Death of 14-year-old boy and serious injuries to a 15-year-old boy from a traffic collision whilst travelling in a stolen car. Learnings include: a child's exposure to domestic violence constitutes emotional abuse and neglect; professionals need to be clear and persistent with parents about their concerns, their offer of help and the potential impact on their children if parents fail to engage; minimisation of multiple professionals working with the same family; child protection processes are necessary where parents do not engage in meaningful long-term change; lack of school attendance can be indicative of a safeguarding issue; where ongoing significant harm due to neglect is suspected, the holding of a strategy meeting is appropriate; professionals should always ask 'what is the impact of our actions on the child's outcomes?' and if a plan is not working, it needs to be changed; any solution or amelioration of the problem of criminality linked to familial neglect needs to be part of a multi-agency strategy including police and CSC. Recommendations include: prioritise an enhanced focus on the part of all agencies on effective, impactful engagement with families with young children, where neglect is identified; CSC should provide assurances that appropriate thresholds are applied in relation to neglect and that step-up processes are appropriately used in situations where parents are resistant to making the changes needed for their children; CSC should review and strengthen arrangements for dialogue and information sharing with schools and other agencies in order to better connect with the insight that these professionals can offer.
      
 Title:  Child 1 and 2: LCSPR. LSCB: Wigan Safeguarding Partnership Author: Anthony Haley Date of publication: 2021  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.                                          Child 1 and 2 LCSPR    Anthony Haley 2   Contents Executive Summary ................................................................................................................................................ 3 Methodology .......................................................................................................................................................... 5 Abbreviations .......................................................................................................................................................... 6 Terms of Reference ................................................................................................................................................ 7 Family Participation in the Review ......................................................................................................................... 7 Significant incidents for Child 1 .............................................................................................................................. 8 Significant incidents for Child 2 ............................................................................................................................ 10 Analysis of Practice and Learning ......................................................................................................................... 16 Recommendations ................................................................................................................................................ 25 Recommendation 1 .......................................................................................................................................... 25 Recommendation 2 .......................................................................................................................................... 25 Recommendation 3 .......................................................................................................................................... 25  3   Executive Summary This case concerns the circumstances leading up to the tragic death of Child 2, a 14 year-old boy and the serious injury of Child 1, a 15 year-old boy when they were both involved in a road traffic collision while travelling in a stolen car. Both boys were of white British heritage and lived with their respective mothers in the same locality. Neither child attended school regularly. Child 1 was exposed to criminal activity and domestic violence perpetrated by his father and his mother’s subsequent partners. Child 2 experienced a lack of effective parenting and, over time, was increasingly out of his home, seeking food and shelter where he could. Both boys had suffered neglect at home and were known to Children’s Social Care (CSC) from an early age. In both cases parents had been resistant to efforts to bring about improvements in their parenting. Notwithstanding this both children’s cases were closed to CSC and directed towards early help. Support for the families had always been at a level which presumed that the parent would agree to work in partnership with services and, when this did not happen, it failed to achieve significant change in the boys’ home lives. Neither child’s mother had prioritised their needs and, for years, both boys had spent a great deal of time, both day and night, out of their homes and involved with anti-social and criminal behaviour; often while part of a larger group of young people in the area. During the timeline under review, Child 1’s mother was convicted of failing to ensure that he attended school on the last of three occasions.  When agencies escalated concerns about Child 2’s neglect, these did not result in a social work assessment. Resource issues and very high workloads in CSC had led to gatekeeping outside of the published thresholds for service. Child 2’s mother then asked for him to be accommodated due to her needing hospital treatment. At this point he was already out of her control and resistant to any placement, and was reported as repeatedly missing. Child 2’s mother was given a great deal of practical support by CSC. The focus of the work was on the mother’s demands rather than the child’s needs and his lived experience remained substantially unaffected. Despite the plan having been recognised as ineffective, it was continued for some time. In the case of Child 2, when early help services recognised that the case required social work input, they were unable to get beyond what was referred to by professionals as a ‘glass ceiling’ where the threshold would not be found to be met. This was notwithstanding the extensive knowledge, experience and insights of many early help professionals. Particularly good practice was seen on the part of Child 1 and Child 2’s different schools. They were persistent, supportive and creative in their attempts to engage the boys and to communicate with parents and CSC.  The review identified a need to improve CSC’s communication with schools and partner agencies around critical decision making and processes. 4   Over the last summer before the critical incident, the boys’ criminal activity continued and reported incidents increased without an effective response from services. The review has identified missed opportunities to address early problems indicative of significant neglect and emotional harm for both boys. Later intervention became much more difficult for agencies as problems became entrenched and worsened. When the families proved resistant to working to improve the children’s respective circumstances, in their early life, step-up processes were not used and the impact and risks of allowing the neglect to continue were not fully understood. 5   Methodology This Local Child Safeguarding Practice Review was commissioned by Wigan Safeguarding Partnership under Working Together 20181. This is a systems-based review which has benefitted from the considerable work of a wide range of professionals and the involvement of frontline practitioners and managers who proved invaluable in informing the analysis and conclusions that have been arrived at. The work of the review was overseen by a review panel. Interviews were held with professionals who had been involved at the time, and relevant professionals participated in an online learning event. Participants are thanked for their insightful contributions. The review has focussed mainly on the period from the 1st of April 2018 to the 12th of October 2019. The review panel was comprised of:  Designation Agency Review Author and Chair of Panel Independent Business Manager Wigan Safeguarding Partnership Learning and Improvement Officer Wigan Safeguarding Partnership Service Lead Children’s Social Care, Wigan Council Service Manager - Inclusion Wigan Council SEND Representative Wigan Council Detective Constable Serious Case Review Team, Greater Manchester Police Service Lead,   Practice   Improvement   and Quality Assurance Children’s Social Care, Wigan Council Education Psychologist Wigan Council Specialist Nurse Safeguarding Children, (also representing Acute Services) WWL Community Practice Manager Targeted Youth Support Services (TYSS) Safeguarding Lead Newbridge Community Learning Headteacher Cansfield High School Senior Assistant Head and DSL Cansfield High School Deputy Headteacher and DSL Platt Bridge Community Primary School Deputy Headteacher and DSL Platt Bridge Community Primary School Startwell Worker Startwell Deputy Designated Nurse - Safeguarding Wigan Borough CCG  1https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/ Working_Together_to_Safeguard-Children.pdf 6   Abbreviations   CSC Wigan Children’s Social Care M1 Mother of Child 1 F1 Father of Child 1 M2 Mother of Child 2 F2 Father of Child 2 TESS Targeted Education Support Services CIN Child In Need IRO Independent Reviewing Officer SW1 Social worker for the period when Child 2 initially became looked after SW2 Social worker for the period when Child 2 following the first period of accommodation FSW Family support worker PCSO Police Community Support Officer ACT Achieving Change Together Project 7   Terms of Reference The terms of reference below were used to establish learning through the prism of Child 1 and 2’s experiences:  • How effectively did partners identify and address neglect where it was combined with parental non-engagement?  • How confident can WSP be in the robustness of CIN and CP step-ups and step-downs and in the use of escalation processes to resolve professional differences?  • To what extent were safeguarding considerations sufficiently in focus for children who had challenging behaviour, poor attendance and potential involvement in Child Criminal Exploitation? Was the multi-agency support for these children sufficient?  • Where parents have been convicted for failing to ensure that their children attend school, what should the partnership response have been?  Family Participation in the Review The panel would like to express thanks to Child 1’s mother who agreed to be interviewed.  Her own life experience had been affected by considerable trauma and it had influenced her approach to school. She believed that the area in which she lived was not safe to walk around and that there was a lot of crime. She thought that the police knew what was going on and should be taking more action. When her son was much younger, she did not see any benefit in the support she was offered by CSC but is appreciative of what is now being done. She recognised the benefits of the support that her son had had from his school in the weeks immediately before the incident. The panel would also like to thank Child 2’s mother and sister who shared their views in an interview. They described Child 2’s personality and approach to life in warm terms.  Child 2’s mother spoke about the large number of professionals that had been involved with the family. She perceived some to have been very supportive but she was critical of most social workers and other professionals as not helping her. She recalled unhappiness in her own childhood and her lack of a model for her parenting of her own children. Child 2’s mother was highly critical of the role of the police in their dealing with youth crime in the area and around the tragic incident. 8   Significant incidents for Child 1 Child 1 lived with his mother (M1), his father and two brothers, one 2 years older and one two years younger. The family is of white British heritage. Child 1’s father was known to be a drug user and had committed a large number of criminal offences. In 2015 his father left the family home and following this Child 1 has had little contact with him. Child 1, from his very early years, experienced many incidents of domestic violence between his mother and father and then between his mother and her subsequent partners. Prior to the period covered by this review, there were a number of years where there was a pattern of referrals to Children’s Social Care (CSC). These resulted in offers of voluntary support for the family’s complex issues. They particularly related to the impact of continuing domestic violence, neglect and housing issues on the children. Parenting support was offered but there was very limited take up by M1, and each time the case would be closed with a report of failure to engage with services. The Attendance Service and the school had been working to improve Child 1 and his brother’s school attendance. M1 had been prosecuted for failure to send them to school in October 2017 and January 2018 and had been found guilty on both occasions. On the second occasion M1 received a conditional discharge.  Neither conviction significantly impacted on the children’s attendance. A referral to CSC in late 2017 related to Child 1’s poor school attendance and to neglect. A social work assessment concluded that the case should be again dealt with at family support level without the need for allocation to a social worker. Child 1’s behaviour at school was often challenging and his progress was limited. The school requested a learning assessment in 2017 from the Targeted Education Support Service (TESS) which identified him as having needs relating to language and communication, social and emotional skills, literacy and medical issues. The TESS and the school felt that his educational needs were more as a result of poor attendance than underlying ability, but it was thought to be important that nothing had been missed. Although a support programme was planned, Child 1’s continued sporadic attendance meant that he did not engage with the support. At the beginning of the time period covered by this review, Child 1’s absences from school continued and M1 did not wish to work with the professionals from several family support initiatives. The 9   issues with the family were discussed at Huddle meetings2. As M1’s voluntary engagement was required for these services to be provided, agencies planned to close the case. In June 2018 M1 and Child 1 were involved in an altercation involving an ex-partner of M1 and she was advised by the police to prioritise her children above her relationships. A referral by the police to CSC resulted in failed attempts by CSC to contact M1 by phone and a subsequent letter to her offering support, to which she did not respond. Another referral by police, in September 2018, relating to Child 1’s school attendance did not progress as it was felt by CSC that there were no safeguarding concerns.  Both the school attendance team and the local authority attendance and enforcement team made approximately 80 home visits but this proved unsuccessful in sufficiently improving Child 1’s attendance. In November 2018 M1 took Child 1 to A &E with a suspected anxiety attack. He was subsequently referred to CAMHS but M1 then did not take him to appointments, so he was not seen. At Huddle meetings, concerns that Child 1 was carrying a knife, and had taken it into school, were discussed. His mother refused consent for him to complete sessions with the Targeted Youth Support Service (TYSS) on knife crime awareness despite tenacious efforts by the service to engage her. The school felt that there was little alternative provision for children like Child 1 locally and developed provision within the school. They identified highly skilled staff and created a small unit in order to address the needs of Child 1 and others with similar issues while avoiding having to exclude him. The attendance officer made another referral to CSC as M1 potentially faced a custodial sentence if convicted again for failing to send her children to school. A letter was sent to M1 asking her to make contact to discuss arrangements for the children but M1 did not respond, and the case was closed. In February 2019 M1 was convicted in her absence and a warrant was issued for her arrest. M1 was shocked and distressed when she was later arrested and taken to court by the police. She received a further 12-month community order with an unpaid work requirement. Following the hearing she was spoken to by probation and said that the boys would not miss a day of school.     2 Meetings held as part of Wigan’s place based integrated working. https://www.wigan.gov.uk/Docs/PDF/Council/The-Deal/Deal-conference/Place-based-working- Presentation.pdf 10   M1 did then send her children to school. Child 1 attended his part-time timetable every day for several weeks, and began to benefit from the alternative provision. M1 failed to attend subsequent probation appointments or meetings with the school. By the end of May 2019 Child 1’s attendance and behaviour had deteriorated again and his anxiety about returning to mainstream classes had meant that he remained on a part-time timetable. Over the summer months, there were an escalating number of police reports involving Child 1 who was with Child 2, smoking cannabis and being involved in vehicle crime and anti-social behaviour in the area. Much of their time was spent with a gang of up to 30 young people, aged between 11 and 19, who were well known to the police and other services. Child 1 returned to school in September to start year 11 and attended well for the first few weeks but, when not in school, was still often out with others involved in crime and anti-social behaviour. M1 failed to attend court for the breach of her probation order and a warrant was issued. This warrant was still live, many months later, at the time of the incident when Child 1 sustained his injuries.  Significant incidents for Child 2 Child 2 had a sister who was 2 years older than him. Their parents had split up early in Child 2’s life and their father had moved away, having little subsequent contact with the family. Two half siblings were born as a result of his mother’s later relationship; a brother 2 years younger than Child 2 and a sister 6 years younger. At the beginning of the time period of this review the new relationship had ended and Child 2 was living with his mother (M2). All his siblings had all been living for some time with the father of the younger children and their grandmother. Child 2 had an extensive history of involvement with CSC from his early years because of neglect.  He was known to be associating with a large group of mainly older youths and had smoked cannabis from the age of 9. He first came to the attention of the police at the age of 10 for threatening to stab another child. Police records indicate that he perpetrated a number of assaults and was himself a victim of several assaults. However, prosecutions were not supported by the victims. At the age of 12 there were concerns from his school that Child 2 was ‘sofa surfing’. He was often sleeping and being fed in the homes of various friends. His behaviour problems had become evident when he was in nursery. He had attendance and behaviour issues at primary school and after a short period at a mainstream secondary school he was transferred to a specialist school for pupils with social, emotional and mental health needs. 11   Child 2’s mother said that she thought that he had ADHD. Notwithstanding this, she did not take him to appointments for diagnosis or to other health appointments. In late 2017 Child 2 reported to school staff that he had been camping out and taking cars, driving cars, racing with other drivers and taking spice. He told staff that he had earned £150 in a week by going into people’s houses and stealing car keys. A few months later Child 2 had an injured back and leg. There was evidence shared with his school by another pupil that he had been driving a stolen car and had gone through the windscreen when he crashed it. His mother said that this was not true. TYSS attempted to engage with Child 2 and to encourage him to attend school but he was often avoidant. At this point the family had been open to early help for around six years. M2’s interactions with professionals were often characterised by her demanding and threatening behaviour. At the start of the timeline the primary school that Child 2 had attended, and which his younger siblings still attended, had already used the Professional Conflict Resolution Policy to inform CSC senior managers of concerns that they were not addressing the multitude of emerging and longstanding issues in the whole family which had already been raised. The escalation was accompanied by a thorough analysis of how the case met thresholds of need against the CSC published threshold document. It identified that CSC appeared to see each issue as an individual piece of work and issues were never viewed holistically or in context. These included “many examples of ineffective and absentee parenting”. When CSC continued not to attend meetings to discuss the issues, the matter was escalated to the safeguarding board manager. In response to this escalation, a CSC manager made a commitment that social workers would attend meetings on the family but this was not followed through. Because of the concerns about neglect shared by Child 2’s school and TYSS, a Graded Care Profile3 was completed by a TYSS worker and passed on to CSC. This identified significant issues, but no action by CSC resulted. TYSS then persisted in engaging with Child 2 and arranged with the school that he could attend a bike mechanics course if he attended school. At the end of May 2018, M2 contacted CSC as she had to go into hospital and, although her other children were able to live with her ex-partner and his family, they would not look after her son, Child 2, while she was in hospital and had a period of recovery at home.    3 https://www.wigan.gov.uk/Docs/PDF/WSCB/Wigan-Graded-Care-Profile-toolkit.pdf 12   It would appear that M2 had initially contacted the CSC team which she had dealt with previously as she felt that they knew all her family history but the manager of that team would not accept the case so it had been passed to the duty team. A senior manager decided that it should stay with the duty team. A neighbour had been previously supporting Child 2 when he needed a meal or a shower. M2 initially agreed to the neighbour being a potential carer but then withdrew her consent. She also refused to allow Child 2 to be introduced to his foster carers to prepare him for his placement. As no alternatives could be found, a decision was made to accommodate him under Section 20 of the Children Act 19894 for a period of 6 weeks. At this point Child 2 had poor attendance at school. Staff at school had not seen Child 2 to be violent or aggressive but M2 had described him as violent towards her. She was, however, adamant that she did not want the care arrangement to be permanent. Once placed, Child 2 went missing repeatedly from a series of foster care placements over the next few weeks. Each time this was reported to the police. He was often either sleeping in an old caravan or in his home, which he had broken into while M2 was in hospital. He was regularly seen with the large group of young people which also included Child 1. Child 2 continued stay out at night or stay at his home when M2 returned from hospital. A CSC strategy discussion agreed a plan to take Child 2’s case to a Legal Gateway meeting. His Independent Reviewing Officer (IRO) reviewed the case; finding that Child 2 was not attending school and very reluctant to engage with professionals. M2 had been obstructive during missing from home investigations and denied that he was home when neighbours had seen him there. M2 reluctantly agreed to discharge Child 2 from Section 20 accommodation at the end of July 2018 as he had effectively not been residing in a care placement. His social worker was then not in work and, in her absence, an assessment concluded that M2 was willing to engage with services and that Child 2 had self-care skills. M2 spoke, in interview, about her experience with social workers throughout Child 2’s life. She felt that when she asked for help they would often want her to do something and she felt blamed. She described her response as “giving it them straight” and did not recognise herself as having been given any advice on improving the situation. M2 did remember benefitting from the delivery of a specific program of Multi-Systemic Therapy (MST) to help with her relationship with another child. This service, however, had been discontinued by the time she asked for similar support for her issues with Child 2.  4 https://www.legislation.gov.uk/ukpga/1989/41/section/20 13   In interview, the social worker recalled how extremely difficult it had been to work with M2. Less senior staff had been advised not to take calls from M2 because of the emotional impact of her difficult calls. She found M2 very angry and resistant to any suggestion that she modify her parenting behaviour. M2 would become very upset if a conversation was not focused on her needs and demands. This was the same pattern of behaviour that had already been observed by both of Child 2’s schools. It was also observed in M2’s interactions with health professionals and early help staff. On the occasions where the duty social worker (SW1) spoke to Child 2, he avoided eye contact. He was poorly dressed with torn and dirty clothes and had holes in his shoes. He did not want to be in care and believed that he could look after himself. M2 had received, and continued to receive, a great deal of practical support, organized by CSC. This consisted of deep cleaning the house, removing large quantities of refuse, and repairing and replacing windows and doors. Household appliances and money were provided, as were new clothes for Child 2. Child 2 was bought a mobile phone so that he could be contacted when missing. In addition, food parcels were frequently provided by a Family Support Worker (FSW). M2 was transported to her hospital visits and GP appointments by Child 2’s subsequent social worker (SW2). This type of support by professionals, in clearing and repairing damaged houses was one that had repeated several times over in Child 2’s earlier life. The local community were also known to have helped by re-clearing the house prior to CSC arranged visits. Unfortunately the community efforts also had the effect of removing some of Child 2’s clothing and therefore made his personal situation worse. In mid-September M2 again requested that Child 2 be accommodated as she was due to have further tests in hospital. Child 2 was clear in his view that he wanted to stay at home. CSC recorded that M2 was unable to prioritise her son’s needs above her own and that Child 2 did not recognise the danger and risk as he had been exposed to this on a regular basis previously when he had been left to spend his time as he wished. During this period of accommodation, the same pattern was repeated of Child 2 being reported missing and often then found by police to be spending his time with other youths in the area. Child 2’s use of the house while his mother was away contributed to very poor living conditions and CSC again arranged for professional cleaning, removal of refuse and the removal and replacement of broken beds. The Complex Safeguarding Team recorded 29 Missing From Home (MFH) episodes for Child 2, and had been unable to contact M2. Child 2 refused to engage with MFH interviews and a letter was 14   sent to M2 asking her to contact them. She did not do so. It was then decided not to report any further MFH if his whereabouts were believed to be known. M2 did make requests for information about his whereabouts via social media. The school continued to engage with Child 2 and he began to attend a bike mechanics course. Child 2 had an interest in mechanics and motorbikes and was motivated to attend the course. At night he was either at his home, out with other young people, or at the homes of friends including Child 1 rather than with his foster carers. Despite only sporadic attendance at school, he was allowed to continue with the bike mechanics course, as this was seen to be a safe place for him to be. Child 2 was very well regarded on the bike mechanics course. His passion and natural talent would have been likely to have made him successful in a career as a mechanic. He was always cheerful when on the course and the first to offer help to less able students. Child 2 had not had a foster placement since mid-October as each one had broken down. This period of accommodation was formally ended at the end of March 2019 when M2 advised CSC that Child 2 was now staying with her friend M1. From that point his case was stepped down to CIN level. M2 would cancel appointments on the grounds of her or Child 2’s ill health. She had accompanied him to A&E when he was suffering from a severe tooth abscess but failed to take him to follow up appointments or to appointments to assess him for ADHD. CSC social workers and managers recognised that M2 was avoiding an assessment of her own needs by adult social care and she was using the CSC social worker to fulfil her needs rather than her son’s. When the case was discussed with the social worker in supervision this was acknowledged but no better plan was suggested than to continue to attempt to engage with M2 and Child 2. M2 was allocated an adult social care social worker but continued to ask for, and accept, support from SW2 and FSW in the form of transport to appointments, funding for her needs and support in sorting out her benefits. She was still reluctant to allow professionals into her house. Visits were cancelled or took place on the doorstep. SW2 took Child 2 to his appointment and he was diagnosed with ADHD. M2 then applied for Disability Living Allowance (DLA). In a further supervision discussion between the principal manager and team manager, it was acknowledged that little had been done for Child 2 as most of the support had been for M2, and she was leaving him to fend for himself rather than parenting him. After a discussion with early help 15   services which had previously withdrawn due to lack of engagement, CSC’s involvement was to be reconsidered. During the summer Child 2 was seen repeatedly with other young people, including Child 1, on stolen motorcycles riding around the area and causing damage to property. In October 2019 Child 1 and 2 were involved in a road traffic collision where Child 2 was driving a stolen car. Child 1 was one of several passengers. Child 2 died shortly afterwards and Child 1 was seriously injured. 16   Analysis of Practice and Learning The considerable trauma that M1 had experienced in her own life, impacted on her capacity to allow services to become involved in her family. She had disengaged from school herself and her poor experience would have affected her understanding of the potential of education. Her perception of agencies’ attempts to engage with her, when her son was younger, was that they were not helping her. She recalled, in interview, that she did not feel they offered her anything useful. A critical factor in Child 1’s life was his exposure to domestic violence. The Greater Manchester safeguarding procedures5 recognise the repeated exposure of a child to domestic violence and abuse as neglect in itself.  Each time CSC were involved with the family, avoidance by M1 led to case closure as effective work could not be done. There is little indication that any of the attempts to work with Child 1’s family resulted in any progress that would be meaningful for him. M2’s parenting was affected by her life experiences and her illnesses. Her lack of a positive parental model meant that she was very much in need of support and advice when she became a parent. M2 had developed a pattern of highly confrontational behaviour when dealing with others that was functional to the extent that it had the effect of deflecting from any professional challenge and maintained the focus on her needs as she perceived them. It was against this context that professionals struggled to focus on Child 2. It was clear from M2’s interview that there had been attempts by professionals to offer some challenge but that this had not been sufficient or persistent enough to overcome her resistance to advice or for her to understand their cause for concern. She did not understand that the purpose of CSC’s involvement was to improve the lived experience and outcomes of her children. She saw them as either succeeding or failing in the extent to which they met her perceived needs which were largely material and practical. As challenge from social workers never got through her resistance, M2 genuinely did not develop any insight into the potential of her parenting to improve her children’s life chances.      5 https://greatermanchesterscb.proceduresonline.com/chapters/p_neglect.html?zoom_highlight=neglect Key Learning – A child’s exposure to domestic violence constitutes emotional abuse and neglect. 17    Both Child 1 and Child 2’s separate lives were known to services significantly before the timeline. A lack of parental supervision and structure in their lives had already led to them spending a great deal of time out of their homes and out of their respective schools. In these circumstances they had both found a sense of belonging within a group of boys with similar backgrounds who were involved in criminality and anti-social behaviour. Social workers dealing with challenging parents and carers need to be particularly skilled, and have a clear plan which is persistently followed until the child’s needs are sufficiently met. To do this they will need to be well supported and the vital importance of early intervention with parents of young children should be understood. Although neglect was identified early in Child 2’s life, it was strongly linked to material conditions in the home. A short-term focus by CSC on temporary improvements led to the case being stepped - down without proper consideration of other aspects of the child’s lived experience. Inappropriate closure, and a new social worker every time the case was re-opened, did not assist in meeting Child 2’s needs. Given the difficulty of working with Child 2 and his mother, the number of individuals who were trying to deliver services was problematic. Multiple services and individuals with differing emphases attempted to engage M2 and her son. What happened, in effect, was that the impact of collective efforts was diluted.  It was entirely appropriate to begin work with both these distinct families by attempting to support them to engage with services which assumed a willingness on the part of the parent to work in partnership. However, when it became clear that there was no prospect of real cooperative engagement, despite the persistence of professionals, and the welfare of a child continued to be compromised, there was a need to use statutory processes at the appropriate level. This did not happen in either case; primarily as a result of workload pressures within CSC. There was some consensus between professionals that CSC routinely dealt with workload pressure by responding to issues in isolation rather than holistically. Consequently, once attempts had been made to address the immediate presenting issue, the case could be closed without reference to the Key Learning – Professionals need to be clear and persistent with parents about their concerns, their offer of help and the potential impact on their children if parents fail to engage. Key Learning – Multiple professionals working with the same family should be minimised wherever possible. 18   overall context of the child’s life. Social workers were carrying very heavy caseloads and, at the time, the threshold for a social work assessment was much higher than the published thresholds. Much is in the public domain about the effects of the application of thresholds in Wigan’s Childrens Services. An Ofsted focused visit in January 2020, looking back at the second half of 2019, commented on the effects of extremely high caseloads. A subsequent visit by Ofsted in November 2020 recorded that ‘inconsistency remains in the quality of practice and not all children receive the right level of support, particularly those experiencing chronic neglect’6. Recent changes in management and resourcing have seen significant improvements in the operation of thresholds in CSC. However, it remained the view of many stakeholders in this process, at an event held in February 2021, that they were not yet confident that neglect would be managed very differently. This area therefore needs to remain in focus until the effect of changes is seen.  The best opportunities to significantly improve both individual children’s life chances were missed early on. This would have been when issues were first identified, pre-school. Dr Julie Wilkinson explored the issue of parental vulnerabilities in the evidence review ‘The impacts of abuse and neglect on children’. She identified a number of parental vulnerabilities that are associated with increased risk of maltreatment of children including: parent's exposure to adverse experiences during childhood (e.g. parental domestic violence, substance misuse, mental health issues); domestic abuse; mental health difficulties; drug or alcohol misuse; a history of crime; patterns of multiple consecutive partners; acrimonious separation; multi-generational cycles of child maltreatment. Providing earlier, effective support to parents, whilst keeping the child's welfare in mind, can reduce the risk of maltreatment7. Early, assertive and impactful intervention is vital. Where persistent offers of support for children are declined or minimal progress is achieved, closure should not be the next step. Rather, in the face of continuing harm through neglect, the step-up process should be followed until such time as positive engagement achieves an improvement in the child’s life chances. M2 benefitted from a program of support (Multi-Systemic Therapy) when another of her children experienced significant health and behavioural problems and M2 was having difficulty with this. The therapy was very specific in its focus but was effective in engaging M2 who has retained some of    6 https://files.ofsted.gov.uk/v1/file/50156333 7https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/602148/ Childhood_neglect_and_abuse_comparing_placement_options.pdf Key Learning – Only holistic assessments will draw out the impact of neglect on children over time. 19   the learning from the process. This serves to illustrate that there was potential to undertake meaningful work with M2.  During the timeline, CSC received referrals where the presenting issue was Child 1’s lack of school attendance. This was not seen as a safeguarding issue, and not seen in the known family context of neglect and domestic violence. It has been acknowledged by CSC as part of this process, that the situation would have been better dealt with by undertaking a social work assessment, but this was not done. Had it been done, Child 1’s lived experience, and the risks therein, might have been better understood. Poor attendance can have a number of causes, including child physical and mental health or parental capacity, and professional curiosity is required to identify the service required.  Good practice was seen in the work of both children’s schools. Child 1 had missed a great deal of learning and was anxious about attending mainstream lessons. His school was persistent in trying to find a way of working with him and his mother. They were mindful of his vulnerabilities and when his behaviour in school potentially merited his exclusion, they were determined not to give up on him. By creating high quality alternative provision within the school, they benefitted Child 1 by improving his engagement and confidence, and ultimately, by the start of year 11, his attendance. A great deal of persistence was evident in the work that the school and the attendance service undertook together in attempting to engage with M1. There is considerable evidence that these efforts significantly contributed to eventual progress with his attendance and better engagement and confidence as he moved into his last year at school. The attendance service worked well with the school to try to engage with M1 and ultimately, when this proved impossible, to bring a series of prosecutions, which led, eventually, to her making her children’s attending school a greater priority. It was her concern at her arrest which changed, for a time, M1’s pattern of avoidance and improved Child 1’s attendance at school. When M1 did want the children to attend school they did so, demonstrating that this was not outside of her control. The role of the attendance service in the life of Child 2 during our timeline was complicated by his mother’s illness and a lack of clarity about whether M2 had sufficient influence to get him to attend school. While he was accommodated it became the responsibility of CSC to ensure his school Key Learning – Child protection processes are necessary where parents do not engage in meaningful long-term change, in order to avoid a child suffering significant harm through neglect. Key Learning – Lack of school attendance can be indicative of a safeguarding issue. 20   attendance. This meant that attempting to go down the route of prosecution would have been inappropriate. Child 2’s primary school were persistent in pursuing his welfare even after he had left the school. This included the thorough analysis of his issues which accompanied a complaint to CSC about their lack of engagement which was later passed to the safeguarding board manager. The detailed breakdown of the family issues set against the local authority’s published threshold document were not effective in changing decision making as managers believed that the case did not meet the thresholds that they were applying and these were not the published thresholds. An issue raised at the learning event is that many find the Resolution of Professional Disagreements Policy8 difficult to use as it requires contacting an equivalent professional without the structures being clear who that might be. The use of this policy in the case of Child 2 only occurred because of the longstanding contacts the school had already made, and their tenacity in spending considerable time putting the concerns in writing and attempting to contact CSC at social worker and management level. Child 2’s school offered him some refuge at times of particular stress. Child 2’s community special school demonstrated high quality pastoral care and he developed significant relationships at school. The school did not experience the levels of aggressive and destructive behaviour that were reported by his mother and seen in the community. Child 2 was seen by the school as not violent and very honest. This may have been because of the good relationships they had formed with him and because he had no boundaries at home and there was no consequence to his revealing his criminal activity. The school worked with TYSS to provide a route for Child 2 to attend Bike Mechanics which engaged with his interests and skills. Child 2’s interest in eventually pursuing a career as a mechanic was a real positive in his troubled life. TYSS were persistent in attempting to gain M1’s consent to knife crime awareness work with Child 1. Given his mother’s refusal to permit this, they might have considered escalating the matter as a safeguarding concern and given CSC clearer understanding of the risks. However, the high thresholds at the time would have made the case unlikely to progress to an assessment. When TYSS’s concerns about Child 2 led them to complete a Graded Care Profile and they shared their concerns with CSC. At the time, CSC did not give proper consideration to concerns of neglect raised by partners. Again, high thresholds meant that no action was taken.   8 https://greatermanchesterscb.proceduresonline.com/chapters/p_resolv_prof_dis.html 21    Neglect is a very difficult issue for CSC and partners to deal with. It is the most prevalent form of child harm and often does not manifest as a serious incident that can be investigated but causes cumulative damage over time if not effectively addressed. Given its nature, it is less likely that neglect will trigger a strategy discussion or meeting under Section 47 of the Children Act 19899 but a strategy meeting should be held whenever there is reasonable cause to suspect that a child is suffering or is likely to suffer significant harm.  By the time M2 requested accommodation for Child 2 the local authority had few good options. He was very much beyond parental control and was resistant to being in the care of the local authority. Without the use of powers to place him in secure detention under Section 25 of the Children Act 198910, he was unlikely to stay where he was placed.   At this point in his life Child 2 would have been likely to have absconded from any non-secure residential provision. A period of secure accommodation would have allowed intensive work with him that would not have been possible otherwise. This might have been beneficial in dealing with his health issues and providing educational opportunities. It would have given him an experience of boundaries and may have helped him to develop insight into his predicament. However, the local authority could not make an application under Section 25 without being able to demonstrate that every other option had been comprehensively considered and rejected. The case had been previously managed and closed without the use of child protection planning, and without exhausting all other options so the criteria was not met. Even if secure accommodation had been an option, it would not have been a long-term solution and would not have been without psychological risks. Both boys had been discussed in Huddle meetings. When Huddles were established, the intention was that there would be an integrated response by services including CSC. In practice this did not occur and the lack of social work involvement limited the usefulness of these meetings as a vital component service was not present. It is recognized that this was a significant gap. Huddles are now being replaced by Complex Care Panels and this model is currently being developed. Going   9 https://www.legislation.gov.uk/ukpga/1989/41/section/47 10 https://www.legislation.gov.uk/ukpga/1989/41/section/25 Key Learning – Where a Graded Care Profile is completed and significant concerns are identified by agencies, CSC should always provide a response. Key Learning – Where ongoing significant harm due to neglect is suspected, the holding of a strategy meeting is appropriate. 22   forward it will be important that there is an appropriate link with CSC so that social work supports, and is engaged with, forthcoming complex care panels. Reflecting on the situation at the time, professionals identified general issues with lack of communication from CSC about critical decision making, including not being informed of changes of social worker, moving between teams or changes in plans including case closures. This meant that, for example, schools and partners often believed that children were being worked with when they were not, and had to take the initiative to seek out the information. They recognised this as a symptom of a system under considerable pressure with a high turnover in staff at the time. A change in working practices during the pandemic has led to online meetings which are much more accessible for professionals. This should be capitalized on as future processes are developed to facilitate more consistent attendance by agency representatives so that those attending are familiar with the cases being discussed and the content of previous discussions. An agenda with specific timeslots for discussion of individual children might make more efficient use of school staff and other professional’s time as they would then need only attend to discuss relevant cases. Day-to-day information sharing might be improved by the use of a single point of contact in the local authority. Such a person might also be best placed to consistently chair the meetings.  When Child 2 had become a looked after child, the focus of services was on the time consuming and expensive, but easily achievable, practical support that failed to address or impact on the underlying behaviour of both M2 and Child 2 and its cause. It was therefore likely that M2 would not maintain the material conditions of the home and that, when she was in hospital, Child 2 would enter the property and do significant damage. Child 2 did not see much benefit from the material improvements to the house and released his frustration by damaging again the internal doors that had just been replaced. M2’s diagnosis with illness made challenge more difficult as professionals became focused on the support of M2’s health needs and priorities. A clear understanding of M2’s health issues was obscured by M2’s own lack of understanding of her health, compounded by her health anxiety and her refusal to allow social workers to speak to her GP. Key Learning – High quality communication between services and schools is crucial. Changes necessitated by the pandemic, allowing easier attendance at meetings, should be capitalized upon as they present opportunities for more efficient working. Clearer supportive links with CSC might further enhance what schools are able to achieve. 23   Services encountered resistance from M2 except where they were responding to her demands. Her positive response to the practical and material help, created a false sense that she was engaged with services, but she remained resistant to issues that were not on her agenda. Her often challenging approach to professionals was functional as it had the effect of deflecting from Child 2’s needs to her demands. Help was provided to M2 and a great deal of professional time and effort was expended but there is little evidence of any effective challenge which resulted in a change in her parenting. It was clear to the social worker, and to the managers who reviewed the case in supervision sessions, that the effort being put in to supporting M2 was not effective in improving Child 2’s life. It was recognised as being more appropriately provided by her own adult social worker. Professionals worked hard but neither the family support workers nor the social workers were engaged in focused action in support of a potentially impactful plan.  Wigan, together with Rochdale, pioneered a model of complex and contextual safeguarding working which has been recognised and widely adopted across Greater Manchester. The formation of a complex safeguarding team followed from the previously successful project Achieving Change Together (ACT) which worked intensively with young people vulnerable to child sexual exploitation (CSE). This work was done in a way that recognised that children at risk of exploitation were not being effectively protected by becoming looked after. Evidence that the project was successful11 led to the use of its evidence base to inform the development of complex safeguarding across Greater Manchester. The principles that underpinned the ACT model were recognised as having a broader application to other forms of exploitation beyond CSE alone and would involve collaboration between agencies, including the police and CSC. The ambition for this work, as briefed in January 2019 and reported by BASW, was to encompass criminal activity involving children where there was ‘exploitation and/or a clear or implied safeguarding concern’12.    11  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/601976/ Child_sexual_exploitation_project_Wigan_and_Rochdale_evaluation.pdf 12 https://www.basw.co.uk/system/files/resources/Safeguarding%20during%20adolescence- Briefing_Jan19_v3.pdf Key Learning – Professionals should always ask ‘What is the impact of our actions on the child’s outcomes?’ If a plan is not working over time, it needs to be changed. 24   In practice this wide a remit has not been implemented and the current model is focused on CSE and Child Criminal Exploitation (CCE). The criminal and anti-social behaviour of the group of boys which included Child 1 and 2 did not meet the current remit of the complex safeguarding team as these boys were associating with a group of similar young people without a strong hierarchy and there was no evidence of grooming or exploitation but rather more of participation in loosely organized joint enterprise. Both boys were believed by the police, to not directly commit crimes but were often involved on the periphery. For example, they were not stealing the vehicles themselves but were driving stolen cars and motorbikes. In reality, no agency had a strategy for dealing with the activities of these young people and the problem had become entrenched.  Key Learning – Any solution or amelioration of the problem of criminality linked to familial neglect needs to be part of a multi-agency strategy including Police and CSC. 25   Recommendations Recommendation 1 The safeguarding partnership should prioritise an enhanced focus on the part of all agencies on effective, impactful engagement with families with young children, where neglect is identified. Recommendation 2 Children’s services should provide assurances to the partnership that appropriate thresholds are applied in relation to neglect and that step-up processes are appropriately used in situations where parents are resistant to, or avoidant of, making the changes needed for their children. Step-down processes should not be used unless there is assurance that the necessary progress has been achieved. Recommendation 3 CSC should review and strengthen arrangements for dialogue and information sharing with schools and other agencies in order to better connect with the rich seam of knowledge and insight that these professionals can offer. Greater effort should be made to consult with schools about changes in plans, allocations and planned closures. 