days post birth.  1.3.15 This change to service delivery via clinics and children’s centres is more efficient and has the advantage of encouraging parental links with community resources and other parents. The disadvantage of this change may though be the ability to develop a trusting relationship with practitioners: this can impact on the quality of assessments undertaken as well as the chances that further help is requested. Weaknesses in the assessments undertaken 1.3.16 The assessments that were undertaken by health and children’s centres accepted mother’s self-reported accounts of intensive support from relatives. Without such help, she would have struggled to cope. What was missing from the assessments, and the ongoing work with the family, was an understanding of exactly what this support involved and its consistency and regularity over time. Other than the case worker from the FMU, no local practitioner met with any family members, even when a relative was present in the home during a home visit after the birth of Jamilla.  1.3.17 The assessments undertaken did not adequately seek to understand the implications for mother being of dual heritage and how this affected her experiences both currently and in the past; in particular what this may have meant within her extended maternal family. Given that she had fled a forced marriage arranged by her family this was a relevant area to explore, especially given mother’s reliance on these relatives for frequent and regular support.   Housing provision 1.3.18 Mother was provided with a comparatively good housing service, given the resources available: she was immediately provided with temporary self-contained accommodation within Tower Hamlets and following her complaints was moved to an alternative temporary accommodation a few months later.  1.3.19 Unfortunately, the first flat was on the fourth floor of a building without a lift; this was a potential risk to a heavily pregnant woman and her two young children. However, given a steep rise in homeless applications and the portfolio of aging accommodation without lifts in the borough, this was the only available provision at the time. This lack of suitable resources is a continual problem both in the borough and elsewhere in London.   9   1.4 Could it happen again? 1.4.1 This tragedy was unexpected and could not have been predicted on the basis of the evidence practitioners had of mother’s parenting skills and her capacity to cope with obstacles in her life. 1.4.2 Given that services are provided in response to current problems and concerns, there will always be a risk that changes in parenting capacity are not later detected. Those children at highest risk are pre-school age children or those without regular children’s centre / pre-school attendance. 1.4.3 In consequence, services need to be sensitive to any changes or apparent withdrawal from services in families where children are not being regularly seen by professionals. The need for this is even greater when underlying parental vulnerabilities are already identified, as in this case. In these circumstances there should be multi-agency co-ordination of services by a lead professional, to maximise the possibility of:  Developing a trusting relationship with the parent/s so as to be able to detect changes in parenting capacity  Be aware of the overall pattern of behaviour by the family, including involvement and co-operation with all the service providers 1.5 What will the LSCB do in response to this? 1.5.1 At the end of each finding in section 6 recommendations have been made for the LSCB. The LSCB has prepared a separate document which describes the actions that are planned to strengthen practice in response to the findings and recommendations of this serious case review.   10  2 INTRODUCTION 2.1 Initiation of Serious Case Review 2.1.1 An ambulance was called to the home of four month old Jamilla in October 2013. Jamilla was found to be in cardiac arrest and was taken to the local Hospital where it was established that she was deceased: the suspected cause of the cardiac arrest was malnutrition. Her two older siblings appeared to be exhibiting signs of neglect and the family home was described by police as being in a poor condition.  2.1.2 The children's mother was subsequently arrested and charged with causing or allowing the death of a child and the neglect/ill treatment of all three children. She pleaded guilty to manslaughter of Jamilla and cruelty in relation to Jamilla’s elder siblings. 2.1.3 Following a recommendation from the Local Safeguarding Children Board (LSCB) Case Review Group, Sarah Baker, the Independent Chair of the LSCB, decided to initiate a serious case review (SCR) on the grounds that the circumstances met the criteria in accordance with Working Together to Safeguard Children 2013:   ‘Abuse or neglect of a child is known or suspected and  The child has died or been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child’. 2.1.4 The Department for Education and the National Serious Case Review Panel were informed on 29 October 2013. 2.2 Methodology 2.2.1 Statutory guidance5 requires SCRs to be conducted in such in a way which:  recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings                                                            5 Working Together to Safeguard Children, 2013 Chapter 4  11  2.2.2 In order to comply with these requirements Tower Hamlets Safeguarding Children Board (referred to as the LSCB) developed a systems approach methodology to use for this case.  This approach aims to understand professional practice in context, identifying the factors that influence the nature and quality of work with families and make it more or less likely that the quality of practice will be good or poor. The systems principles and data collection process in the Social Care Institute for Excellence Learning Together Systems Guidance6 has been used in developing this local approach. Period under review 2.2.3 The period under review is from the point when Jamilla’s mother approached UK authorities for help to return to the UK in 2012 until Jamilla died in October 2013. Information that was held by agencies about the mother’s family prior to this period provides a context of what was known or ‘knowable’ to practitioners during the period under review. Process 2.2.4 The process used involved:  Agreement that the Independent  LSCB chair Sarah Baker would be the chair of the serious case review panel   A review panel of senior managers to oversee the process, meeting monthly (see appendix 1)   Identification of agencies involved with the children in the family and their mother  Collation of a detailed chronology of professional activity  Obtaining information from Brent and Westminster LSCBs following the information that the family had lived initially in these 2 boroughs prior to moving to Tower Hamlets  The appointment of an independent lead reviewer, Edi Carmi, to work collaboratively with the review panel, lead the analysis and write the review report  The lead reviewer and  panel members’ involvement in  speaking to practitioners so as to understand what happened and why - the rationale for actions, inactions and decisions  The review was undertaken from a multi-agency perspective from the outset: consequently individual management reviews from agencies were not requested   NHS England expects health management reviews: the authors of these were part of the review panel and all health staff interviews were undertaken in collaboration with the lead reviewer   The direct involvement of practitioners and managers through one individual and three group meetings to provide information and to participate in the findings of the review; including the thinking about what helps and hinders the safeguarding of children in such circumstances (see appendix 2 for details)  Involvement of family members: mother and maternal grandfather agreed to participate in the process, once the criminal proceedings had ended                                                            6 Learning Together, Fish, Munro & Bairstow SCIE 2008  12   Consideration of a variety of written records and reports undertaken as part of the ongoing work of practitioners and, as appropriate, as part of the criminal investigation and court proceedings including the witness statements obtained by the police as part of the criminal investigation, psychiatric and psychological reports undertaken as part of parallel legal processes   Quality assurance process involving the scrutiny of the report by the overview author for another serious case review in a neighbouring borough (Barking & Dagenham), sharing the same Independent LSCB Chair Family participation 2.2.5 In order to enable mother to participate in the review, the report was delayed until she was able to speak with us, following the end of the criminal processes and when she was considered, by those professionals currently providing her with support, to be sufficiently settled to undertake this task. 2.2.6 Maternal grandfather also participated in the review once the criminal proceedings ended.  2.2.7 Attempts were made to contact the children’s maternal great aunt, but no response was received. Her witness statement to the police has been accessed and this has contributed an understanding of the support provided by the great aunt and other family members. 2.2.8 Subsequent delays occurred due to the time taken to enable mother to read and understand the contents of this report, with the help of a support worker. Mother was able to provide useful feedback which led to some additions, primarily acknowledging when her memory of events was different to that of practitioners.    Limitations 2.2.9 The information about what happened to mother whilst living in Somaliland from the age of 12 – 17 years old has been obtained from statements mother and family members made to the police as part of the criminal investigation, information mother provided to the Forced Marriage Unit and information from interviews with mother and maternal grandfather . Some of this information is not clear, especially in terms of what injuries were involved and any involvement of family members, other than her husband, in the alleged abuse perpetrated against mother. Given that mother was a child herself at the time this is perhaps not surprising. 2.2.10 Mother spoke about receiving help from a family friend who worked for a local community organisation. This was not known until September 2014. The LSCB has attempted but been unable to obtain details of the service provided. 2.2.11 Mother chose not to complete reading this report prior to publication, so did not provide feedback to the second half of the document [section 5 onwards].   13  2.3 Structure of the report 2.3.1 The report is structured as follows:  Section 3 provides: o details of family members mentioned by the mother  o historical information of professional involvement prior to the mother’s move to Somaliland in 2007 and o what family members understood about the mother’s history prior to her return to the UK  Section 4 explains what happened from the perspective of those involved at the time, including both professionals and family members  Section 5 provides an analysis of the themes emerging from the practice in this case  Section 6 provides the overall  findings and recommendations   14  3 CONTEXT 3.1 Family composition 3.1.1 Jamilla lived with her mother and 2 siblings in Tower Hamlets at the time of her death.  Table 1: Household members Term used in report Relationship to Jamilla Age on 04.10.2013 Jamilla subject 4 months sibling 1 eldest sibling 3 years sibling 2 sibling 1 year 7 months Mother Mother of Jamilla 18 years 3.1.2 Whilst the composition of the household is known, it has been difficult to understand fully the structure of the extended family and significant people.  3.1.3 The children’s father lived, and remains in Somaliland. Also there are Jamilla’s maternal grandmother (MGM) and four maternal uncles/aunts. 3.1.4 The following table 2 shows other significant people mentioned by mother to practitioners and their locations during the period under review. All were family members. Table 2: Significant people as understood by practitioners at the time Term used in report Relationship to Jamilla Location on 04.10.13 Father Jamilla’s biological father Somaliland MGM Maternal grandmother Somaliland  3 Maternal uncle / aunts Jamilla’s mother’s half siblings Somaliland  MGF Maternal grandfather LB Brent Maternal step-grandmother  Jamilla’s maternal grandfather’s partner LB Westminster MGGM Maternal great grandmother LB Tower Hamlets Great aunt Maternal great aunt Not known Mother’s cousin 1 Jamilla’s mother’s cousins LB Tower Hamlets Mother’s cousin 2 LB Tower Hamlets Father’s cousin Jamilla’s father’s cousin London 3.1.5 Through reading police witness statements, further information has emerged of the family members. There is no evidence of mother having direct social contacts with anyone outside her family, except she mentioned one other woman with whom she had occasional contact who was the victim of forced marriage in Somalia. 3.1.6 Further significant people in contact have been identified from the police witness statements. However, the structure and members of the family are not totally clear. This confusion may arise from the cultural practice to call some family friends ‘cousins’, ‘aunties’ and ‘uncles’, as well as a desire to keep some privacy around family arrangements.   15  3.1.7 The witness statements highlight further family in Somaliland and London and in occasional contact with the family was a maternal great uncle, a large number of cousins and a further contact whose exact relationship is unclear.   3.2 Knowledge of family by professionals prior to period under review Introduction 3.2.1 The knowledge of the family prior to the period under review is when:  Mother lived in London as a child, before she and her 2 siblings were taken to Somaliland by MGM in July 2007 - at that point mother was aged 12 years old and was near the end of Year 7 at school   During the years she lived in Somaliland, when she was married as a child and gave birth to 2 children 3.2.2 This information gives a context of what happened before and was known or knowable to agencies. It is though prior to the scope of the serious case review, so the practice will not be subject to analysis. 3.2.3 The following information comes from agency records, witness statements that formed part of the criminal investigation, mother’s own accounts of her life given at various points to professionals and within the criminal investigation and interviews with mother and MGF for the purposes of this serious case review. 3.2.4 When individuals recounted memories of events on different occasions, the details provided were not always consistent, and the dates varied. Such inconsistencies are not explored as they are not significant in terms of either the mother’s experiences or the way agencies worked together during the period under review.  Prior to move to Somaliland 3.2.5 Professional records of this period understood that MGM and her family were from Somalia but were living in London [mother has since explained they came from Saudi Arabia].  MGF is white British, and had converted to Islam. MGM and MGF separated when Jamilla’s mother was about 6 months old and it is understood that there was little subsequent contact between mother and MGF.   16  3.2.6 Prior to the family’s departure for Somaliland in 2007 there had been contact between MGM and the police due to reported incidents of domestic violence, between  MGM and  firstly MGF (during 2 contacts following their separation) and then several incidents between MGM and her second husband in 2003 and 2004. By 2004 the couple had separated and MGM spoke of being assaulted by her second husband on several occasions, including an allegation of being stabbed in her leg, as well as an allegation about his abuse of the younger children in the family. Police investigations were undertaken but did not substantiate the allegations and MGM’s second husband was not located. He was thought to have left the country7 .    3.2.7 By 2005 MGM and her three children had moved to Tower Hamlets, where mother attended the last year of primary school and first year of secondary school. Mother attended secondary school for 10 months; this was a difficult period for mother, with staff recalling her being bullied and the identification of her having a low reading age [6.08 years] and receiving extra literacy input. She also received help from a Somali support worker, who found mother to be shy with low self-esteem. Subsequently there were concerns about mother’s school attendance and her increasingly challenging behaviour.  3.2.8 Staff participating in this review recalled that mother looked much older than her age and had difficult relationships with some of her peers, especially the older Somali girls. It was understood that this was partly due to attitudes about her mixed heritage, but also due to communication difficulties, which led to misunderstandings. This was thought to be part of a language and communication learning difficulty, for which she was going to be referred to the educational psychologist for an assessment, but left the school prior to this happening. 3.2.9 In the months preceding the family’s departure there was involvement of police on two occasions when MGM reported her 12 year old daughter, Jamilla’s mother, as missing. On one occasion she was gone for a few days and on the second she was a few hours late home. 3.2.10 Children’s Social Care liaised with the school and MGM during the first episode, but did not become further involved. Mother was located at a maternal great aunt’s home after four days absence. The deputy head teacher recalled in interview for this review that mother sometimes stayed with an ‘auntie’ (possibly Jamilla’s maternal great aunt).                                                            7 Further allegations have been made against this man as part of specialist assessments in legal proceedings. These have been reported to the police for further investigation, along with possible information about his whereabouts.   17   3.3 Additional information of the history prior to 2012 from family members 3.3.1 Police witness statements from family members provide additional history that was not known to professionals including:  MGM, mother and siblings went to Somaliland on holiday, prior to MGGM deciding to live there   MGM stopped mother’s contact with MGF during her 2nd marriage, but when MGM ceased living with her second husband contact resumed for about a year until MGM and her children went to Somaliland for a fortnight; subsequently they were never home when MGF called and he discovered eventually they had gone to Somaliland to live  Great aunt  and a cousin remembered relatives in the UK being shocked / upset to hear that mother was being married (variously said to be at the age of 13 or 14) and her husband was 20 years old, although another cousin  heard she wanted to get married and was ‘in love’  Great aunt refers to MGM being worried about mother being ‘beaten up’ by her husband and ‘abused verbally’ but commented that ‘Somali women have no power’ so her sister [MGM] ‘could not do anything’ – on one occasion MGM reported to great aunt that mother had telephoned after being punched so hard in her face that it had loosened her front tooth and her mouth was bleeding  Two cousins were aware of domestic violence and that mother was said to have had a miscarriage  3.3.2 Mother provided further allegations in interview including the loss of two pregnancies due to domestic violence, a complaint to Somaliland police following the loss of her tooth due to domestic violence and her attempt in Somaliland to escape to her MGM. Both police and MGM are understood to have returned mother to her husband.   18  4 APPRAISAL OF PROFESSIONAL PRACTICE 4.1 Introduction 4.1.1 Section 4 provides a commentary on professional practice during the period under review.  4.1.2 To understand the rationale for professional practice, what happened is described from the perspective of those involved at the time, professional staff and family members. The information is derived from agency records, interviews with staff and information from statements provided to the police after Jamilla’s death.  4.1.3 4.2 gives a brief table of the key events in what occurred and 4.3 – 4.9 gives the details of what happened, broken into time periods. The commentary within the shaded boxes at the end of each time period is an appraisal of professional practice. Where such appraisal and explanation reflects a recurrent theme regarding the service provided, there is a cross reference to subsequent analysis and/or findings.  4.2 Key events 4.2.1 The following table provides the key events during the period under review, which are then explained in more detail in the rest of section 5. Date  Event October 2012 Mother and her 2 children arrive in London and are understood to move to MGF in Brent Brent Children’s Social Care advise MGF of services that mother could access 23.10.12 Mother’s pregnancy confirmed via GP in Westminster 30.10.12 Mother presented as homeless at Tower Hamlets and provided with temporary flat 31.10.12 Housing refer family to Children’s Social Care, who refer to the health visitor and Children’s Centre  November 2012 Health visitor transfer in visit Family Support Worker, Children’s Centre visits home and agrees service Mother complains to Housing about being on the 4th floor without a lift Mother starts receiving regular midwifery services from the community midwife  January 2013 Midwifery service from the Gateway team8 provided in light of mother’s age and vulnerability Mother starts to attend the Young Parents Group early February 2013 Health visitor sees family at clinic: 2nd health visitor contact End Feb.  2013 Family move to more suitable accommodation March 2013 Case closed at the children’s centre and mother declined referral to a Children’s Centre closer to her home – she continued though to attend the Young Parent’s Group                                                            8 The Gateway team provides midwifery services for vulnerable women  19  April 2013 Unknown to staff MGGM leaves the UK and returns to Somaliland May 2013 Jamilla  born Change of midwife : 2 home visits by new midwife and one clinic appointment June 2013 Health visitor’s new birth visit Mother attended 2 Young Parent’s Group sessions Mother DNA midwife appointment at the clinic July 2013 Mother attended post natal check at GP: last contact with health Jamilla seen by health visitor and GP for 6 week developmental check: last time Jamilla seen by health practitioners Mother and all children seen at pre-school for ‘settling in ‘ visit Mother does not attend midwife appointment at the clinic August 2013 No professional contact September 2013 Home visit by preschool staff on 6th Family attend one pre-school session on 19th – subsequently mother says sibling 1 unwell Family attend briefly again on 30th, but leave when explained mother will need to stay with sibling 1 as he is new to the pre-school (settling in period) 04.10.13 Mother speaks to pre-school and says that they have been staying with MGF Ambulance called to Jamilla 4.3 13th – 30th October 2012: Mother returns to the UK 4.3.1 In October 2012, mother (aged 17 years 11 months) came to the British Embassy in Addis Ababa, requesting passports for herself and her 2 children, aged 8 months and 2.5 years old. She had travelled with her husband from Somaliland. Mother explained her history to Consular staff including allegations that she was a victim of forced marriage at the age of thirteen and of domestic violence and rape from her husband.  4.3.2 Whilst consular staff undertook the Nationality Authentification Test (to confirm mother’s right of entry to the UK), she and her 2 children remained with her husband in a hotel for several days. The specialist caseworker of the Forced Marriage Unit (FMU) in the UK was told by Embassy staff that on one of days mother arrived with blood on her scarf, which she explained was the result of her husband hitting her. He signed the travel documents in the belief that mother would sponsor him subsequently to join her. 4.3.3 MGF liaised with the Forced Marriage Unit in London about mother’s circumstances. He purchased flight tickets for her and his grandchildren to travel to the UK; staff at the Unit understood the plan was for the family to stay with MGF in Brent. 4.3.4 The FMU Specialist Caseworker referred the family to Brent Children’s Social Care on 12.10.12 due to awareness of mother’s general vulnerability: aged under 18 years old, having endured a forced marriage, given birth at a very young age in difficult circumstances and whose children may have witnessed violence.  4.3.5 Although there were no specific concerns about the welfare of the children the FMU worker made the referral as ‘I wanted to check that her and her children were ok and felt they needed a professional (social services) assessment in case additional support was required.....’.   20  4.3.6 Brent Children’s Social Care telephoned MGF on 15.10.12 obtaining confirmation of the family’s return and offered advice about local services (Children’s Centre, GP, health visitor and Housing). Mother told the author she was present during the telephone conversation, but the social worker did not ask to speak with her.  4.3.7 MGF has explained that mother and children stayed with MGF’s ex-partner’s (maternal step-grandmother1) home in Westminster. A week after returning to the UK, mother consulted a GP in Westminster and following a pregnancy test it was confirmed that she was expecting a baby. She did not at this point disclose any history of forced marriage or domestic violence to the GP, who made a referral for antenatal care. Mother attended the local hospital accompanied by step grandmother1.   Comment: Return to the UK Mother and children received a responsive sensitive service from staff at the Consulate and in the FMU, which took account of her precarious position and facilitated her return to the UK.   The FMU does not generally provide a service once a victim is repatriated. If there are specific issues or concerns a referral is made to the relevant authorities. In this instance the referral to Children’s Social Care in Brent was appropriate given mother’s youth, vulnerability and perceived potential need for support. Because it was understood the family would stay with MGF, no referral was made to housing.  Brent did follow up the contact made by the FMU by checking the family had arrived in the UK and signposting MGF to services. They did not though treat this as a ‘referral’, did not make any assessment of need, did not check if any services were accessed, or if health knew of the existence of the children in the UK. This is discussed in section 5.4.   4.4 Provision of temporary accommodation in Tower Hamlets: 30th – 31st October 2012  4.4.1 On 30.10.12 mother presented as homeless to Tower Hamlets, explaining she was familiar with the area before she went to Somaliland. She saw an Assessment Officer the next day, when she attended with her 2 children and described her forced marriage and return to the UK. Mother gave 2 addresses; the first was step grandmother’s home in Westminster and the second an aunt (maternal great aunt) in Tower Hamlets.  4.4.2 The Assessment Officer noticed that mother was fluent in English and ‘good with the children’. Sibling 1 was observed to be very active during the interview, whilst sibling 2 was carried by mother. She was affectionate with both children and sibling 1 gave his mother lots of kisses.   21  4.4.3 The Assessment Officer organised immediate temporary accommodation for mother and children in a flat on the 4th floor in a building, without a lift. She also organised emergency financial assistance to buy nappies and milk and informed the Housing Specialist at Children’s Social Care of mother’s situation (forced marriage, 18 years old, 2 children and 3 months pregnant) as she felt Children’s Social Care should ‘keep an eye on the family’ due to mother’s vulnerability. The Housing specialist within Children’s Social Care asked for a duty social worker to call mother the next morning and get her linked to the nearest Children’s Centre for support in sorting out her finances and furniture.   Comment:  Housing immediate response Housing provided an immediate and responsive service to mother and children. The provision of a flat was fortunate: the Assessment Officer commented this is often not available and families are then placed initially into Bed and Breakfast accommodation.  The fact it was on the 4th floor without a lift is recognised to be far from ideal, but reflects the scarcity of temporary accommodation. This is discussed further in 5.12. The recognition of mother’s vulnerability and referral to Children’s Social Care was appropriate response. 4.5 Temporary accommodation in Tower Hamlets: 31.10.12 – February 2013  4.5.1 During the next 3 months mother lived in the 4th floor flat without a lift and had frequent contact with Housing, the GP, midwifery and children’s centre, as well as 2 contacts with health visiting services and a telephone contact with the FMU. Throughout this period professionals who saw the family were impressed with mother’s parenting of 2 small children and her overall positive and optimistic attitude to life. Children’s Social Care role 4.5.2 Children’s Social Care were not directly involved with mother, but responded to the referral from Housing by trying to speak to her on 31.10.12. In the face of a lack of response to a message left on the mobile number provided (belonging to a cousin of mother), the social worker made urgent referrals to the health visitor and Children’s Centre and advised that should there be any further concerns to contact Children’s Social Care.  Both the health visitor (HV1) and the children’s centre made contact with Children’s Social Care that day and the Children’s Centre also allocated the referral to a Family Support Worker (FSW). Comment on LBTH Children’s Social Care role Children’s Social Care understood the vulnerability of mother and ensured that she received immediate support services via the Children’s Centre and the health visitor, but did not become directly engaged with the family. This is discussed further in 5.4.   22  Housing problems 4.5.3 From the outset, mother made it clear that she was unhappy living in a flat without a lift due to problems managing the four flights of stairs with two little children, a buggy and being pregnant. She complained in person to Housing within days of the move and followed advice from the Assessment Officer to put the complaint in writing (possibly with help from the Officer).  Once again the Officer noticed positive interactions between mother and children, and a woman understood to be MGGM was seen in the distance. Mother continued to complain and got written support from the FSW at the Children’s Centre and the GP: the FSW received a written response that mother was on the transfer list, but that there was a shortage of temporary accommodation. 4.5.4 Meanwhile the Assessment Officer continued with background enquiries which indicated that because mother had left Tower Hamlets at age 12, she did not meet the criteria for a local connection, and because MGF lived in Brent it was judged that Brent held responsibility for housing mother and children. Mother was sent notification of this on in mid-November and her solicitor wrote to Tower Hamlets Housing two weeks later seeking a statutory review of the decision to refer to Brent. In early January 2013, Housing decided that the full homelessness duty rested with Tower Hamlets not Brent and on 26.02.13 the family moved to a new temporary tenancy. 4.5.5 It is of note that during the two months of negotiation with Housing, mother displayed admirable assertiveness as well as ability to co-ordinate the services in her support. She prompted the FSW as well as the GP to write to Housing to support her and also sought legal support.  Housing Comment Mother and family received a comparably good service from Housing, in the light of current resources. However, the initial flat was unsuitable for a young isolated pregnant woman with 2 small children and this could have been perceived as a risk to their welfare. See section 5.12 for further discussion.  Mother is likely to have experienced stress because of the initial decision that the homeless responsibility lay with Brent not Tower Hamlets. See 5.12 for further discussion. Children’s centre involvement 4.5.6 The Family Support Worker’s (FSW’s) involvement between November 2012 and February 2013 provided the most consistent professional contact during the period of the review. This consisted of 1 home visit, seeing the family when mother brought the children to play sessions at the local children’s centre and sometimes accompanying the family to the centre. From late January 2013 mother and children attended the Young Parent’s Group held at another Children’s Centre; the FSW was one of the staff involved with this group.  23  4.5.7 Throughout this contact mother presented as positive about the present and optimistic about the future, planning to continue her own education and wanting the best for her children. She was perceived to have a strong survival instinct and was ‘pretty canny for one so young’ (FSW description). 4.5.8 The children were observed to be well and to have a good relationship with their mother. Sibling 1 was very lively whilst sibling 2 was crawling and wanting to be near her mother. The home was clean and tidy and raised no concerns. 4.5.9 At the FSW’s supervision in mid- February it was decided to end the FSW’s allocated role with mother, as all objectives had been met and practical support and advice provided. The FSW would continue to see the family at the Young Persons Group and at sessions at the children’s centre. This was discussed with mother in early March. 4.5.10 The FSW was aware of the local family support, and understood that there was a cousin in the area and that MGGM lived locally and planned to stay with the family when the baby was born. The FSW never met any of these family members.  Comment on children’s centre service The involvement of the FSW to help mother access practical benefits and facilitate her and the children’s involvement in the children’s centre activities was a positive service. Although it was judged that mother no longer needed an allocated FSW, the FSW continued to see mother regularly through on-going attendance at the Young Parent’s Group. This support was understood by other professionals as valued by mother and it is of note that because of the continuing involvement at the Centre mother still referred to herself having a FSW in her contacts with health professionals. Health visiting service 4.5.11 HV1 initially had some difficulty accessing the family as the contact telephone number provided, understood to belong to a cousin, had no voicemail. Moreover no-one was at home on two opportunistic visits. However the health visitor managed to speak with mother eventually and after some initial reluctance and suspicion mother agreed to be visited the next day. The health visitor arranged for an agency health visitor (HV2) to undertake this visit, highlighting the need to explore the family’s vulnerability. 4.5.12 On 09.11.12, HV2 visited the family. Mother spoke of her history including the forced marriage and domestic violence. She also spoke of being socially isolated, but having relatives living in the borough. HV2 noted that mother spoke to her children in a kind and loving manner, and they appeared ‘well cared for and thriving’. Their immunisations were not up to date and mother said the family were still registered with a GP in West London. A referral was made to the local children’s centre for assistance in obtaining financial help and for support. Mother’s vulnerability was noted within the record, but no arrangements made for any follow up home visits, possibly due to the fact that sibling 2 would be due her 8-12 month review 3 months after this visit.  24  4.5.13 HV1 saw both children at a clinic visit for sibling 2’s developmental review in early February 2013. Sibling 2 was on the 75th centile for height and just below that for weight. She was meeting all her developmental milestones. Sibling 1 was also observed to be well and healthy, with good interaction noted. He had started to be toilet trained.  Mother was reminded to make an appointment for sibling 2’s 12 month immunisations, and HV1 planned to consult the GP about sibling 1’s immunisation status. The GP wrote to mother in late February following this up. 4.5.14 Mother told HV1 about her history, her current housing problems and that she had fallen on the stairs the previous week. A high level of vulnerability was noted, along with mother reporting she got a lot of help from the FSW at the children’s centre.  Comment on health visiting service HV1 appropriately considered that the children were eligible for an enhanced health visiting service. However in practice due to a lack of specific concerns identified during the assessment process it was left open to the mother to access any service additional to the universal provision provided to all families. See 5.6 for discussion about the level of health visitor service provided. GP and midwifery 4.5.15 Mother’s ante-natal care was shared between the GP and community midwifery in the GP surgery and the Gateway team.  There are weekly meetings attended by GPs and midwives, with monthly attendance by Gateway midwifery – this is the main form of communication. No concerns were ever identified, so the family was not discussed at this meeting. 4.5.16 The Tower Hamlets GP had his 1st contact with the family in November 2012, when mother brought sibling 2 as she had a chesty cough. She was noted to be a bright alert and happy baby. There was no mention made of forced marriage or domestic violence. Mother was also referred to the local hospital for antenatal care as the GP was advised this was the fastest way to get the care in place. Mother had received some ante-natal care in West London, but was unsure of which hospital and the GP had no electronic notes from the previous GP. The GP recalls mother as articulate, with a good understanding of the processes and the urgent need to see a midwife.   25  4.5.17 Mother had her 1st contact with midwifery in Tower Hamlets in early December 2012, after missing an appointment 2 weeks earlier (1st missed appointment or DNA for ante-natal care). The community midwife took a full medical, obstetric and social history and discovered that mother had previously been seen at St Mary’s Hospital, Paddington9. A referral was made to the Gateway team due to mother being a vulnerable teenager, having recently arrived from Somaliland. Mother replied ‘no’ to the question about domestic violence, but she was known to be in the UK without the father, living in temporary housing and moving around. 4.5.18 Following this appointment mother saw her GP again on 18.12.12 when she mentioned her history of domestic violence and forced marriage. The GP recalls his main concern was mother’s safety and support networks. He had the impression she was coping and saw nothing to alarm him in relation to her behaviour or interaction with her children; in fact her son was boisterous and she was able to calm him down effectively. 4.5.19 Mother attended scans and routine community midwifery appointments in December 2012 and January 2013, but missed her first appointment with the Gateway Team on 13.01.13 – she later explained she had not got the letter as had changed her address about this time (this was not in fact true). This was her 2nd DNA for ante-natal care.  4.5.20 Mother went on to miss 2 Glucose Tolerance Tests in February 2013 and explained this later to the midwife as difficulty fasting overnight. These were her 3rd and 4th DNAs. She did though keep her appointment with the Gateway midwife in mid-February (midwife 1), when she was 28 weeks pregnant and ‘obstetrically well’. This was a holistic appointment and mother spoke fully about her history as well as discussing her housing, her financial position, the support she received from the FSW, MGF and her extended family. Mother went on to keep her next routine community midwifery appointment a week later. 4.5.21 Midwife 1 recalled in discussions for this review that she observed mother’s appropriate and positive management of sibling 1’s behaviour, using distraction methods, encouraging him to listen to the baby’s heartbeat. Sibling 2 remained in her pushchair with a bottle. Comments on GP and midwifery service Initially mother did not disclose details of her past to the GP and midwife, but the midwife appropriately picked up her need to be identified as a vulnerable teenager and made the referral to the Gateway team, who undertook a holistic assessment.  During this period of 4 months, mother did not attend 4 appointments relating to her ante-natal care. This is discussed in 5.7.                                                            9 Despite contacting the relevant LSCB it has not been possible to locate any earlier ante-natal records for mother at St. Mary’s Hospital. This will be reported to the relevant LSCB.   26  Contact with FMU 4.5.22 In January mother contacted the FMU to express interest in helping to raise awareness of forced marriage in the Somali community. She reported to the specialist case worker she was doing well, in a flat and 6 months pregnant. This indicated to the case worker that mother was feeling very positively about her new life. 4.6 New home prior to birth of Jamilla: March – mid May 2013 4.6.1 The family moved to their new home at the end of February and Jamilla was born mid May 2013. There was regular contact with midwifery during this period and for a while the case worker from the FMU. Mother and children still attended the Young Parent’s Group, but contact with the FSW had decreased as there were no longer individual sessions with her and contact was solely at the Young Parents Group. Mother continued to be cheerful in contacts with practitioners and indicated she had lots of support from family as well as professionals, including the FSW, 4.6.2 At the beginning of March mother and children came to the children’s centre to discuss her move. She was offered a referral to a children’s centre near the new home to help her develop familiarity with the new area, but mother declined according to the FSW. Mother does not recall this service being offered. The case was then closed at the first children’s centre and both HV1 and Children’s Social Care informed.  4.6.3 Shortly after this, mother had her 5th health DNA when she missed an appointment with the Gateway team on 12.03.13. She later explained this was due to a family member being unwell.   4.6.4 Also on that day staff at the GP surgery alerted HV1 to fact that the children’s immunisations were not up to date and mother had missed several appointments. HV1 made contact by telephone that day with mother and advised her to make another appointment. It is not known whether she did so (see 5.7 for discussion about DNAs). 4.6.5 When mother attended her next midwifery appointment 3 days later, she explained that MGGM was now staying with her for support. Her mood was good and she was excited about her unborn baby. The glucose tolerance test was re-arranged. 4.6.6 Mother was visited by the specialist case worker from the FMU on 3 occasions in this period to discuss mother’s involvement in a film on forced marriage. On the second occasion the case worker was accompanied by a colleague who was providing advice about financial problems relating to child benefit.   27  4.6.7 On all 3 occasions the home was ‘immaculate’ and ‘spotless’. MGGM was there the first 2 visits. Mother’s relationship with her children was ‘impressive’. Sibling 1’s behaviour was demanding as he was very active and trying to play with electrical sockets, taking his sister’s toys and drinks. Sibling 2 had just started walking and was wobbly, quiet with lots of smiles. Mother appeared slightly immature, but the case worker thought this was a reflection of her youth and lack of the usual UK adolescent experiences.  4.6.8 Mother spoke to the case worker about her experiences of domestic violence and racism whilst in Somaliland.  Mother spoke of MGF and that he visited once a week, but she did not refer to MGM.  4.6.9 It was agreed that mother should not be in the film about forced marriage due to possible risks to herself. Such risks were highlighted by mother’s description of being threatened locally by her husband’s relatives. The case worker reported this incident to the police, who visited the family. Mother explained that the incident had occurred several weeks earlier.  She spoke of her husband’s uncle saying he could take the children to Somaliland. The incident had happened prior to her move, so mother felt confident that her new address was not known.  4.6.10 Police officers visited the home and found MGGM there with the family. Mother explained the incident was prior to her move and involved a threat to take the children to see their father unless she helped her husband come to the UK. The police assessed the risk as ‘standard’ and advice was provided. The police officer wrote that mother was ‘clearly a level headed and sensible young lady and has the utmost care and concern for her children.....aware of how to report any new matters that might arise.’ The PC wrote in his subsequent statement that mother apologised for the flat being untidy, but that in fact it appeared ‘clean and tidy’. Mother was described as being optimistic about her pregnancy, despite the trauma and circumstances of the baby’s conception. 4.6.11 Children’s Social Care was informed and a manager notes consideration given to referral to the children’s centre for additional support. Mother was telephoned and she reported being fine, knew what to do and listed all the people supporting her: a FSW at the children’s centre and MGGM often staying with her. No call was made to the children’s centre to ensure the FSW knew of the incident or to clarify what support was provided /needed and the case was closed. 4.6.12 The police notification of this incident was also sent to the consultant midwife and forwarded to community midwife and the Gateway team. The health visitor was unaware of this incident.  4.6.13 Mother continued to attend the Young Parents Group and on 20.03.13 attended a pathways to employment session. Although no longer allocated to the FSW, mother continued to see the FSW at the Young Parents Group and still referred to her as providing support when speaking to others (HV1, midwife 1 and Children’s Social Care). She continued to attend the Young Parents Group in late pregnancy and after the birth.  28  4.6.14 Mother attended her own health / maternity appointments in late pregnancy but did not bring sibling 1 for his planned 3.5 year health review at the end of April. This was the first recorded DNA relating to the children’s health appointments, but the health visitor was informed by GP staff in March that the children’s immunisations were not up to date and mother had not responded to letters inviting them to attend.  Comment on service input March – April 2013 During this period mother slowly withdrew from children’s centre activities, although continued to attend the Young Parent’s Group meeting. She continued to exude cheerfulness and parenting capability in all her contacts with practitioners and spoke positively of the support of family and other services. It is this presentation of herself that re-assured practitioners and they felt confident that she would ask for help if required.  With the exception of the FMU caseworker, no-one visited the home or met any of the family or learnt exact details of their involvement. However, the 3 visits by the FMU caseworker supported this professional perception.  The police notification was sent to midwifery in accordance with the systems in place at the time. The systemic weaknesses within health services which did not ensure all involved health practitioners were aware of such incidents is discussed further in 5.9.   There was no health visitor contact arranged during this period and none was expected. However, mother did not bring the children for immunisations or for sibling 1’s developmental check. There was no follow up to this, due to the lack of any identified concerns in her parenting. See 5.6 for further discussion.  4.7 Birth of Jamilla: May 2013 4.7.1 Jamilla was born mid May 2013. Mother continued to attend her midwifery appointments with the Gateway team and the Young Parents Group prior to the birth. 4.7.2 At a midwifery appointment on 10.05.13 mother attended with her children and her aunt: she was in a good mood, speaking of extended family support after the birth. Midwife 1 informed mother that midwife 2 would take over her care after the birth, as she covered the area where mother now lived. Mother was not happy with this decision and midwife 1 was also disappointed to transfer responsibility, but understood that this was usual practice. 4.7.3 Mother was admitted to the hospital for induction of labour on 16.05.13. Present with her was MGF, step grandmother and other family members. The delivery suite was busy at the time and the induction was re-arranged. Jamilla was born on 18.05.13. Mother and baby were discharged 2 days later.   29  4.7.4 The practitioners involved with the family at that time thought mother was receiving help and support from MGGM and that she was staying with the family: this was the plan she had shared with them. However, MGGM had moved to Somaliland in April and that level of support was never available subsequently. This change in circumstances was unknown to midwifery, health visiting or the workers at the Young Parent’s Group, although mother (in her participation in this review) believes she did tell them.  4.7.5 The police statement of a cousin indicates that by the time of the birth, the sources of support were far more haphazard and unpredictable. This cousin described being telephoned by mother and asked to look after siblings 1 and 2 when mother attended hospital for the birth. The cousin had not seen mother since her return to the UK and had never met the children. She turned up the evening before mother went to hospital to look after the children and described the home as ‘messy’ and the ‘place needed cleaning’. However, mother was described as ‘very loving’ to the children who ‘looked healthy’. 4.7.6 The cousin stayed for 3 ‘nights in total’ and in her statement she describes mother’s return from hospital as ‘she arrived alone by taxi’. MGF explained that he arranged her return home, putting her in a taxi at the hospital and followed her home. The next day MGF and his 7 year old son visited. 4.7.7 In interview for this review mother provided a different account, whereby the great aunt initially had one of the children and subsequently both.    Comment  The decision to transfer case responsibility between midwives after the birth is discussed in 5.8. The rationale for this change was the family’s move some 3 months earlier and that it is the usual practice, although exceptions could be made. In this instance mother did not wish to change and the midwife was also sad to transfer the case, but did not realise there was any discretion possible.  4.8 Post natal period: mid-May – end of July 2013 4.8.1 During the postnatal period there were no concerns about the care of Jamilla or about mother’s mood. She had 6 health contacts and 2 contacts with the pre-school:  3 contacts with midwife 2: 2 at home and 1 at the clinic  2 contacts with HV1  1 contact with the GP and   2 contacts with the pre-school  30  4.8.2 Midwife 2 visited the home the day after discharge, when Jamilla was 3 days old. Mother was caring for Jamilla upstairs, fully breastfeeding and interacting well. Downstairs could be heard children laughing and another adult’s voice. Two days later the midwife returned and no concerns were noted. Mother was keen to get out so the next appointment was made at the clinic, when Jamilla was 10 days old. Mother brought her to the children’s centre for that appointment and there were no concerns, the baby’s weight was above the birth weight and mother was still fully breastfeeding. Mother spoke of her plans to take the baby to the Young Parent’s Group (which she did). 4.8.3 Because HV1 was visiting the following week, midwife 2 arranged to see mother in 4 weeks, on 28.06.13 at the children’s centre.  4.8.4 During June and July 2013 there was some contact between mother and the FMU about her difficulties obtaining child benefit, due to doubts about her children’s birth certificates. The FMU wrote letters on mother’s behalf to explain the situation and asked her to get back to them if any problems continue. They did not hear any more. 4.8.5 The new birth visit by HV1 occurred on 04.06.13, when Jamilla was aged 16 days old. The visit was delayed due to communication difficulties between mother and the health visiting service and mother changing the appointments made. HV1 noted Jamilla was alert and active, exclusively breastfed, had regained birth weight, had colic, but also (and contradictorily) to be easy to manage and sleeping through the night. The baby was not weighed as the midwifery service remained involved and she had been weighed at the clinic. Mother was observed to be cuddling her baby and reported to be bonding well. Mother was very positive about Jamilla’s development (said to be smiling), reported she did not feel depressed and made references to extensive family support from MGF, aunts and MGGM, who was still understood to be living in the home10. The record also refers to visits from paternal grandfather, but it is not clear who this is.  4.8.6 This was recorded using a vulnerable child template and the plan was to offer an enhanced service and liaise with other agencies involved with the family. HV1 did liaise with midwife 2, who discussed the positive impression conveyed by the mother, a ‘mature’ young woman, managing her children well with support from extended family. She also mentioned the attendance at the young parents group as a positive factor.                                                             10 NB Mother is adamant that she told practitioners that MGGM had gone to Somaliland, but this is not recalled by practitioners and is not in any agency records made at the time: it is possible that there was some confusion for practitioners about the distinction between MGGM and great aunt   31  4.8.7 HV1 also encountered the FSW at the health centre and mentioned concerns about sibling 1’s speech and language development. They agreed that the FSW write to mother to consider a referral at a children’s centre local to her address for structured play activities to support his speech development, and for the FSW to accompany her there. The next day mother attended the Young Parent’s Group (the last time she attended) and the FSW remembers that mother was happy showing her new baby to others. She had a 2-seater pram with the baby on top, sibling 1 walking and sibling 2 underneath the baby. Everything was clean and tidy. Mother was understood to decline a referral for the children’s centre, saying sibling 1 talked at home, so she was not concerned. Mother does not recall declining this. 4.8.8 Mother did not attend the planned appointment with midwife 2 on 28.06.13 (DNA 6 for mother’s appointments) and when contacted explained she was staying at her father’s address in West London and would be there for another 2-3 weeks. A new appointment was made for 23.07.13 and mother spoke about not being happy with HV1’s talk about the MMR vaccine. Information from MGF as part of this review confirms that mother and children stayed for a few days on 2 occasions during this period. 4.8.9 Mother did not attend the July appointment with the midwife (DNA7). She was never discharged but there was no further contact from the midwife, despite the midwife’s intention to contact mother in September and additionally receiving a missed call from mother in August. Mother’s memory of this is different and she is adamant that she did not miss any midwifery appointments and had a text from the midwife that she would send her date for an appointment. 4.8.10 Mother was however back in Tower Hamlets by early July, and attended a post natal appointment with her GP and HV1. Mother was observed to be fine and Jamilla was still breast fed, doing well, and smiling. HV1 undertook a mental health screening using a standard tool (PHQ9). Mother reported she was not depressed, was managing fairly well with support (misunderstood to be from MGGM). Jamilla was weighed and was gaining weight. The family remained on an enhanced service, but no further appointments were made. 4.8.11 Sometime in late June /early July mother came to the Pre-School to request a place for sibling 1 in September. The pre-school, had vacancies so a place was offered and a settling in visit arranged for mid-July. 4.8.12 The family attended the settling in visit. Sibling 1 was walking and the 2 younger children were in a double buggy. The family stayed for about 20 minutes, during which time sibling 1 played confidently, whilst the younger children remained in the buggy. Mother appeared confident and well presented. There were no concerns identified.      32   Comments As before mother continued to present impressively to practitioners, so despite identifying that she was vulnerable, she was not provided with any more services than a mother of 3 children aged under 4 without identified vulnerabilities. This was because of her observed competence and to her reports of family support, in particular of the MGGM’s role. In reality MGGM had by then left the UK.  While all practitioners noted the family support, as disclosed by mother, no-one explored the detail i.e. which family members and how often they visited. Moreover no local practitioners met any family members, albeit one was in the home during the first home visit of midwife2, but was elsewhere in the flat with the siblings.  This is not unusual, as a wider assessment involving families tends to be undertaken when there are concerns.  4.9 August to October 2013 4.9.1 There was no professional contact with mother and children during August, except for midwife1’s missing a call from mother on her mobile and mother’s call to Housing on 30.08.13 to inform of Jamilla’s birth and to elicit information on properties she had made a bid for. She agreed an appointment for 06.09.13 to bring in Jamilla’s birth certificate, but cancelled this on the day and failed to turn up on the re-arranged date of 09.09.13.  4.9.2 The subsequent contacts with practitioners were all with pre-school staff, at:   a home visit on 05.09.13  At pre-school on 19.09.13  Telephone contact between manager and mother on 23.09.13  At pre-school on 30.09.13  Telephone contact between manager and mother on 04.10.13, the day of Jamilla’s death 4.9.3 The deputy manager of the pre-school visited mother and children on 05.09.13 along with a colleague. Mother presented as happy and confident, and spoke of MGF providing a stair gate. The deputy manager noticed the bedroom in passing was tidy and presentable. The lounge was reasonable.  Sibling 1 was very active, whilst sibling 2 was shy and remained close to her mother. At one point the manager held Jamilla so mother could sign the forms. There was no concern about her or her siblings.  4.9.4 Mother spoke of being concerned about sibling 1’s speech and language skills and not always understanding what he was saying. She also spoke about still only receiving child benefits for the baby as the older two were not born in the UK. Mother explained about her past and that she received support from her family. She was not identifying herself as needing further support.  33  4.9.5 The only issue identified was a smell of urine and that the flat was warm. The manager did not raise this with mother as she wished to first establish a relationship with the family and was wary of scaring mother from engaging with the pre-school. She did though wonder if urine had soaked into the badly chipped laminate flooring which would then retain the odour. The deputy manager discussed this with the manager of the pre-school and agreed that given the mother’s self-reported history it was indicative of a need for support. However, in the context of mother and children’s positive presentation it was not perceived to be a safeguarding issue. 4.9.6 Sibling 1 started pre-school mid-September, 3 days after initially planned. Mother and children attended for the whole afternoon session. Mother mentioned that Jamilla had now progressed from breast feeding to formula milk and that sibling 1 was happy to attend the pre-school. All the family were well presented.  4.9.7 The manager recalled that towards the end of the day the room started to smell of urine and some staff members thought that this came from the pram. This prompted the manager to try to find out more about the family. With some detection work she located the FSW that mother had spoken about and communicated by email (as the FSW was out of the Centre).  The FSW decided to make contact with mother to check on her welfare.  4.9.8 Meanwhile mother had not brought sibling 1 back again and on 23.09.13 telephoned to say he had a temperature.  4.9.9 On 30.09.13, mother brought sibling 1 to the pre-school and wanted to leave him saying that she had a health visitor’s appointment (in fact this was not correct and she had no appointment). Because sibling 1 had only attended once, staff explained that he could not stay without mother remaining.  4.9.10 Sibling 1 did not want to leave as he had just arrived and had started playing, but his mother remained calm and patiently managed his behaviour whilst she put on his coat again. The other two children were quiet. As on all other occasions, mother and children were well presented and mother’s ability to cope with all three was admired. However, as before, the double buggy smelt of urine. 4.9.11 On 02.10.13, the FSW wrote to mother having failed to be able to contact her by phone on 3 or 4 occasions.  4.9.12 The next day 03.10.10 sibling 1 was not brought to the pre-school and on 04.10.13, when the manager telephoned mother to enquire about his whereabouts, mother said they had been staying with MGF because of a ‘problem’ and would attend on 07.10.13.  34  4.9.13 Tragically later that afternoon an ambulance was called to the family home by neighbours, after mother asked for their help because her daughter was not breathing.  Jamilla was taken to the local hospital’s emergency department. On arrival she was in asystolic cardiac arrest and after resuscitation attempts she was pronounced dead at 17.45.  4.9.14 During August and September it appears that mother’s contact with family members also reduced. The information for this is derived from the witness statements given to the police as part of the criminal investigation and from the interviews with mother and MGF. This demonstrates that over the summer mother was withdrawing socially, not answering the door to a cousin who tried to visit twice and not seen her father since July. Her regular week-end contact with great aunt also seems to have ended, with great aunt saying she had not visited for 3 weeks, but still spoke on the phone every 3 or 4 days.  4.9.15 Another extended family member also visited 3 weeks prior to Jamilla’s death and described the flat as clean and relatively tidy.   Comment During the last 10 weeks of Jamilla’s life, there was very little professional contact with the family, and none with any of the professionals who knew mother, such as the health visitor, GP or the Young Parents’ Group, nor with the midwife who had kept the case open to the service, intending to make contact in the September. Mother had ceased to attend the Young Parents Group, so had no direct contact with the FSW, although the FSW had tried to contact mother in the days prior to Jamilla’s death. The only contact with professionals was in the 3 direct contacts with pre-school staff, who had not known the family earlier and were consequently not in a position to be able to ‘pick up’ any changes in mood and presentation of mother and children. The only source of concern at this point was the urine smell from the buggy. Pre-school staff registered this needed to be followed up and chose the FSW because mother spoke highly of her, she knew the family and would be in a good position to judge any changes. The FSW is to be commended for trying to reach out to the mother for the second time since Jamilla was born (previously had discussed the possibility of help for sibling 1’s speech development), despite mother no longer being a client of the FSW and of the first children’s centre. Whilst this was appropriate, the health visitor should have been consulted as she had ongoing responsibility for the family and would have been in a better position to act quickly. However, the lack of communication with the health visitor reflects the lack of an identified lead professional.    35  5 THEMATIC ANALYSIS 5.1 Introduction 5.1.1 Section 4 considers professional practice thematically, explaining why actions and decisions were taken in this case. Section 5 provides the systemic findings and recommendations arising from this analysis. 5.2 Neglect  5.2.1 The prosecution’s opening note at Crown Court in April 2014, mentions mother’s failure to feed her baby daughter and failure to seek medical attention, as well as failing to feed the elder siblings ‘properly’ and to keep them clean.  5.2.2 The practitioners who met this family were shocked and surprised at what had occurred. The universal perception of mother was of a young woman who had demonstrated her resilience in overcoming the abuse and trauma she had experienced as a child and teenager, who demonstrated good parenting capacity and who provided a good standard of care for her children. There was no professional knowledge whatsoever of any concerns around mother neglecting her children. 5.2.3 Family members largely shared this perception, albeit, around the period of Jamilla’s birth a few relatives described in their witness statements to police an untidy or ‘messy’ home.  However, this would not be surprising given a single 18 year old mother, heavily pregnant with 2 young children, or caring for a new baby and 2 very young children. 5.2.4 For most of July and August mother had little social contact with family and none with professionals. She told the author that an incident occurred which led to her having ‘flash-backs’ of childhood abuse she had experienced. Along with this her husband kept telephoning from Somaliland, after MGGM gave him her telephone number. Mother recalls feeling ‘so tired’, ‘lonely, sad, unloved and ashamed of things that happened to her’. She thinks she became ‘somewhere else in my head’. 5.2.5 When the pre-school staff visited the home 4 weeks before Jamilla’s death, the home was reasonable and the only issue was the smell of urine. The children all were considered to be well. The last family members to see the family was great aunt and another female relative; they visited separately but both spoke of visiting the home 3 weeks previously, Great aunt did some cleaning in the lounge and kitchen. She was aware that mother was feeling ‘low’ and suffering from the ‘baby blues’ and had up till then been providing some support.  5.2.6 In the next 3 weeks, mother and children were seen twice at the pre-school and again, other than the smell of urine in the pram there was no concern about the children or mother.  36  5.2.7 Little is known about what was happening within the home in these last weeks, but unknown to the professionals, the family support previously understood to exist did not occur. From the police investigation as cited in the Crown Court Opening Notes, mother spent a great deal of time on Facebook, and in her communications with her new ‘virtual’ friends she described herself as living with her mother and her younger siblings.  5.2.8 One relative tried to visit the family in September a couple of times, but the door was not answered despite hearing a child crying inside, and mother did not answer her telephone.  5.2.9 Statements made by neighbours to the police include one that noted a smell when walking past the flat in September and another who had contact with mother the day before Jamilla died, due to mother being oblivious of a tap overflowing in to the neighbour’s flat. When the neighbour knocked on her door, there was no reply, and after 10 minutes of knocking on the door and shouting through the letter box, mother apologised but would not open the door. She later came to the neighbour’s flat and apologised. 5.2.10 The description by police and witnesses of the state of the family home following Jamilla’s death is a total contrast to that described by professionals and family members. The Crown Court Opening Statement gives a neighbour’s description of dirty and dishevelled children who ‘stank of stale urine’ and ‘dirt and sweat’...’place unfit even for livestock’. The police officers who went into the flat were quoted as encountering ‘an overpowering smell of faeces, urine and rotting food’ and ‘there was no edible food in the fridge’. Persistence & neglect 5.2.11 This case highlights the difference between the common perception of neglect (which whilst harmful to children over a long period) is not usually associated with such a sudden and life threatening impact on children. The common understanding of neglect is that the risk to children relates to a long term inadequacy of care. This is embodied in the definition of neglect provided by Working Together:  ‘Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development’. 11                                                            11 Working Together to Safeguard Children,  DFE March 2013  37  5.2.12 Such a definition though is not congruent with the circumstances in this case, when there was an extremely quick and speedy deterioration in the home circumstances during the latter half of September. It is important that both professionals and public understand that neglect can lead to risk to children within a very short period of time, especially in relation to babies and young children. In this case, there were very few indicators known to professionals of the change in the home circumstances and to mother’s parenting capacity, other than the smell of urine from the children’s buggy.  This rightly alerted the pre-school to make contact with those that knew mother, but in itself did not give rise to concerns about the immediate safety of the children.  Research findings on fatal cases of malnutrition: invisible children 5.2.13 Brandon et al12, in a study of neglect and serious case reviews, points to how unusual this type of death is in their study:  ‘The number of serious case reviews undertaken where the baby or child was dangerously emaciated has been low; typically only one or two per year. .... (there has) only been six serious case reviews undertaken in relation to fatal cases of malnutrition in a six-year period between 2005–11. In addition there were a small number of non-fatal cases, where malnutrition had been so severe that the child was within days of death, but had fortunately survived after intensive hospital treatment.’ 5.2.14 None of the 6 fatal cases of malnutrition in Brandon’s study involved children subject to a child protection plan, but what was common was that it involved children who were ‘invisible’ with parents that were withdrawing from services and children not seen by universal health services. 5.2.15 The question arises in this case: were the children in this family ‘invisible’ and the mother withdrawing from services in the way that Brandon et al describe? Until early July 2013, this was not the case. The children had been seen regularly during mother’s pregnancy and in the postnatal period, due primarily to mother’s contact with maternity services and the GP. 5.2.16 However, after the postnatal appointment early in July, the situation changed. It is of note that from the post natal appointment in early July, neither mother nor the children were seen by any professional who knew them. Mother ceased to attend the Children’s Centre Young Parent’s Group and failed to keep her appointment at the clinic with the midwife at the end of July.   5.2.17 Unknown to the health visitor and midwife, mother did initiate contact herself with the pre-school, but subsequent engagement was limited; without prior relationship with the family staff there were not in a good position to observe any changes.                                                            12 Neglect and Serious Case Reviews, A report from the University of East Anglia commissioned by NSPCC Marian Brandon, Sue Bailey, Pippa Belderson and Birgit Larsson, 2013  38  5.2.18 Because there was no health visitor or further midwifery appointments provided over the summer (after the DNA in late July) and none in September, mother was not perceived as withdrawing from services. The children were in the minds of health practitioners, but were not actually seen and the family’s isolation was not identified. The midwife’s intention to contact mother in September did not happen and the health visitor’s plan to make contact in October had also not yet happened. It is not known whether mother would have responded had contact been made and appointments offered.  However, the high level of contact with professionals the family had received prior and immediately after Jamilla’s birth, ceased.  5.2.19 This lack of visibility of the children over a period of 10 weeks is not a reflection on the individual members of staff, but is the usual service level provided in the absence of current concerns about mother and children. Staff planned to make contact, but there was no evidence of any urgent need to do so. 5.3 Threshold responses & assessments of need 5.3.1 The Tower Hamlets Family Wellbeing Model13 provides professional guidance on the tiers of need and the relevant thresholds for service provision for everyone who works with children, young people and parents /carers in Tower Hamlets. This provides comprehensive and detailed guidance on the required professional response to different levels of need. The version in force in 2012 / 2013 outlined 3 tiers of need:  Tier 1: Universal, which described needs that can be met via universal services with at times ‘additional or differentiated support’, ‘minimal intervention’ and usually do not require an ‘integrated response’  Tier 2: Targeted, when needs are more complex or more intensive and additional specific support is required – in the 2014 model this has been revised to include ‘early help’ as well as targeted   Tier 3: Specialist, when families / children are already experiencing poor outcomes and need ‘specialist and statutory support’ 5.3.2 The guidance provides indicators for each of the dimensions of the Framework of Assessment14 i.e. development of baby, child or young person; parent factors and family and environmental factors. These all focus on the current functioning of parents, and the health and development of their children.  5.3.3 In this case mother was open about her past and all practitioners recognised her vulnerabilities. However, all were impressed with her competence in parenting and her relationship with her children. Whilst it was noted that sibling 1 was extremely active and had possible speech and language difficulties, this was not on a level to raise concerns about his welfare. Sibling 2 was very quiet in comparison, but again there were no concerns about her health and development.                                                             13 The Tower Hamlets Family Wellbeing Model 2012 14 The Framework for Assessment of Children in Need, originally DOH 2000  39  5.3.4 Agency records do not show the level of assessed need in terms of the 3 tiers, but with the exception of midwifery, the family were in practice provided with a tier 1 service. Moreover, the descriptors within each tier within the Family Wellbeing Model focus on current functioning and the fact of parental vulnerability in itself does not push a family into tier 2 provision, without evidence that the vulnerability is affecting the current parenting. Tier 1 provision does not require a CAF to be initiated, nor co-ordinated support and a lead professional.  5.3.5 Such a welfare model does not cope well with parental vulnerabilities, which may have different impacts on parenting at different times and rely on consistent practitioners with sufficient contact with the family to be able to have a holistic understanding of the family’s needs, knowledge of the overall multi-agency service provision and an ability to identify changes in need over time. 5.3.6 It is notable that in this case, in the absence of an identified lead professional, both the health visitor and the pre-school liaised with the FSW at the Children’s Centre over concerns (speech and language for sibling 1 and smell of urine respectively), despite the fact she had ceased to have a formal role many months previously. This was perhaps in recognition that the mother perceived the FSW as having been ‘her worker’ and also reflected the absence within the network of a ‘lead professional’. 5.4 Thresholds for children’s social care involvement 5.4.1 Mother and her 2 children were referred to Children’s Social Care on 3 occasions, firstly to Brent and Tower Hamlets in October 2012 and again to Tower Hamlets in March 2013.  5.4.2 The referrals to both local authorities Children’s Social Care in October 2012 were around the vulnerability of the family given mother’s very young age (nearly 18 for Brent and just 18 for Tower Hamlets), the trauma she had experienced since leaving the UK at age 12 and her heavy responsibilities of being a parent of two children aged under 3. Additionally Tower Hamlets were aware also of her third pregnancy. 5.4.3 Despite the recognition of vulnerability, there had been no concerns raised about mother’s care of her children, but the referrals made suggested that both the worker at the FMU and within housing recognised the potential risk if mother was not provided with support. 5.4.4 In Brent, mother was understood to be living with MGF, so it appears that an assumption was made that support was available and other than providing MGF with information of services, no contact was made directly with mother, no assessment made of her needs and no checks undertaken to see if the children’s existence was subsequently known about within health. The lack of speaking directly to mother is, according to her account, even more striking as she was present at the time of the social worker’s call.  40  5.4.5 Such a response of advice and signposting in the absence of identified concerns about the current welfare of children is consistent with a welfare model that relies on universal services to identify whether or not there is a need for targeted services. However, such a model relies on universal services able to identify the risks to children and families. This in turn is dependent on the children’s existence being known about by GPs and health visitors, who will then be able to assess whether any further support is needed. In this case, Brent Children’s Social Care did not ensure that:  Universal services knew of the children’s existence nor that  Universal health services knew of mother’s background and vulnerability nor that  Any assessment was undertaken by the health visitor, in the absence of a social work assessment.  5.4.6 In Tower Hamlets, Children’s Social Care tried but did not manage to speak to mother, but financial assistance was provided (via Housing) and referrals were made to the children’s centre and health visitor to ensure that help was offered and that universal health services knew about the presence of the children in the borough.  5.4.7 This response ensured that the family would be offered support and that assessments would be undertaken both by the health visitor and the Children’s Centre. What it did not do was neither take any active part in deciding the type of assessment undertaken nor ensure that co-ordinated support was provided via a Team around the family.  5.4.8 Staff as part of this review reflected that when there are such parental vulnerabilities as indicated by mother’s youth and troubled history, practice has now changed and Children’s Social Care would take a greater role in ‘stepping down’ to universal services, so as to ensure a team around the family approach, with a lead practitioner and the undertaking of a Common Assessment (a CAF).  5.4.9 This would have provided an improved assessment of mother’s circumstances and consequently an improved understanding of her vulnerabilities over a longer period. However, it is not clear from the London Borough of Tower Hamlet’s Family Wellbeing Model that this would in fact occur (see section 5.3) or that a social worker is able to implement such an arrangement on other agencies. For this reason a recommendation is provided in section 6 about the use of the CAF and a lead professional in such circumstances.  41  5.5 Use of history in determining agency responses 5.5.1 Although mother lived in Tower Hamlets as a child, the knowledge of her childhood history was not accessed. In this case CSC history would have been limited to the knowledge about mother having been missing from home for a few days aged 12 years old. Such knowledge would have marginally increased the awareness of mother’s vulnerability, but would not have made a substantive difference to the decisions made at the time. CSC’s records would not have included all the information held by police about domestic violence prior to moving to Tower Hamlets, nor would mother’s educational difficulties have been in these records.  5.5.2 However, this case has highlighted the lack of checking of historical records, even though in this instance it is unlikely to have made a difference. Practitioners acknowledge that in 2012 this was not consistently undertaken due to:  The high rate of referrals / contacts at that time meant that the screening role did not necessarily involve accessing of historical records  Earlier records are less accessible due to the details not being on the current electronic system  Not all practitioners have access to the old SWIFT and CRIS records, so the search for historical data is time consuming for a duty officer 5.5.3 Practitioners and managers were confident that the routine checking of historical records is now more consistently undertaken at the screening stage, but further research on this needs to be undertaken to be confident of such a change in practice. 5.6 Health visiting service provision 5.6.1 Health visitors provide universal / targeted interventions and referrals to other services such as Children’s Social Care according to the level of vulnerability identified. The Tower Hamlets Family Well-Being Model provides professional guidance on the tiers of need and the relevant thresholds for service provision.  5.6.2 The universal health service provision involves health visitors providing:   ‘movement in’ visits to children and families who re-locate into the geographical area or register with a local GP so as to identify health needs, assess levels of vulnerability and signpost or support the family in meeting those needs by referring to local services  New birth home visit – 10-14 days from birth  6-8 week review – undertaken in conjunction with the family’s GP at the surgery/clinic  8-12 month developmental review – clinic based  2 year developmental review – clinic based  42  5.6.3 All health visiting clients are encouraged to attend Child Health Clinics across the borough should additional support be required. Any intervention additional to this universal service, including further home visits is available for those assessed as requiring an enhanced health visiting offer. 5.6.4 Mother’s self-reported history at the transfer in visit with the agency health visitor provided sufficient information for her to be identified as vulnerable in the records. The health Individual Management Review considers that this should have led to the family being provided an enhanced service, although this was not specified by the agency health visitor.  5.6.5 At the clinic visit in early February 2013, HV1 (the allocated health visitor) noted mother’s history and high level of vulnerability. She explained, as part of this review, that an enhanced service was assessed, but that this would be provided via open access to additional services if mother wanted them. The rationale for this was mother’s competent parenting skills and apparent ability to cope. In practice without mother requesting additional help, the family received the universal health service offer and health visitor contact was limited to:  the transfer in visit by the agency worker in November 2012  The clinic contact in February 2013 for the 8-12 month review for sibling 2 and   The new birth visit in  early June 2013  The joint 6/8 week post natal review at the GP surgery in July 2013 5.6.6 The lack of additional input arises from:  The health visitor’s assessment of the family i.e. mother coping well despite her youth and history and demonstrating good parenting capacity  The reliance on mother’s self-reporting about the provision of support from the family members and the FSW at the children’s centre  The lack of definitive local guidance as to what constitutes an enhanced health visiting service, with the decision being left to the clinical judgement of the practitioner.  The assessment that mother would have the insight and ability to request support if she required this 5.6.7 Until July 2013 the family had a high level of contact with health practitioners. However, by middle to late July:  The high level of health contacts with the mother and baby had ceased (as is standard) following the end of the post natal period  Mother had chosen not to see the midwife on two occasions  Siblings 1’s developmental check remained outstanding  The health visitor was aware of sibling 1’s possible speech and language problems, and that mother had declined the FSW’s offer to make a referral to a children’s centre   The children’s immunisations remained outstanding and mother had not attended appointments for these  43  5.6.8 The service provided was entirely consistent with local requirements for an enhanced service, which does not necessarily involve additional input over a universal service.  5.6.9 In this case although there were no identified concerns about the children’s care, both the GP and health visitor were aware that immunisations and sibling 1’s developmental check had been missed. Also the health visitor was aware of sibling 1’s slow speech and language development and of the mother’s decision not to be referred to a children’s centre nearer home for group activity to help develop sibling 1’s language skills.  5.6.10 The health visitor had identified the need to follow up the children and planned to make contact in October. At the time the lack of any reported concerns from elsewhere meant that the priority to initiate contact was not perceived to be urgent. Had the health visitor known in September of the smell of urine in the flat and in the pram this may have increased the priority.     5.7 Mother’s co-operation with health services 5.7.1 Practitioners involved with the family were impressed at the time with how well the mother coped with the care of her small children and other than an initial resistance to seeing a health visitor in November 2012, she was thought to accept help and co-operate with professional plans and advice. 5.7.2 Table 4 shows the health appointments mother kept for her and the children and those which she did not attend (DNA). Also shown in the right hand column are her contacts with the children’s centre and pre-school.    Table 4:  Health and welfare face to face contact with family Month No of health appointments for mother No of health appointments for children Total health appointments kept Total health DNAs Children’s Centre / Pre-school attendances / home visits Appointments kept DNA Appointments kept DNA November 2012 6 1* 1 + 0 7 1 2 December  2012 3 0 0 0 3 0 1 January 2013 4 1* 0 0 5 0 3 February 2013 2 2 ~ 1 + 0 3 2 2 March 2013 2 2 #~ 0 0 2 2 2 April 2013 2 0 0 1 2 1 0 May  2013 6 + hospital for birth 0 0 1 6 1 2 June  2013 0 1* 1 +  0 1 1* 2  44  July 2013 1* 1* 0 0 1 1* 1 August 2013 0 0 0 0 0 0 0 September 2013 0 0 0 0 0 0 3 1st – 4th October 2013 0 0 0 0 0 0 0 TOTAL 26 8 3 2 29 10  *Midwife / GP ante / post natal appointments  # GP unspecific appointment ~ glucose intolerance tests (which was subsequently completed) + 3 health visitor appointment s : transfer –in visit, clinic appointment included developmental assessment and new birth visit Mother’s appointments 5.7.3 Overall the number of health appointments kept by mother was 29, and she had 10 ‘DNAs’ i.e. a rate of nearly a quarter of missed appointments – 10 out of 39. Further analysis of this shows that  All but one DNA concerned her health in pregnancy and post-natal, as opposed to the children’s appointments  Very few health appointments were provided for the children – 4 were offered in total, and whilst she missed 2, one was re-arranged a few days later (the new birth visit for Jamilla). However sibling 1’s 3.5 year developmental check DNA was not followed up, despite subsequent awareness of concerns about his speech and language development and knowledge of lack of immunisations (see 4.7.6 for further discussion)  Mother missed 8 appointments out of 26 health appointments for herself: 3 antenatal appointments with midwifery, 2 tests for glucose intolerance, an unspecified GP appointment and 2 post natal appointments with midwifery Gateway team 5.7.4 Staff interviewed for this review explained that given a young single pregnant woman with 2 children aged under 3 and then with 3 children aged under 4, such a DNA rate would not be unusual and was not perceived to be a risk indicator. In practice given that mother’s antenatal appointments were re-arranged and she attended the next ones, the ante-natal DNAs were not significant. 5.7.5 The CCG (Clinical Commissioning Group) aggregated root-cause analysis report 15 examines the missed appointments in this case and the authors conclude that:                                                            15 Tower Hamlets CCG Aggregated Root Cause Analysis Report of the Health Provision for Jamilla; the subject of a Serious Case Review conducted by Tower Hamlets LSCB 2014, Authors: Rob Mills, Nurse Consultant Safeguarding Children and  Dr Owen Hanmer, Designated Doctor Child Protection   45  ‘none of the DNA’s in this case proved to be significant in relation to the jeopardising of (mother’s) pregnancy or in contributing to the circumstances leading to the death of Jamilla. ‘ Children’s appointments 5.7.6 The issue with regard to the children’s appointments is more complex. Mother missed 2 of the 4 known appointments, but one was re-arranged, leaving only the 3.5 year developmental check outstanding. Given that this appointment was just before the birth of Jamilla, it is not surprising that mother did not attend, given the number of other health appointments she was keeping and having sole parenting of 2 small children. However, this appointment had not been re-arranged over the next months. 5.7.7 We do not know the extent to which mother did not attend nursing appointments at the GP surgery, as the routine recording of DNAs was for appointments missed with the GP and not for nursing. The health visitor was told she had missed her immunisation appointments, but the review does not know how many had been provided. This indicates a systemic recording problem within the GP surgery which has been addressed with a recommendation in the CCG Aggregated Root Cause Analysis Report of the Health Provision for Jamilla. Conclusion 5.7.8 The recognition of mother’s vulnerability by midwifery and health visiting did not lead to a holistic perspective which would have picked up that:  From the end of June mother did not keep her 2 midwifery appointments AND  She had not brought sibling 1 to his 3.5 year developmental check in April and had  not brought the children to an unknown number of immunisations appointments 5.7.9 This lack of integrated working between different parts of the health service is discussed further in 5.8 below. 5.8 Lack of co-ordinated multi-agency provision 5.8.1 Mother received services from housing, children’s centres, a pre-school, midwifery, GP and health visitors. Despite the high level of professional contact in the early months, there was little communication evident between the various agencies and professionals, after the initial signposting between services. In line with tier 1 service provision as identified in the Family Well Being Model, no CAF was initiated, nor a lead professional identified.  5.8.2 The lack of any co-ordinated service input meant:  That there was no communication about the service being provided to the family between the children’s centre and the health visitor and midwifery – so despite notification that the FSW had closed the case in March 2013, the health visitor continued under the misapprehension that the FSW was providing regular support   46   Lack of recognition of mother’s increasing isolation from family and professional contacts once the intensive health contact during pregnancy ceased  Lack of understanding of the importance of providing mother with consistent input given her vulnerability and to avoid change of workers, i.e. change of midwife after the birth  Lack of communication between pre-school and health visitor  5.8.3 Within health, there was very little direct communication between practitioners, especially health visitors and midwifery. The GP does hold regular monthly meetings which include the gateway midwife and the health visitor. The GP cannot recall any concerns raised about this family, but in the past the discussions were not noted on patient records (this has now changed so is not subject to a recommendation). 5.8.4 The lack of any ongoing assessment process meant that no practitioner had a grasp of the level of support mother received either from other agencies or from her own family. She did though at the time speak positively about the support she was receiving from services and from extended family members. See section 5.9 for further discussion about family. 5.8.5 The two professionals who had been a regular feature of the mother’s life ended contact around the birth, with a change in midwife following the birth and the regular contact with the FSW ceasing due to the mother’s withdrawal from the Young Parents Group after June 2013. It is telling that in interview for this review, mother spoke both about never getting to know any of the professionals, as well as at her distress at the change of midwife and ending of an allocated FSW. This apparent contradiction perhaps indicates her desire for having wanted an ongoing relationship with individual practitioners.   5.8.6 At this point, consistent with the tier 1 service provided there was no lead professional to understand that mother had started to withdraw from contacts, missing 2 post natal midwifery appointments, having no contact with the health visitor or GP following the post natal check at the beginning of July and ceasing to attend the Young Parents Group. During the next 3 months no practitioner who had previously met mother and children saw the family.  5.8.7 The pre-school had no previous contact with the family, and hence were not able to note any deterioration in the family’s functioning. They were though sufficiently concerned about the smell of urine and lack of regular pre-school attendance to make contact with the FSW and commendably (as she no longer had a professional role with the family) she agreed to try to intervene. Through the review process, staff from the pre-school realised that it may have been more appropriate and effective to have at that point liaised with the health visitor. This was not identified at the time, as the usual practice is for the first point of call to be within the early years services unless there are identified concerns.  47  5.8.8 Health members of the serious case review panel have clarified that the health visitor role (prior to a CAF and for cases held in health) is the “lead professional” for under 5s due to universality of service and a coordination and signposting role. There is no evidence within this case that such an understanding of the health visitor’s lead professional role existed in the professional network. There is a need for clarification about when and how the lead professional role operates within Tower Hamlets. 5.9 Health practitioners knowledge of police notifications 5.9.1 When children come to the notice of the Police, notifications of the event are sent to relevant partner agencies so that involved practitioners are aware of any risks to the children. This notification is called a Merlin by the Metropolitan Police Service.  5.9.2 Following an earlier serious case review recommendation in Tower Hamlets, in 2009, health (as well as social care) was routinely notified by the police of Merlins, when domestic abuse was the reason for the report being generated. The rationale for this was that whilst not all would meet a Children’s Social Care threshold, as health is a universal service there would be a health visitor record for all children subjects of such a notification. Health visitors could then decide whether to make contact with the family and offer early help and support or if such information, together with that held by health, warranted a referral to Children’s Social Care. Furthermore, such notification ensured that health staff undertaking home visits alone, were aware that there were potential risks to the visit. 5.9.3 A weakness of the system arose due to the way that health managed the information from the Merlin, if both midwifery and health visiting were involved. The information would be put only in the midwifery record with an expectation that the midwife would read the record and then inform the health visitor. 5.9.4 This case highlights the systemic weaknesses in such an arrangement. The Merlin was sent to advise health of the threats mother had received from a relative of the father and this information was entered into the mother’s midwifery record. However the midwife did not access the entry and the health visitor remained unaware of what had occurred. 5.9.5 Since September 2013, the Metropolitan Police Service (MPS) have decided that all Merlin reports should be processed via the newly developed MASH16 (the Multi-Agency Safeguarding Hub). However, since that time health has not been receiving any Merlins. This limits health practitioners’ ability to offer the early intervention service, as described in 5.9.2. This changed occurred across London and is addressed in a recommendation in section 6.                                                             16 The MASH or Multi-Agency Safeguarding Hub is the single point of contact for all safeguarding concerns regarding children and young people.   48  5.10 Task centred versus relationship based provision of support 5.10.1 Barlow & Scott17 refer to the importance of building a trusting relationship ‘with clients has been acknowledged and emphasised by a range of helping professions, including social work, psychotherapy, nursing and medicine, but that there is a wide variation in the extent to which that relationship is regarded as central to professional practice’. A review of the evidence of effective interventions18, showed the importance of a ‘dependable professional relationship’ for parents and children, in particular with those families who conceal or minimise their difficulties. 5.10.2 Mother told the author of this serious case review that she did not know the practitioners who offered her support well enough to trust them. Whether this was always the case is not clear, but by July those she had developed a relationship with, the first midwife and the FSW at the children’s centre were no longer involved with the family. The health visitor continued to have an ongoing responsibility, but had only met mother and children on 3 occasions over 7 months, twice at the clinic and once at home. It is unlikely that such a level of contact would be able to provide a trusting relationship. However, such a level of contact is usual given the lack of assessed concerns. 5.10.3 It is of note that the FMU caseworker only met the mother on 3 occasions, but was able to learn more about her and her family in these contacts than other professionals.  She learnt details about MGF’s personal circumstances which limited his contact at that time. She met MGGM and discussed her attitude to forced marriage. Most critically she identified there was a level of disconnection between the capable mother and her underlying immaturity and that she described the traumatic events in her life, as if they had happened to someone else. 5.10.4 It is likely that this difference in mother’s openness and to the FMU caseworker’s understanding relates to the 3 visits being undertaken within a short space of time, occurring within the home and being more relationship than ‘task focused’.     5.10.5 At one time universal health provision involved home visits by health visitors to households with pre-school children and midwives visiting the home for 10 consecutive days post birth, providing practitioners with a greater understanding of the family circumstances. A challenge for practitioners undertaking assessments in the current way services nationally are structured, is the focus on tasks as opposed to developing relationships and that usually contact takes place outside of the home.                                                             17 Safeguarding in the 21st Century – Where to Now: Jane Barlow with Jane Scott. Research in Practice 2010 18 Effective Interventions for Complex Families where there are Concerns about, or Evidence of, a child suffering Significant Harm, Thoburn et al, 2009  49  5.10.6 The change to the contemporary picture of service delivery via clinics and children’s centres provides a more efficient use of scarce resources and has the advantage of encouraging mother’s to use community resources and get to know other parents. The disadvantage however, is in the ability to speak openly and develop a stronger relationship. This can impact on the quality of assessments undertaken as well as the potential to develop the trusting relationship in which parents feel able to express their worries and concerns. 5.11 Social isolation: family contact with extended family and community 5.11.1 The decrease in family support was not known by professionals and indeed their services were at the same time reducing following Jamilla’s birth and immediate well-being.  5.11.2 Practitioners in health and the children’s centre identified mother’s vulnerability but were re-assured by 2 main factors:   Mother’s parenting capacity as observed by all and   The support from extended family, in particular the regular input from MGGM and the intention for MGGM to stay with the family around the birth of Jamilla  5.11.3 Whilst mother’s initial accounts of the support from family members was accurate, the witness statements provided to the police indicate that mother and her three young children lived an increasingly isolated existence with sporadic support from extended family members, as opposed to a stable constant level of support (see 4.9). Other than family, there is no evidence that mother had any social contacts whatsoever. 5.11.4 This change in her circumstances remained unknown to professionals. None of the local practitioners met family members or verified the nature and extent of the support. Given the lack of current concerns, this would not be part of usual practice. MGM’s relatives in London 5.11.5 The FMU caseworker did meet MGGM and she was providing support to the family in March 2013. MGGM was also present when the police attended the flat that month. 5.11.6 After the birth of Jamilla, when the midwife visited the home, she heard the children playing downstairs and understood there was someone caring for them. Cousin 4 in her police statement mentions that the health visitor called when she was there, but they did not meet. It is more likely that this was the midwife. 5.11.7 Through reading the statements made to police, it is evident that whilst there was initially a high level of support from family members as described by mother, the situation changed and this was not understood by the various health clinicians still involved with the family (GP, midwifery and health visitor), nor by the workers at the young parents group.  50  5.11.8 The main change was that MGGM left to live in Somaliland in April 2013, before the birth of Jamilla and from that time onwards, social contacts and support provided became less consistent and regular from relatives, with assumptions being made that maternal great aunt and a great uncle were helping regularly.  5.11.9 Maternal great aunt remained in contact and saw mother and family regularly, most week-ends, according to her police statement, but did not stay over and mentioned that the only time she ever changed a nappy was during the days she cared for the siblings after the birth of Jamilla. She helped with cleaning, cooking and shopping and  considered that mother was suffering with the ‘baby blues’, describing the situation as ‘like a baby having a baby’. However, she judged that mother, who was trying to ‘potty train’ sibling 1 at the time, was a ‘good mum’, ‘very mature for her age’ and ‘loved her children’.  5.11.10 Great aunt was aware of mother’s ongoing financial problems, only receiving child benefit for one of the 3 children and that she lacked any friends or contacts other than family. However, despite the financial hardships great aunt referred to mother as not asking for help as ‘she wasn’t English, she would not ask for anything’. 5.11.11 It appears that by September, this regular week-end visiting pattern had ceased and great aunt had not visited for about 3 weeks prior to the death of Jamilla, although she spoke to mother every 3 or 4 days on the phone. On her last visit to the home she did some cleaning, but said in her witness statement ‘about three weeks ago stopped going round’. 5.11.12 Great uncle, who others thought was providing support, did help the family to settle in Tower Hamlets and, according to his statement to the police, had 4 direct contacts with his niece – a visit to the first flat, escorting her to a solicitor (presumably about her housing problems), helping her move in February and on return from a trip to Somaliland at the end of May, the great uncle visited again in June / July – he was concerned about mother’s ability to shop for food, but she explained she did this via the internet. 5.11.13 Other family contacts as explained in police witness statements show a pattern of intermittent and largely decreasing visits following the birth of Jamilla:   A cousin  told police he spoke daily initially and saw mother 5 or 6 times, including at her home on 3 or 4 occasions – he described her as seeming ‘happy’ and looking after and loving the children, taking them he understood to playgroup: this cousin did not see the family after the birth of Jamilla  Another cousin provided care for siblings 1 and 2 for 3 days when mother was in labour and giving birth, although mother says that great aunt did this not a cousin  Another relative visited the family on 2 occasions, one before and one after the birth of Jamilla and attempted to see them again in September, but got no reply when called at the home or made telephone calls  51   Another cousin told police that mother stayed with her family for a few days at some point and helped them move into their flat – the cousin visited a few times but then lost touch  An ‘auntie’ visited a couple of times before and after Jamilla’s birth and described the flat as looking clean, and mother was beast feeding  Another cousin visited twice and described that on the second occasion the place was a ‘tip’ and they cleaned the flat – mother and children visited this relative in August, when mother seemed tired, but the children looked well  Another cousin last saw the family when mother was 8 months pregnant and the flat was messy  – prior to an argument the cousin had visited every Friday afternoon to help mother Maternal grandfather and family 5.11.14 Practitioners also understood that MGF and his family were providing support to the family. Certainly MGF assisted mother’s return to the UK and mother and children lived with his partner in Westminster. However, direct contact with MGF and other members of his family was limited once the family moved to Tower Hamlets and according to information provided in police witness statement by and in interview with MGF consisted of:  MGF visiting the family a ‘few times’ in the beginning, but then not seeing each other for a ‘couple of months’ possibly after a ‘minor dispute’ but also from MGF’s perspective as both busy with their own lives   Texting prior to birth of Jamilla  Being present at the hospital during labour, but not at the birth  Arranging a cab to bring mother and baby home   A few visits following Jamilla’s birth  Mother and children staying with his family in Westminster on 2 occasions after Jamilla was born  A loss of contact for 3 months, before getting back via text messages, when mother said she was fine and taking the children to nursery  Mother visited MGF’s mother a few times after the birth of Jamilla and they had telephone contact 5.11.15 Another female relative police she visited the flat on 3 or 4 occasions, the last being 3 weeks prior to Jamilla’s death – at that point the flat was clean and relatively tidy Summary of family contact 5.11.16 The information from the police statements confirms that the extended family were providing support to mother, but that the extent, regularity and consistency of this was declining over time, at the same point that professional contact declined. Mother would have spent days at a time without any social interaction with adults, living an isolated existence in the flat with her 3 very young children.  52  5.11.17 Information from family members also demonstrates the role of family members in cleaning and shopping activities to support mother, and some had noted a messy or dirty flat and according to the great aunt that mother was feeling low and having the ‘baby blues’.  5.12 Shortage of housing resources 5.12.1 As explained in the comment box at the end of 4.4, the family experienced an immediate and timely response from Housing, and were fortunate to be placed in a flat as opposed to Bed & Breakfast accommodation; such provision is often not available. When mother complained about the unsuitability of the first flat, they were again fortunate to be provided with more appropriate accommodation within 3 months. 5.12.2 It is recognised that given the housing shortage in London and Tower Hamlets this was a comparatively good outcome.  The Service Head, Housing Options has provided the review with the information in the graph below on the significant rise in homeless applications this council (and the rest of London) has been experiencing and how the council’s accommodation responses are influenced by this.  5.12.3 Mother applied to the council in October 2012 and the decision to accept a full duty was made in January 2013.  The graph above shows how homeless numbers was rising in Tower Hamlets, manifested by the (significant and growing) use of Temporary Accommodation.  53  5.12.4 In such a climate, the council is forced more and more to rely on bed and breakfast (B&B) accommodation. This is particularly significant in the context that Tower Hamlets was one of the first boroughs in London to originally end the use of B&B for families and consequently did not regularly record B&B usage for families, only starting in the November of 2012 when 45 families were recorded.  Within 6 months, that had doubled.   5.12.5 Because of the desire to avoid placing families in B&B, all forms of self-contained accommodation is used, particularly if within the borough, in a desire to avoid exporting vulnerable and/or homeless households refers. Despite this the 6-week statutory maximum stay in a B&B is sometimes breached due to the lack of resources. 5.12.6 The use in this case of a walk-up block was a reflection of firstly the desire to avoid an initial B&B placement and secondly, in the context of an aging portfolio of properties in the borough such ‘walk-up blocks’ are not uncommon. These properties are deemed reasonable for occupation for permanent and secure housing so consequently their use for temporary homes is considered as reasonable. 5.12.7 The positive judgement of the service provided to mother and children is therefore based within the knowledge of this resource context. However it is worrying that the option to place a pregnant lone mother of 2 children aged under 3 years old in a 4th floor flat in a building without a lift is the best option available, despite potential risks to safety of mother and child.  5.12.8 Mother’s move to more suitable temporary accommodation relied on her having the ability to complain. When she did this, she was provided with support to put this in writing and was moved in a relatively fast time frame, albeit it might not have felt that fast to the family. Referral to Brent 5.12.9 Mother is likely to have suffered further anxiety due to the decision that Brent held responsibility for housing the family, as opposed to Tower Hamlets, on the basis that because MGF lived there this was her local connection. Whilst this is in accordance with The Housing Act 1996 and accepted practice in the UK, it would not have been in the family’s best interests as mother had never lived there and the family who provided her with the more regular support were based in East London.  5.12.10 In this case because mother engaged a lawyer who requested a statutory review of this decision a team manager reviewed the circumstances and decided that the process had been invalid as referral on family connection grounds should be undertaken after:  Firstly a consultation with the applicant about their wishes and   Secondly if the client wishes to be in the same area as the family connection  54  5.12.11  In this case neither of these conditions had been met, so the referral to Brent was withdrawn. The reason behind this mistake is understood to be due to the infrequency of such circumstances and a consequent lack of experience by the officer concerned. 5.13 Culture 5.13.1 Jamilla’s mother is of dual heritage, with a Somali mother and a white UK father; her father had converted to Islam. The mother had little contact with her father as a child and grew up as part of the extended Somali family living in East London. She was though, according to the police statement of cousin 2 ‘the first half Caucasian person in our family’.  5.13.2 It is not clear to what extent the mother’s dual heritage has caused her problems in being accepted within the local Somali community or within her extended maternal family, but there are indications that this fact has caused her a level of difficulties at times due to the reactions of others.   5.13.3 The psychiatric report undertaken as part of separate legal proceedings refers to mother’s account of conflict with her mother around the age of 10 and 11 years old because she did not wish to wear traditional Somali clothing to school. The secondary school recall that mother had some conflict with older Somali girls, possibly because she was different. The psychologist’s report mentions mother’s account of encountering cruelty and racism in Somaliland due to being ‘half white’. This was re-iterated in interview by mother for this review, and she spoke of both her husband’s negative attitude to her mixed heritage and that people in Somaliland would throw stones at her.  5.13.4 Since her return to the UK, until the death of Jamilla, mother was always dressed in traditional clothing with a scarf covering her head, and described as well groomed. The police witness statements from Somali neighbours though note her difference and describe her as a ‘white looking lady’’ or ‘white or mixed Arab type race’.  5.13.5 From the discussions held with practitioners, it does not appear that any explored the impact on the family of mother’s dual heritage. Only the caseworker from the FMU discussed with the mother the response of her maternal family members to her having left her husband. From the statements it appears that this was not a problem and there was a great deal of sympathy for her plight at being married at the age of 13 to a violent man. Cousin 4 said ‘It is not frowned upon to be a single mum within the Somali community’.  55  5.13.6 Practitioners have explained that the assessments that mother did not need additional services were based both on observations of her parenting skills and on her reports of family support. Given the identified vulnerabilities, any such assessment outcome, which relied on the support of others, needed to be based on a full understanding of the potential impact on family relationships of cultural factors, so as to take into account the:  Impact for mother of being of dual heritage   Impact of the abuse she had suffered   Impact on her of being deprived of the teenage experiences she may have grown up expecting prior to her move to Somaliland at the age of 12  Attitude of the maternal family to mother given she had left her husband   5.14 Financial Problems 5.14.1 An ongoing problem for the family was financial hardship, due to not receiving child benefit for her two children born in Somaliland. This came over clearly in some of the witness statements to police and directly from mother.  5.14.2 The witness statements for this review show that the joint head of the FMU was trying to assist and had written to the Child Benefit Office in April and July. The problem was caused because the Somali birth certificates were not acceptable as proof the children belonged to mother and the letters therefore explained that national verification test had been undertaken and UK travel documents provided.  5.14.3 The joint head of the FMU did not hear from mother after July 2013, and consequently assumed that this problem had been sorted. Like all the other professionals, she expected mother to be able to telephone if the problem persisted.  5.14.4 However, what followed was the period when mother ‘shut down’ and her contact with the outside world decreased. At age 18, with 3 very young children she continued to face financial hardship and also had her application for tax credit refused because she had filled this in incorrectly.   56  5.15 Addiction to social networking sites? 5.15.1 One of the puzzling features of this case for the professionals involved was how this competent and loving mother changed her parenting behaviour to such an extent that she neglected her children to such an extent as to cause the death of Jamilla. 5.15.2 The review has established that from the beginning of July she had no contact with professionals who knew her or her children and her face to face family contact decreased and in the case of MGF ceased altogether. She has also explained that following an incident soon after Jamilla’s birth, flashbacks of earlier abuse in her life returned. Also that her husband started to ring her frequently and this worried and upset her.  5.15.3 The expert psychiatric opinion undertaken as part of the criminal proceedings indicate that during the period from July to October mother was suffering    ‘...from a mental disorder characterised by dissociation....such that she was unable to predict risk to her children and ensure their basic needs were met’19. 5.15.4 It is known from the prosecution’s Opening Notes at the Crown Court that during this period mother spent increasing amounts of time on Facebook, where she developed an alternative identity of a student living with her mother and younger siblings.  5.15.5 There is now research into the phenomenon of addiction to Facebook and other social networking internet sites, which are being compared to addiction to gambling as well as to substance misuse. For example: ‘the internet and virtual social networks are new technologies that have had most impact on young people and have provided many benefits to their users. However, some people become obsessed with the internet, are unable to control their use of it, and may put their work and relationships in jeopardy. 20 5.15.6 The focus of the research tends to be about young people at educational establishments and the impact such addiction can have on their studies, but Kuss & Griffiths21 quotes Cohen 22 in “I’m an addict. I just get lost in Facebook” replies a young mother when asked why she does not see herself able to help her daughter with her homework. Instead of supporting her child, she spends her time chatting and browsing the social networking site (1’.                                                            19 Psychiatric report, 17.12.13 20 Addiction to new technologies and to online social networking in young people: A new challenge, E Echeburúa, P de Corral, Adicciones, 2009 - europepmc.org 21 Online Social Networking and Addiction—A Review of the Psychological Literature Daria J. Kuss and Mark Griffiths  International Gaming Research Unit, Psychology Division, Nottingham Trent University, 22 Cohen, E. Five Clues that You Are Addicted to Facebook; CNN Health: Atlanta, GA, USA, 2009;    57  5.15.7 This suggests that this case may not be unique in terms of social networking impacting on parenting capacity, to the extent of its addictive features. This is considered to be a greater risk for those with lower self-esteem (Kuss & Griffiths). 5.15.8 Other research links the risk to other mental disorders: Prior research has utilized the Zung Depression Inventory (ZDI) and found that moderate to severe rates of depression coexist with pathological Internet use.23 5.15.9 It is likely that given the trauma mother had suffered, her social isolation and difficulty in managing everyday life with very little support, the attraction of being a teenager without her responsibilities in a ‘virtual’ life would have been attractive. It is not clear to what extent this ‘hobby’ became an addiction which in itself contributed to the tragedy that occurred.                                                            23 KIMBERLY S. YOUNG and ROBERT C. ROGERS. Cyber Psychology & Behaviour. SPRING 1998, 1(1): 25-28. doi:10.1089/cpb.1998.1.25.  58  6  FINDINGS & RECOMMENDATIONS 6.1 Introduction 6.1.1 This section contains the overall findings of this serious case review, with the associated recommendations for the LSCB. The findings relate to what we have learnt about the strengths and weaknesses in multi-agency safeguarding systems through examining what happened to Jamilla and her siblings. 6.1.2 The LSCB has prepared a separate document with their responses to these findings and the plans to address the recommendations. 6.2 Findings and recommendations 1) Predictability and preventability 6.2.1 This serious case review concerns the tragic death of Jamilla in circumstances of extreme neglect in late September and early October 2013. Both her siblings also suffered neglect.   6.2.2 Prior to the death all the practitioners and most of the extended family members who came into contact with the family were impressed with how well the mother cared for her children and how they were flourishing. Even in the last few weeks in September, when the pre-school had contact with the family the concern (smell of urine from the children’s buggy and sibling 1 not yet attending voluntary pre-school consistently) was not of the level that the circumstances at home could have been predicted.  6.2.3 If a professional, a member of the family or a member of the public had gained access to the property during the last days of Jamilla’s life, had understood the level of neglect and its impact on the children and alerted the police and children’s social care it may have been possible to intervene and prevent the tragic death. However, by this point mother was not answering the door to visitors. 6.2.4 Had any family member or professional seen mother and identified the changes in her were a risk to the children it may have been possible to intervene, although the seemingly rapid deterioration in mother’s care may have made this unlikely.  59  2) The focus of multi-agency assessment and subsequent response is based on current levels of functioning within families, with insufficient consideration of the potential risks arising from ongoing vulnerabilities 6.2.5 The Tower Hamlets Family Wellbeing Model mirrors the Framework of Assessment in a focus on current family functioning and concerns, without giving sufficient attention to the role of ongoing parental vulnerability when considering the needs of the family. This approach, which forms the basis of service provision nationally, provides additional services in response to current needs.  6.2.6 Such an approach relies on the existence of a universal health and welfare system able to identify if and when parental vulnerabilities may re-surface, even when a parent has demonstrated her or his resilience in overcoming past traumas . This may work effectively for older children who attend schools and are seen regularly and for families who attend children’s centres. It also may have been reasonable at an earlier period when health visitor resources provided for regular home visits to younger children. However, the contemporary health visiting structure is based around open access to health visitors at clinics. The national specification provides after the 6 week review for two contacts: at 8-12 months and at 2 years. These are clinic based and if not attended rely on the individual health visitor to follow up. In the absence of identified concerns, any additional contact depends on parents voluntarily accessing clinics. Such a system will provide an effective and supportive service for the majority of the population, who cope with parenting and access help if required, but does risk the possibility of children who are not seen by any professionals for considerable periods of time and are reliant on family and neighbours to alert services if there are concerns.  6.2.7 The Family Wellbeing Model does not specify any level of additional support, such as undertaking a CAF24 or delivering multi-agency support with a team around the family (TAF) and an identified lead professional. Whilst health agencies may consider the health visitor to be the lead professional for children under 5 years of age, in the absence of a social worker, this case illustrated that this is not understood within the professional network. 6.2.8 Another aspect of the way that services were delivered is reflected in mother’s comment that she did not know the practitioners well enough to speak about her worries. Whilst this also may reflect the defences she has developed in her life, it is striking how she spoke more openly to the FMU caseworker than she did to local professionals.                                                             24 The CAF is a shared assessment and planning framework for use across all children's services and all local areas in England. It aims to help the early identification of children's additional needs and promote co-ordinated service provision to meet them via a standardised approach to conducting an assessment of a child's additional needs and deciding how those needs should be met.  60  6.2.9 The FMU caseworker visited her at home and met MGGM. She discussed the attitude of MGGM to forced marriage and obtained more detail about MGF’s infrequent contact and family circumstances. She sensed the disconnect between mother’s exemplary parenting skills and her immaturity. She noticed that mother spoke about her past in a distant manner, as if recounting something that had happened to someone else. Had local practitioners experienced this, they may have been less confident about the mother’s ability to ask for help when required. 6.2.10 The ability of local practitioners to develop a relationship with mother which might have facilitated a deeper understanding of her capacity is limited by the setting (mainly out of the home at clinics and children’s centres) and possibly the task centred, as opposed to relationship focused, nature of their role. This is not a reflection on any individual practitioner, but of the nature of the services provided. Recommendations  1 - 3 1. The Children & Families Partnership to review the Tower Hamlets Family Wellbeing Model so as to clarify how, where there are underlying parental vulnerabilities which may impact on parenting in the future but no current concerns about parenting of pre-school age children, this is reflected in the classification of the level of need. This should result, if more than one agency is involved, in the provision of a co-ordinated multi-agency CAF, with a team around the child and a lead practitioner to ensure a holistic approach to the family and the development of sufficient a relationship to enable an in depth ongoing assessment of need.  2. Practitioners in all agencies should clarify within records the assessed tier of need within which services are being provided and the rationale for this. 3. The Family Wellbeing Steering Group to review the guidance on the lead professional role and strengthen the need for relationship building, as well as task focused work, and the use of home visiting to facilitate this.  Please note: recommendation 6 also addresses the Family Wellbeing Model  3) Enhanced health service provision 6.2.11 The knowledge of mother’s vulnerability appropriately provided the family with a service from the Gateway midwifery team and an enhanced health visiting service. 6.2.12 The links between health provision and the Family Well Being model are not stated clearly in the Family Well Being model. The draft management report provided to the serious case review by the named nurse25 refers to:  ‘This level of vulnerability and risk factors places (mother) and her children into Tier 2 Tower Hamlets Family well –being indicators’.                                                             25 Draft comprehensive Investigation Report V3, Barts Health NHS Trust    61  6.2.13 Such a level of need would involve a CAF according to the Family Well Being model and single agency support if the needs are focused, or lead practitioner and team around the child if needs are complex. In this case it was considered that single agency support was appropriate. The CCG Nurse Consultant Safeguarding Children has advised that the assessments undertaken by health visitors are CAF compliant, so this would be consistent with tier 2 focused needs.  6.2.14 The Gateway midwifery team provide services for vulnerable pregnant women. The service was appropriate to health needs prior to the birth of Jamilla. It was unfortunate that there was a change of midwife following the birth, despite mother’s stated preference to remain with the practitioner. The rationale behind this change was that it was a consequence of the family’s move nearly 3 months earlier, and is the usual practice, misunderstood by the midwife concerned to be required practice. Whilst it is not known whether mother would have continued to keep optional midwifery appointments following Jamilla’s birth, it would have been more likely had there been continuity of the individual practitioner. Given that this is a service for vulnerable women, it would be sensible for ‘usual’ practice to be to retain continuity, unless there are good reasons to transfer responsibility.  6.2.15 After the birth, mother saw the midwife 3 times and then missed 2 appointments. Because this is a service for vulnerable women, the midwife did not discharge her from the service and planned to make contact in September. However this did not happen and the health visitor was not informed of the DNAs.  Given that the service is designed for vulnerable young women, there is an argument for the following up of missed appointments, offering the possibility of a home visit, by either the midwife or the health visitor.  6.2.16 Whilst midwifery did provide focused single agency support in line with the Family Well Being model through the involvement of the Gateway team, the health visiting provision, although assessing the family as requiring an enhanced service, in practice provided the universal offer, with the added option for mother to ask for additional help. This relied on her to have the insight to ask for that help. She never requested additional help from health visiting services. 6.2.17 The reason behind this arises from the lack of local definitions about what constitutes an enhanced service, leaving it up to professional judgment.  Evidence from this case suggests that in the circumstances when a family has been assessed as eligible for an enhanced service the avoidance of developmental checks should trigger timely follow up.   62  6.2.18 The lack of co-ordinated multi-agency input meant that no one lead professional understood that mother had not brought her son for his developmental check, had not attended her last 2 midwifery appointments and had ceased to attend the children’s centre. If this had been understood, there may have been attempts to follow up at home with mother during the summer.  Recommendations 4-6 4. The Gateway midwifery team to provide consistency of the individual midwife for ante and post natal care as standard provision, except in circumstances when a change is judged to be in the interests of mother and baby. 5. When the health visiting provision is re-commissioned by the Council, the specification for an enhanced health visiting service to include:  Minimum level of contact depending on age of child and parent / carer and vulnerability of family  Need for timely follow up to non-attendance at developmental checks   Liaison expectations with other practitioners, especially within the health service 6. The Children & Families Partnership to review the Tower Hamlets Family Wellbeing Model so as to clarify the linkage between health assessments and tiers of need: if the health assessment is CAF compliant how does it lead to multi-agency involvement, the formation of the team around the child and the identification of a lead professional? 4) Minimising risk of invisible children following moves into the UK or into a local authority 6.2.19 In this case, the Forced Marriage Unit informed Brent CSC of the family’s arrival in the UK, but did not tell the health services. The social care response of a telephone call to father did not ensure that the existence of the newly arrived children in the UK was known about by universal health services, so risking ‘invisible children’. Fortunately the mother herself did register with a GP. 6.2.20 Tower Hamlets CSC did liaise with other agencies and ensured that the presence of the children was known by universal health services as well as the local children’s centre. The practitioners, as part of this review, identified that they did not take a sufficiently pro-active role in ensuring that in the light of mother being potentially vulnerable there was an adequate assessment and co-ordination of services (a CAF, a team around the child and a lead professional).  6.2.21 The lesson from this is the need for Children’s Social Care to be more pro-active when signposting referrals to other services, so as to ensure that the ‘stepping down’ process results in sufficient assessment of need and co-ordination of services. It is understood that in both boroughs the arrangements for receiving referrals has changed since 2012 and that the current functioning of the ‘front door‘ service is likely to be more pro-active with the development of a Multi-Agency Safeguarding Hub .                                         63  Recommendations 7-9 7. Both Brent and Tower Hamlets LSCBs to undertake multi-agency audits of their front door processes to examine the following on those cases that do not meet the threshold for a social work assessment:  The extent to which historical  records are accessed  How cases are ‘stepped down’ from Children’s Social Care and whether this includes any involvement in ensuring arrangements for a CAF and a lead professional when there are indications of parental vulnerability  That action is taken to ensure the children’s presence within the local authority is known by universal health services, so as to help prevent ‘invisible’ children 8. The Forced Marriage Unit to inform local child health services whenever they are aware that children have moved into an area 9. The Children & Families Partnership should build upon the introduction of the MASH and the revised Family Wellbeing Model to introduce a clear process by which cases that do not cross the social care threshold can be passed to a lead professional who will take responsibility for coordinating the work of the "team around the child / family" - in some local authorities this role is described as that of the CAF Coordinator 5) Think Family Approach  6.2.22 Think Family was a cross-departmental programme introduced in 2009, jointly funded by the then DCSF, the Home Office, Ministry of Justice and the Department of Health, and supported by the Department of Communities and local government. The aim was to make sure that the support provided by children’s, adults' and family services is coordinated and takes account of how individual problems affect the whole family.  6.2.23 One of the features of this case is that only the case worker from the FMU met any family members and the assessments undertaken by practitioners did not involve obtaining much information about the family and the meaning and significance of the support that was being provided – even though without that support it would have been extremely difficult for mother to have been able to care for children without additional services. 6.2.24 Health practitioners and the Children’s Centre accepted that mother was getting support from her family, and that MGGM was living with her at the time of the birth of Jamilla. This was not in fact the case and in order to assess the risk to the children of a lone parent aged 18 with three young children under the age of four, it was important to understand the exact nature of the support available. 6.2.25 Judgements about needs were based on self-reported information relating to the involvement of extended family: such accounts may not be accurate and such levels of support may not be sustainable. If such support is critical for the family’s well-being, it needs to be verified by the inclusion of wider family within the assessment and the scope of service provision.  64  6.2.26 The midwife visited the family home after the birth and was aware of the children downstairs laughing and assumed this was with an adult. However, the focus of the home visit was mother and baby and the midwife did not see the other children or the adult thought to be with them. This was a missed opportunity to be able to check on both the welfare of all children, but also the veracity of self-reported information. Whilst perhaps not a part of the remit of the midwife’s current role, if the expectation is to ‘think family’ within adult services, then this is even more critical for practitioners within children’s services.   Recommendation 10 10. The LSCB to consider how to change the broaden of working with families, so that practitioners take the opportunities to meet those extended family members who play a major part in supporting children and/or parents, through their involvement in assessments and ongoing services 6)  Culture & Forced Marriage 6.2.27 Practitioners in this case did not obtain an understanding of the implications for mother of being of dual heritage and the significance this had within her family and within her community. Even more relevant was the lack of knowledge of the extended maternal family’s views to mother having escaped from a forced marriage in Somaliland. Given the assessment of the family’s needs was inextricably linked to the provision of support by relatives; this was a critical area to explore. 6.2.28 In this case it appears to have not made a difference to the level of extended family acceptance of mother and the children, but we do not know if it impacted on the support provided by any individuals. 6.2.29 Also what was not explored with mother was the impact on her of being deprived of the teenage experiences she possibly grew up expecting prior to her move to Somaliland at the age of 12.   6.2.30 A particular experience mother missed was a secondary education. Practitioners need to be aware with all service users, and especially those who come or return to the UK after periods abroad, that they may have difficulties reading, writing or comprehending verbal information, even when as in this case, mother was an English speaker. None of the practitioners was aware of mother’s literacy abilities and it is not known if her lack of secondary education contributed to her difficulties, nor if she had any other underlying communication difficulties. It is possible that some appointments may have been missed through such literacy problems.  65  6.2.31 A further difficulty for the family was the lack of financial resources as a consequence on the older children being considered to be not eligible for child benefit, due to the lack of birth certificates. This ongoing and apparently insoluble problem for the family was not known by local professionals and hence mother was left without anyone to advocate on her behalf.  6.2.32 Discussions with practitioners about the lack of such discussion with mother highlighted the reluctance to ask intrusive questions, when there is a lack of identified concerns. Also, the challenge of having such conversations when contact is in public places, such as clinics, as opposed to the home. 6.2.33 The incidence of Forced Marriage in 2012, as collected by the Forced Marriage Unit26, involved 1485 cases, of which 21% are in London. Given the ethnic composition of Tower Hamlets, which in 201127 had 47% 0f the population from BME groups, staff need to be equipped to speak openly with parents and children about issues of diversity and of forced marriage.  Recommendations 11 and 12 11. The LSCB to review current multi-agency training and practice supervision on race, identity, forced marriage and other harmful practices to evaluate if this equips relevant practitioners with the understanding and skills to:  Explore the implications of their race, ethnicity, culture and identity with parents and children  Explore the impact with parents of having been subjected to a forced marriage or other harmful practice  Consider safeguarding implications of parents experiences of harmful practices  Be wary of the family support provided to victims by families who may have been involved in or supported the marriage  Sensitively explore people’s literacy and comprehension, regardless of the ability to speak English  Be aware of the role of Victim Support services in supporting victims of forced marriage and their ability to advocate to the benefits agency   Consider financial needs for children arriving in the UK, without full documentation 12.  To enable the use of specialist and appropriate services, the use of forced marriage needs to be routinely recorded as a data category by CSC and health practitioners: this will require these agencies to adapt their data collection records 7) Lack of housing resources within Tower Hamlets 6.2.34 Section 4.10 describes the significant rise in homeless applications being experienced within London boroughs, the consequent use of Bed and Breakfast accommodation so as to avoid exporting homeless families and the lack of suitable housing provision in a borough with a portfolio of aging accommodation in buildings without lifts.                                                             26 https://www.gov.uk/forced-marriage#statistics-on-forced-marriage-collected-by-fmu  27 Tower Hamlets Research Briefing 2011-2016 file:///C:/Users/Edi/Downloads/RB%202011-06%20Population%20key%20facts.pdf   66  6.2.35 Within this context the family had a comparatively good service from Housing Options, being provided immediately with temporary housing, and being moved to more suitable accommodation in a relatively short space of time.  6.2.36 However, such judgment is purely in the light of available resources as opposed to what meets the needs of children and pregnant women. To be placed initially on the fourth floor without a lift could be a risk to the health and safety, even though it was undoubtedly preferential than other options.  6.2.37 Further stress was placed on mother through the decision to refer the family to Brent on the basis of a local connection. This action was mistakenly thought to be in accordance with The Housing Act 1996, but in fact contravened the need to only do so with the agreement of the parent. Once the mistake was identified the referral was deemed invalid. Recommendation 13 -14 13. The LSCB to consider how to take up the need for action on housing resources locally and within London, so that children and families are not placed in unsuitable accommodation, that could conceivable be perceived as a health and safety risk 14. Housing Options to provide guidance for their staff about the use of referrals to other boroughs, so as to avoid this being done without the tenant’s agreement  8) Challenging the Myth of persistence in neglect? 6.2.38 A factor in this case is the speed at which the home circumstances deteriorated, which is unusual and not consistent with common understandings of neglect as embodied in the definition of neglect provided by Working Together:  ‘Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development’. 28 6.2.39 Such a definition does not fit with the circumstances in this case, when there was an extremely quick and speedy deterioration in the home circumstances . It is important that both professionals and public understand that neglect can lead to risk to children within a very short period of time, especially in relation to babies and young children, and as a result of single incidents of neglect, such as a lack of supervision.  Recommendations 15 - 16 15. The LSCB to ensure that the new neglect strategy and training programme adequately reflects the risks of neglect in a short period of time, as in this case, or as a result of single incidents of neglect.  16. The LSCB to write to the DfE to challenge the current definition of neglect used in Working Together 2013, which refers to ‘persistent failure to meet a child’s basic needs’: such a definition can be misleading for both the public and professionals, and may risk under recognition of the extent of risk to children over short periods of time or in relation to single incidents of neglect such as lack of supervision in the bath.                                                            28 Working Together to Safeguard Children,  DFE March 2013  67  9) There continue to be systemic difficulties around ensuring that relevant information from MPS Merlins is provided to enable early interventions 6.2.40 During the period under review the weakness of the system for communicating information from Merlins29 to health practitioners stemmed from the restriction in being placed only within midwifery records and a reliance on an individual midwife to access information entered by others and communicate it to any other involved health practitioners.  6.2.41 Since that time the process has changed and Merlins are no longer sent to health agencies, but assessed within the MASH and shared as required. In practice this has led to the ending of such information sharing with health practitioners.  6.2.42 Moreover, within Tower Hamlets, schools have never been provided with such information, although the rationale of the potential for early intervention applies equally to education. In some instances such information sharing will add to knowledge held within universal services, which together will point to the need for Children’s Social Care involvement.  Recommendation 17 17. The LSCB to ask the London SCB to urgently review the current information sharing arrangements around Merlins, so that universal services have access to such relevant information, especially around domestic abuse                                                            29 Merlins are the MPS notification of a child coming to the attention of the police  68  GLOSSARY OF TERMS & ABBREVIATIONS   CAF Common Assessment  CCG Clinical Commissioning Group CSC Children’s Social Care DfE Department for Education DNA Missed health appointment – Does Not Attend ED Emergency Department of a hospital FMU Forced Marriage Unit FSW Family Support Worker at the children’s centre Gateway midwifery team The Gateway midwifery team provide ante and post natal services for vulnerable women GP General Practitioner HV Health Visitor LSCB Local Safeguarding Children Board MASH Multi-Agency Safeguarding Hub Merlin MPS notification that a child has come to the attention of the police MGF Maternal grandfather MGM Maternal grandmother MGGM Maternal great grandmother MPS Metropolitan Police Service TAF Team around the Family   69   APPENDIX 1: PANEL MEMBERS   The review panel consisted of the following members: ROLE AGENCY Sarah Baker - SCR Panel Chair & Independent LSCB Chair (Tower Hamlets) Independent Edi Carmi, Lead Reviewer & Report Author Independent  Interim Service Head – Children’s Social Care LB of Tower Hamlets Service Head – Learning and Achievement LB of Tower Hamlets Service Manager – Child Protection & Reviewing LB of Tower Hamlets Nurse Consultant Safeguarding Children & Designated Nurse Tower Hamlets Clinical Commissioning Group Lead Named Nurse for Safeguarding Children Barts Health NHS Trust Director of Nursing & Governance Barts Health NHS Trust Designated Doctor for Safeguarding Children Barts Health NHS Trust Service Head – Strategy, Regeneration & Sustainability (Housing) LB of Tower Hamlets Specialist Reviewing Officer Metropolitan Police Service LSCB Business Manager LB of Tower Hamlets   70   APPENDIX 2: PRACTITIONERS INVOLVED IN THE SCR PROCESS  The following practitioners were involved in individual and group meetings with the lead reviewers and other panel members: ROLE AGENCY Specialist Case Worker Forced Marriage Unit Health Visitor Barts Health NHS Trust  Gateway Midwives  (Midwifery Team for Vulnerable Women) Barts Health NHS Trust  General Practitioner Tower Hamlets Clinical Commissioning Group Team Manager LBTH Children’s Social Care Social Worker LBTH Children’s Social Care Family Support Worker LBTH Children’s Centre Family Support Work Practice Manager LBTH Children’s Centre Pre School – Manager and Designated Safeguarding Officer Independent Early Years’ Service Provider Pre School – Deputy Manager  Independent Early Years’ Service Provider Pre School - Lead Practitioner for 2 year olds Independent Early Years’ Service Provider Senior Homeless and Housing Assessment Officer LBTH Homeless & Housing Service Head  LBTH Housing Options Assistant Head Teacher (Designated Teacher) Secondary School    