Alleged rape of a 14-year-old girl (Child H1) by her stepfather in July 2015. The stepfather was found not guilty of rape at his trial. Child H1 was the eldest of 5 children, born shortly after her mother arrived in the UK from Rwanda seeking asylum. Her mother was known to suffer from mental health problems. The family received services from a range of agencies for a period of 11 years. At various times, the children were looked after by the local authority and the children were the subject of child protection plans (CPP). At the time of the incident Child H1s mother was admitted to hospital suffering from acute psychosis. The children were left in the care of the presumed father of the three youngest children. Key findings include: a danger that neglect is left unaddressed when the provision of practical support is prioritised; insufficient attention within a CPP of how a service might benefit the individual needs of children may result in the wrong service provision; professionals feeling uncomfortable asking about a persons background, culture and belief systems; and over-concern about the risks rather than the benefits of information sharing. This review was conducted using SCIEs Learning Together methodology, a systems approach, which seeks to understand professional practice in context. Recommendations include: a review of how communication can be improved between primary and community care to strengthen safeguarding; review learning and development plans within multi-agency services to recognise, assess and respond to risk with particular reference to males in households, mobile isolated families, immigration status and black and minority ethnic communities.
      
 Title:  Child H1: serious case review. LSCB: Manchester Safeguarding Children Board Author: Ann Duncan and Bridget Griffin Date of publication: 2017  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 H1  SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 14TH DECEMBER 2017    INDEPENDENT LEAD REVIEWERS: Ann Duncan and Bridget Griffin  May 2017MSCB Child H1 Serious Case Review Page i  CONTENTS  1. Introduction and Context ....................................................................................... 1 1.1 Introduction ................................................................................................. 1 1.2 Involvement of Family Members .................................................................... 1 1.3 Succinct summary of the case ........................................................................ 1 2. Scope of review ..................................................................................................... 2 2.1 Research questions ....................................................................................... 2 2.2  Appraisal of practice – an overview ............................................................... 3 2.3 Background context ...................................................................................... 3 2.4. What makes learning from this case more widely applicable? ............................ 11 3. The Findings ........................................................................................................ 12 3.1 Summary of findings ................................................................................... 12 3.2 Findings in detail ........................................................................................ 13 4. Responding to the Research Questions .................................................................. 32 4.1 Responding to the Research Questions ......................................................... 32 4.2 Additional Learning: Involvement of GP’s with SCRs and communication pathways within Primary and Community Care....................................................... 34 5 Conclusion .......................................................................................................... 35 Appendix 1 Methodology ............................................................................................ 36 Appendix 2: References ............................................................................................... 39 Appendix 3: Acronyms and Terminology ....................................................................... 40     MSCB Child H1 Serious Case Review Page 1 of 40 1. Introduction and Context  1.1 Introduction  Manchester Safeguarding Children Board (MSCB) initiated a Serious Case Review (SCR) in August 2015 following the alleged rape of the eldest child in the family by her stepfather at the family home; she was 14 years old. At the time of this incident her mother was detained in hospital under Section 2 of the Mental Health Act.1 Stepfather was found not guilty of rape at his trial.  When agency records were reviewed by the MSCB, it was apparent that there had been long-term multi-agency involvement with all members of the family. At the request of the MSCB, this SCR has covered a period of two years and eight months (November 2012- July 2015).  MSCB decided to review this case using the Social Care Institute for Excellence (SCIE) systems methodology (‘Learning Together’). For detail about the review process and methodology- see Appendix One.  1.2 Involvement of Family Members  The involvement of family members is integral to the Learning Together methodology. Regretfully, the Lead Reviewers were unable to speak to any family members, the eldest child declined as she ‘didn’t want to talk about it anymore’; tragically her mother died from natural causes whilst the SCR was being undertaken; and her stepfather’s whereabouts are unknown, he is believed to be living abroad. During this SCR, the Lead Reviewers identified members of the family kinship, including a paternal aunt, the children’s godparents and members of the faith community, whom it was felt would be important to speak to.  Repeated attempts were made to try and ascertain contact with this kinship through Manchester Children’s Social Care (CSC). However, details of this kinship were not shared with the Lead Reviewers and so regretfully the perspectives of family and kinship do not feature in this report2.   1.3 Succinct summary of the case  Mother came to Britain from Rwanda seeking asylum, she had witnessed genocide and lost family members in the political unrest. She was known to suffer from mental health problems since her arrival in the UK.  She was pregnant with her eldest child when she arrived in the UK, the father of the baby did not accompany her. There are five children in the family; the last child was born in May 2014. The family received services from a range of agencies for 11 years. At various times, the children were accommodated by the Local Authority (LA), and at various times the children were the subject of child protection plans.                                             1 Section 2 Mental Health Act 1983, a person may be detained in hospital for up to 28 days 2 This is an important feature of this case and is further considered in finding 4. MSCB Child H1 Serious Case Review Page 2 of 40 During the time covered by this SCR, there were ongoing concerns about the emotional wellbeing of the eldest child, neglect of all the children and worries about the involvement of an unknown male in family life. In July 2015, mother was admitted to hospital suffering from acute psychosis. The children were left in the care of the presumed father (of the three youngest children). After a few days, the eldest child alleged that her stepfather had raped her and he was arrested at the family home. The children were taken into care under a section 20 arrangement.3   2. Scope of review  2.1 Research questions  A vital component of a Learning Together methodology is the formulation of ‘research questions’, which provide a framework for investigation and analysis. These questions are agreed at the outset and identify which aspects of multi- agency safeguarding work it is hoped to learn more about.  MSCB identified six research questions:   How well do multi-agency services identify and respond to the needs of Young Carers in Manchester when providing services to meet their emotional health and well-being?   How well do multi-agency partners recognise, assess and respond to risk across services, with particular reference to males in households, mobile isolated families, immigration status and BME groups?   How well does the current service configuration for adults and children support professionals to ‘think family’ in Manchester?   How well is the learning from SCRs implemented on the front line?   How well are faith and community groups engaged in safeguarding children in Manchester?   How well are the emotional, as well as capacity issues, considered when seeking agreement to care for children under s20 of the Children’s Act 1989?  It is not usual to have so many research questions set. The questions were posed by members of the MSCB SCR subgroup at a time when, following the Ofsted inspection, changes in management had taken place and there was a clear desire to make changes in as many areas as possible to improve services. During this SCR, information emerged that enabled several of these research questions to be explored and where appropriate these                                             3 Section 20 agreement; anyone with parental responsibility can voluntarily allow the local authority to accommodate their children under section 20 of the Children Act 1989 MSCB Child H1 Serious Case Review Page 3 of 40 have been covered in the relevant findings. Questions that are not addressed within the findings are addressed at the end of the report.   2.2  Appraisal of practice – an overview  The Appraisal of Practice forms an essential component of a SCIE Review. It considers the practice in this case, looking at multi-agency decision making, assessments and interventions up to and including the professional response immediately following the incident. The historical context was also considered and has informed the review’s findings. It aims to provide an explanation of ‘why’ things happened; outlining what got in the way of professionals being as effective as they wanted to be. Any issue identified that was common across more cases in Manchester is discussed in more detail in the findings, which are cross-referenced.  2.3 Background context  The appraisal of practice should be read in the context that MCC Children’s Social Care (CSC) underwent major organisational changes during the time covered by this SCR. In part, this was due to the implementation of austerity measures but also to staff shortages, particularly in qualified social workers.   MSCB and partner agencies underwent an Ofsted inspection from 25.6.14 to 16.7.14. The outcome of the Ofsted Inspection was an overall judgement of inadequate.4 It is important to note that receipt of an inadequate rating can negatively affect staff morale; during this review the Lead Reviewers were struck by the continuing impact this judgment seemed to have on multi-agency staff, who described feeling ‘bruised and battered’ (some two and a half years later). Following the judgement there were widespread changes to the city-wide leadership team.  The following areas were identified by the inspection and are pertinent to this case:  - A large number of cases (486) had waited a considerable time for a social work assessment, resulting in a significant number of children not having been seen or their needs assessed or recorded. This potentially left children at risk. - Quality assurance and management oversight is not robust. - Across all social work services, high social work caseloads mean that staff are often unable to prioritise and address children’s needs effectively. Children and families have experienced too many changes of social worker, making it difficult to effect change. - Poor understanding of thresholds by some of the statutory partners, together with poor engagement of agencies in early help, are contributing to high demand, which is not being effectively addressed.                                             4 A local authority that is judged as inadequate is providing services where there are widespread or serious failures that create or leave children being harmed or at risk of harm or result in children looked after or care leavers not having their welfare safeguarded or promoted.  MSCB Child H1 Serious Case Review Page 4 of 40 - Independent Reviewing Officers and conference chairs do not challenge poor social work practice effectively.  During the conversations with Case Group members, the areas that had been identified during the Ofsted inspection were highlighted in the work that was undertaken with this family and are referenced in the report. This includes high social work caseloads, change of social workers for the family, the lack of challenge by conference chairs at the various case conferences, and a lack of management oversight which resulted in case drift. There was also a drive immediately prior to the inspection to ‘stepdown’ families and a new service was commissioned to support this; the family was one of the first to be supported by the new service. This challenging landscape forms the context of this appraisal.    2.3.1 Period 1: The children become Looked after Children (LAC) under section 20 (s20) and prior to returning home are made subjects of Child Protection Plans: November 2012- April 2013.   This period highlights both a lack of coherence in multi-agency working and insufficient attention to the legal detail that underpins child protection work and supports the rights of the individual.   In November 2012, a police response team were called to the family home and found the two youngest children alone; the home was regarded as being in a squalid condition. The police used their powers of protection to remove the children to a place of safety. Although their actions were timely and appropriate they were taken without reference to Children's Social Care (CSC), albeit that the family had been known to CSC for several years. This lack of joint working was contrary to existing guidance and procedure, and fell below expected practice. It was understood that at this time the joint working between the responsible police and CSC teams was poor, since then several significant changes have been made in Manchester to strengthen the joint work between the police and CSC when exercising emergency protection powers. Performance and quality assurance measures are in place to enable relevant data to be reported to the MSCB, and compliance with best practice standards is the subject of regular review. The Emergency Duty Service (EDS) is now co-located with the police and is fully staffed with an on-call Social Worker (SW) out of hours. Therefore, the considerable changes to this safeguarding work since 2012 means that no finding has been made in relation to this issue.   After a strategy meeting, mother was charged and cautioned for neglect and the children were accommodated by the Local Authority (LA) under s20 (voluntary agreement) and placed with two separate foster carers. Although these next steps were timely and appropriate, it was not clear how mother’s consent for s20 was gained. No information was found to demonstrate that CSC had complied with the principles of good practice under s20; to satisfy themselves that mother had the required capacity to give consent, had a clear understanding of the legal framework, and was aware of her legal rights. Gaining consent under s20 is discussed further in Finding 5.  MSCB Child H1 Serious Case Review Page 5 of 40 During the next five months, the children’s SW worked hard to find suitable housing and to secure a budget for rent and for household furnishings, their efforts were commendable. However, the absence of a multi-agency response and the lack of management support to expedite this situation meant that the children were separated from their mother and siblings for a prolonged period. In addition, the time and effort required to find a resolution diverted the SW from their primary task of completing an assessment of need, and resulted in the children returning to their mother’s care without an assessment of parenting. This caused significant delay in how the family was understood and the children’s needs met.  Robust management support and oversight was needed to support the SW to achieve a proactive multi-agency response and to enable them to refocus on their primary task, but this was not provided. In response to the findings made by Ofsted in 2014, strengthened management arrangements have been put in place and continue to be the subject of review. Because of these changes, no finding has been made about management oversight and supervision.   Just prior to the children’s return home an Initial Child Protection Conference (ICPC) was held and the children were made the subject of child protection plans under the category of neglect5, this was an appropriate decision. However, the disproportionate focus on the lack of supervision and ‘unsuitable housing’ resulted in little attention being paid to the causes and consequences of the neglect, and compounded the delays in this case. Finding 1 explores in more detail how a focus on the efficiency with which cases are progressed and a lack of understanding of root causes, particularly in cases of neglect, impacts on how services are provided.   In June 2013, a review Child Protection (CP) Conference was held within the required timeframe. This conference appropriately noted a good working relationship between services and mother, and that considerable changes had been achieved. It was decided that a further period of monitoring under a CP plan was needed, this was an appropriate decision. However, education staff for three of the children were not at the conference and were not sent minutes of the conference. These were key professionals in the life of the children; it was not possible to fully understand the reason for their non-attendance. It was suggested this may be because of resource constraints and this is an issue that can impact on all agencies at certain times. Of paramount importance is that all professionals, whether they attend a conference or not, should be alerted to risks faced by children in their care for children to be safeguarded. It was understood that in Manchester, it is custom and practice not to send minutes to professionals who do not send a report or give their apologies to child protection conferences. This custom and practice is discussed further in Finding 6.                                                 5 Neglect is currently described in government guidance as: “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. Neglect may occur during pregnancy as a result of maternal substance abuse.” Under the same definition, neglect may involve a parent or carer failing to: Provide adequate food, clothing and shelter (including exclusion from home or abandonment)  Protect a child from physical and emotional harm or danger  Ensure adequate supervision (including the use of inadequate caregivers) or ensure access to appropriate medical care or treatment  Respond to a child’s basic emotional needs. MSCB Child H1 Serious Case Review Page 6 of 40 2.3.2 Period 2: ‘Stepping down’ the case to ‘Child in Need’, the birth of the youngest child, closure of the case to CSC and referral to a newly created service (CINIS). November 2013 - December 2014.   This period highlights the challenges encountered by multi-agencies when working with neglect, and with parents who have mental health difficulties. It also covers the difficulties encountered when working with families who are resistant to the involvement of services, and the importance of understanding the strengths and vulnerabilities of a child’s kinship.    In November 2013, a unanimous decision was made by members of the Review Child Protection Conference that ‘the risks have significantly reduced’ and the children’s names were removed from a child protection plan. This was an overly optimistic decision; mother was pregnant with her fifth child and there was still little understanding about the causes of the neglect. Judgements about progress were predicated on mother’s ability to accept the services offered, and the children’s response to the services. This lack of understanding about the causes of the neglect resulted in interventions and service provision, which lacked an overall coherence, and impacted on the way mother understood what she needed to do to bring about meaningful change in the parenting of her children. The importance of understanding the root causes of neglect is discussed in Finding 1.   The conference recommended that the children were provided with services under s17 of the Children Act 1989 (Child in Need CIN). In circumstances where there has been significant progress in reducing the harm to children and achieving plans, this can be the appropriate decision. However, working with families under this legislative framework requires a partnership with families characterised by consent and a willingness to engage. If there is evidence of this partnership being difficult to achieve (as it was in this case), the absence of the formal child protection planning framework can have a detrimental impact on progress. This was not sufficiently considered by conference members; once the children were no longer subjects of a plan, mother was regarded as increasingly distant, ‘hostile and disengaged’; this resulted in a loss of momentum in the progress that had been made. Finding 2 explores the pressures within the system and how these can impact on the way decisions are made about service provision.  Throughout the time the children were the subjects of CP plans and thereafter, mother denied all knowledge of the children’s paternity; stating their conception was a result of ‘a one-night stand’. The professionals were certain there was a man involved in family life but were overly focused on seeking an admission from mother to this effect, rather than reaching a decision based on the information gathered. Thus, the potential risks he posed (and possible strengths he offered) remained unassessed for the duration of service involvement. No finding has been made in relation to this issue as it is an area of practice that has been raised in previous serious case reviews in Manchester and elsewhere, the issues are explored further in the additional learning.     In September 2013, the health visitor (HV) (allocated to the youngest child in the family) started to visit the family and found mother difficult to engage. The HV was concerned about mother’s depression and the impact this had on her ability to meet the children’s needs. Mother’s mental health was managed by her GP; she had been registered with the MSCB Child H1 Serious Case Review Page 7 of 40 same practice for 13 years. Statutory guidance6 emphasises the need for communication to take place between all professionals involved with a family for information to be shared and to enable the network to work together, but this did not happen.  There was no contact with the GP by the HV7 or any other professional, and there was no contact made by the GP with other professionals working with the children. Thus, professionals working with the children did not know about mother’s mental health needs; they understood she was receiving medication for depression but they wrongly assumed she was compliant with her treatment. Conversely, mother’s GP was unaware that the children were the subject of child protection plans and was not aware of the agencies involved with the family.   During this review, it was understood that records kept in the GP practice on the children and the mother were not linked and this contributed to the lack of a shared knowledge about the family. So, whilst the GP practice had received information about the children’s child protection status, this information was stored on the children’s records and as the electronic records held on mother and the children were not linked, the GP treating mother was unaware of this important information. The practice has since recognised that this was a serious issue and have undertaken work to ensure that children and parents are linked within the IT system and appropriate flags are used to highlight any concerns, including safeguarding. This is being reinforced by the work currently being undertaken by the Clinical Commissioning Group (CCG) within the practice and across the city8. As a result, no finding has been made about this aspect of information sharing.  However, this provides only a partial answer to the lack of communication between the professionals. Of greatest importance was the absence of an approach that considered the interrelated needs of both the adults and children in the family. Finding 3 explores how the current configuration of adults and children’s services, and the limitations of current IT systems, impact on the ability of professionals to ‘think family’.  In May 2014, the four children in the family were placed in care under s20 for seven days whilst mother was in hospital for the birth of the youngest child. This was the fourth time the eldest child had been in LA care. Mother repeatedly stated that there was no one within the kinship that could look after the children, and this was accepted. There was information available to suggest there were members of the children’s community / kinship that could have been approached to provide care, but mother’s assertions were not sufficiently questioned. The task of professionals is to remain in a position of respectful uncertainty and display healthy scepticism which in practice means checking the validity of information provided by parents/adults by cross referencing/triangulating with other sources, this did not happen. As a result, the children were separated and cared for by foster carers who were in effect strangers; the emotional impact on children who experience separation from birth family is the subject of extensive research and its findings should be well known. Finding 4 explores the importance of understanding the identity of families so that information about family life (including the involvement of kinship) can be helpfully used to                                             6 Working Together to Safeguard Children, A guide to inter-agency working to Safeguard and promote the welfare of Children (HM Government, 2015). 7 Communication between HV’s and GP’s has been the subject of recent scrutiny and work is continuing to improve this, the additional learning (P.36) details the work that has taken place and the continued developments in this area.  8 Communication between General Practitioners and Health Visiting (2012) Health Visiting Task Force, partnership Task and Finish Group.  MSCB Child H1 Serious Case Review Page 8 of 40 inform service provision.    A few weeks after the birth of the youngest child, a Child and Family Assessment (CAFA) was completed. Within this assessment, the lack of a meaningful understanding of mother’s self- identity (including but not exclusive to her past experiences, her cultural practices and her religious beliefs and how this influenced her internal world and her relationships with her children and wider society) was stark. But this was not specific to this assessment; all previous assessments had been informed by an overly simplistic view of family life. In the absence of exercising curiosity about what may lie beneath the surface of what professionals were observing, plans were vague and assumptions were made. This had a significant impact on how the children were safeguarded and their needs met. The importance of understanding self-identity, beliefs and culture, is explored further in Finding 4.      On completion of the CAFA, the case was closed to Children’s Social Care (CSC) and referred to the new Child in Need Intervention Service (CINIS). An intervention plan was agreed and some relevant areas were covered however, many of the areas identified in the plan should have been previously covered (and concluded) in the 11 months when the children were subject to CP plans. There was little sense that the perspectives of the children were known or their needs understood, there was no clarity about what outcomes were being pursued or what impact mother’s mental health had on her ability to meet the needs of her children or on her ability to make the necessary changes, this compounded the delays in this case. At this time, the volume of work held by CSC was very high; there was a need to either close cases or move the work to other services. Ofsted were due to make an inspection, and this provided an important incentive to move cases through the system to lower levels of intervention. Finding 2 explores how the pressures on services can have undue influence on decision making and service provision.   The CINIS worker and the HV made a joint visit to mother as they both experienced her as ‘hostile’, particularly when they challenged her care of the children. Following a professional meeting in early November, mother was told that a six -week intervention plan with specific goals was her ‘last chance’. Following a visit just before Christmas, mother was recorded as ‘aggressive’ and as ‘refusing to accept the concerns’ that professionals had about her children.  The endless coming and going of professionals in family life, repeated assessments, meetings and plans, meant that the family had been in a constant revolving door of service provision for several years; this perspective was not thought about and the experiences of the family were not appreciated, mother was simply regarded as not working in partnership and was viewed negatively by almost the entire professional network. Finding 2 explores the revolving door of service provision and the impact on families.   2.3.3 Period 3: ICPCC convened Jan 2015.   This period highlights how a revolving door of service provision impacts on families, and the limitations of child protection conferences in challenging drift and delay.    MSCB Child H1 Serious Case Review Page 9 of 40 At the end of December 2014, CINIS referred the children to CSC; the referral was both timely and appropriate and the concerns were clearly outlined. An ICPCC took place at the end of January 2015, the reasons for the conference were stated as: ‘concerns about neglect and the need to escalate the case to consider initiating the Public Law Outline’ (PLO)9. The conference was attended by key professionals, and was held within required timeframes. The children had been spoken to before the conference and ‘Have your say’ booklets had been completed, these were read out in the conference and thus the children’s voices were well represented; this was good practice.    The conference decided that the children should be the subject of CP plans under the category of neglect; this was the correct decision. However, the recommendations made at the conference were vague and largely repeated the same areas covered in the many CIN and CP plans that had gone before. There were no clear outcomes or timescales and despite the minutes recording the need for a legal planning meeting, this did not feature within the plan agreed at the conference. The multi-agency network did not challenge the plan and the same type of services that the family had already received, with little evidence of any improvement, were put in place. As a result, the needs of the family were back around another process cycle of meetings, assessments, plans and service provision. Despite the extensive multi-agency services that had been provided and were being provided, the day-to-day life of the children at home with their mother had not changed. It is understood that since this time changes have strengthened case conferences in Manchester, thus no finding is made about this area of safeguarding work. Finding 1 explores some relevant issues regarding neglect, and Finding 2 explores relevant issues regarding child protection planning.     The view expressed by the SW that the case should progress to PLO was correct however, it is unclear why this had not already taken place. This added process step of holding a CP conference before initiating PLO contributed to further delays. Shortly after the ICPCC, the SW appropriately attended a panel to request initiating PLO but the request was refused.  The Review Team did not fully understand the reasoning behind this decision but in any event the decision was flawed, and the SW was left to go back around the same cycle of service provision again. It was reported to the Review Team that since this time: ‘the lengthy and often stressful and punitive process experienced by SW’s when attempting to progress a case through PLO has been recognised’ and the internal process has been changed. It was felt important to be clear about current expectations in Manchester in situations such as these. In line with statutory guidance10, where a child protection plan is not adequately protecting a child/ren), conference members (including the chair) are expected to make their concerns very clear and if concerns remain, these concerns must be escalated. No finding has been made about this, as it is understood that these changes have resulted in an improved process including: ‘more timely decision making and better management oversight of cases’.    The review conference was held within required timeframes in April 2015, and was attended by key professionals. The conference agreed that there had been little progress                                             9 The Public Law Outline sets out streamlined case management procedures for dealing with public law children's cases. The aim is to avoid care proceedings if possible and for those cases where proceedings are necessary, identify and focus on the key issues for the child, with the aim of making the best decisions for the child within the timetable set by the Court. 10 Working Together 2015  MSCB Child H1 Serious Case Review Page 10 of 40 since the last conference and that the children should remain the subject of CP plans under the category of neglect. It was clear that several recommendations from the last conference had not been progressed, and these recommendations were simply repeated. Neither the chair, nor conference members challenged this lack of progress, nor had no action been taken by the conference members to escalate their concerns. It is expected that both multi-agency partners and chairs of child protection conferences provide effective challenge in circumstances such as this, and escalate matters that remain unresolved.  It is understood that as part of the improvements made to services since the Ofsted inspection: ‘more effective challenge by conference chairs has been put in place’, thus no finding has been made in relation to this area of practice.  Shortly after this, in line with a recommendation made at this conference, a referral was made to the Families First (FF) Service. However, insufficient consideration was given about whether this was an appropriate service. FF provided a very specific time limited service based on intensive family work and complied with a clearly defined model of service delivery.  There was little room to offer something that was not within the service specification, how they were going to make any difference to the level of complex needs in this family was unclear.  The service contacted mother on two occasions, but they were unable to secure mother’s engagement and so withdrew. Finding 2 explores how the pressures on services can have undue influence on decision making and service provision.   2.3.4 Period 4: The deterioration of mother’s mental health and subsequent admission to hospital. June - July 2015.  This period highlights the challenges of working together across adult and children’s services when safeguarding vulnerable children and adults, and reviews practice in relation to gaining consent under s20 of the Children Act (1989).   Mother’s mental health deteriorated and she presented to her GP about 10 days prior to her admission to hospital, she was feeling anxious and having panic attacks. The eldest child also visited the same GP practice, and expressed concern about the amount of stress the family were under and put this down to the involvement of CSC. The GP felt she was ‘sensible beyond her years’, and wrote a letter to CSC expressing his concerns about their involvement; the GP did not mention any concern in relation to the change in mother’s symptoms or try to speak with the SW or other members of the Primary Health Care Team to elicit a professional view or to understand why CSC were involved with the family. The GP’s lack of knowledge about the children’s child protection status, and the absence of the records being linked within the practice, has been previously explored and is discussed further in Finding 3.    Mother was admitted on to a medical ward to exclude any physical condition before being transferred to a psychiatric unit; this is standard practice to ensure that any physical needs are stabilized and managed by appropriately trained staff.  On admission to the psychiatric unit, it was noted that mother had bruising to her upper arm that was thought may have been due to ‘extreme force’ and the use of restraints whilst on the medical ward. The paramedics reported that the attitude and language used by the staff on the medical ward MSCB Child H1 Serious Case Review Page 11 of 40 was derogatory. These observations were appropriately reported and noted however; no adult safeguarding alert was made. This was a missed opportunity to view the mother as vulnerable adult, share information and carry out a risk assessment. The Review Team were concerned about this and made a referral to Manchester Safeguarding Adults Board, the Board have commissioned a multi-agency review to explore why professionals working with the mother did not identify her own vulnerability as an adult.  On admission, mother was mute; her ‘partner’ provided the background to the days leading up to the admission. He told the Doctor that she had accused his family of witchcraft and of sexually abusing her eldest daughter. Whilst the mother was showing clear signs of being delusional, paranoid and psychotic, no matter how implausible, or regardless of the high number of allegations experienced within the service, any allegations such as these should have been investigated and the information shared with CSC.  Because this did not happen, the opportunity to consider the appropriateness of the partner continuing to care for the children was lost. This fell below expected practice, particularly given the children’s child protection status.  An internal management review by the Mental Health Trust has explored these issues and learning is being taken forward, therefore no finding has been made about these issues. This report should be shared with MSCB and read in conjunction with this review.  A few days later, the eldest child alleged that her stepfather had raped her; he was arrested at the family home. The children were taken into the care of the LA under S20 and placed together with one foster family; this allowed the children to be together at a very difficult time and was good practice. The importance of consent when accommodating children under s20 is discussed in Finding 5.   2.4. What makes learning from this case more widely applicable?  The Learning Together methodology uses an individual case to provide a ‘window on the system’ identifying whether the learning that has been identified by one case is more systematic and widespread, thereby leading to a broader understanding about what supports and what hinders processes and practice locally. The findings for the Board are identified arising out of the appraisal of practice, those areas of learning that provide the most significant illumination for wider practice are then prioritised.  This case shed light on several key elements within current systems including: identification and management of neglect, the perceived pressure felt by professionals to move families through the Child Protection system quickly and ‘step down’ to universal services, a lack of understanding or curiosity about the background and belief systems of the families and how this might shape acceptance and understanding of the services provided to them.  All the above make it a good vehicle for understanding practice in similar cases. This case provides us with an example of what can happen to a system that is under severe pressure and exposes how practice becomes routine rather than reflective; things happen in a timely way but not thoughtfully, and plans become focused on practical solutions and interventions rather than considering what might be the needs of individual members of the family. This in turn impacts on the quality of the multi-agency work, as the focus becomes efficiency and moving cases on quickly rather than spending time to fully explore and understand the MSCB Child H1 Serious Case Review Page 12 of 40 perspective of the individuals within families. The result is families start moving in and out of the system in a ‘revolving door’ type syndrome.    This case provides wider lessons for improvement, especially in dealing with cases of neglect; this is a major concern for safeguarding children’s networks, both within  Manchester and nationally. 3. The Findings  3.1 Summary of findings  The Review Team have prioritised six findings for the LSCB to consider. These are:  Findings Category (from typology)11 1. When the provision of practical support is prioritised over understanding the root cause of neglect, the danger is that neglect is left unaddressed. MANAGEMENT SYSTEMS 2. Insufficient attention within a child protection plan of how a service might benefit the individual needs of children may result in the wrong service provision. MANAGEMENT SYSTEMS 3. When services are configured separately for adults and children there is a danger that the impact of risk within the family is not fully understood, which can potentially leave children and adults vulnerable. MANAGEMENT SYSTEMS  4. When professionals feel uncomfortable asking about a person’s background, culture and belief systems beyond the superficial labels used for demographic data collection, children and families’ needs may remain unmet. HUMAN BIAS 5. Local authority management systems are insufficiently challenging of the custom and practice of social workers not to seek or systematically record informed parental consent for S20 accommodation, potentially leaving the support needs of parent’s unseen and making case-drift more likely.  MANAGEMENT SYSTEMS 6. Over-concern about the risks rather than benefits of information sharing is resulting in professionals in Manchester being unsighted as to safeguarding risks to children. COMMUNICATION/ COLLABORATION IN LONGER TERM WORK                                              11 For an explanation of typology refer to ‘Methodology’ in Appx 1 MSCB Child H1 Serious Case Review Page 13 of 40   3.2 Findings in detail   This section represents the main learning from this case review for MSCB and partner agencies. Each finding is set out in a way that illustrates:  - How does the issue feature in this particular case?  - How do we know it is not peculiar to this case? What can the Case Group and Review Team tell us about how this issue plays out in other similar cases/scenarios and/or ways that the pattern is embedded in usual practice?  - How prevalent is the pattern? What evidence have we gathered about how many cases are or potentially affected by the pattern?  - How widespread is the pattern? Is it found in a specific team, local area, district, county, region, national?  - What are the implications for the reliability of the multi-agency child protection system?  The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group, from the records relating to this case, other relevant documentation and from relevant research evidence. Six priority findings were chosen because they represented areas of practice which were significant in how this case was managed, but which also reflected wider patterns of practice and the systems which underpin that practice.  The remainder of this section explores the six Findings. 3.2.1 Finding 1: When the provision of practical support is prioritised over understanding the root cause of neglect, the danger is that neglect is left unaddressed (i) Introduction  It is well known that neglectful parenting is almost inevitably a sign of complex and long standing problems such as mental ill-health, domestic abuse, a poor physical environment or entrenched behaviour by a parent(s). To understand whether neglect is occurring, a range of factors must be considered including emotional and developmental needs as well as the immediate need for an adequate diet, warmth and shelter. It is relatively easy to measure outcomes on compliance with practical support offered and allows cases to pass through the system. It is more complex to understand root causes of neglect and measure progress against these.  This easy measurement fits with the pressure in the system to move cases through to ease log jam in a system faced with constant demand and the need for quick fixes.   (ii) How did the issue manifest in this case? There are several examples of how professionals working with this family prioritised practical support, rather than exploring and gaining an understanding of the causal factors.   MSCB Child H1 Serious Case Review Page 14 of 40 The example chosen to illustrate this, is the accommodation of the children by the Local Authority after mother was cautioned and charged with neglect following the removal of the two youngest children from the family home under a police protection order (PPO).   The children were accommodated under S20 and remained in care for five months; during this time, the focus of intervention was on securing housing. When the children were returned to the care of their mother they were subject to a CP plan for neglect and, in the absence of a parenting assessment or a plan to provide services that dealt with the causes of the neglect, a range of practical support services were provided (such as daily taxis to ensure that the children arrived at school at the correct time). It is unclear whether mother understood the nature of professional concerns about her ability to parent her children, or what she needed to change to meet the needs of her children.  Although mother appeared not to accept responsibility and either blamed the professionals working with the family or the children themselves, conversely, the professionals did not seem to consider how her long-standing mental health issues might lie beneath the neglect, or on her ability to make the required changes. The family were provided with a range of practical support that mother saw largely as an intrusion rather than a solution, decision making about which services should be provided at which level of intervention was based on how well compliance with set tasks was achieved.    In the two and half year timeline, the children were looked after by the LA, made the subject of CP plans, their cases stepped down to child in need services then escalated back to CP and finally looked after by the LA for a fourth time. Their cases moved in and out of services and up and down the thresholds of intervention, over this entire period the causes of the neglect were never established.   (iii) How do we know it is an underlying issue and not unique to this case? It was understood that it is not unusual for children’s cases to move through the system quickly; the number of cases allocated to social workers at this time was high (although has steadily decreased since the Ofsted inspection and has met the target12). In addition, it was reported that at the time: ‘there was an over reliance on providing task focused support interventions and services’ rather than identifying and working with the underlying cause of neglect and changing patterns of behaviour.  It is the experience of practitioners and managers that the constant pressure on resources and the associated pressure to step down children’s cases from a higher level of intervention (to relieve the pressures on the front door), continues and that neglect cases continue to be at risk of being too readily stepped down (because progress is measured by providing services to deal with the symptoms rather than an approach that addresses the causes).  At the time this case was managed, the Review Team commented that there was no effective strategy on how to manage neglect across agencies in Manchester13 and as a result                                             12 At this time, SW’s were allocated 40 -45 cases, -the target figure of 20 cases was met at the end of 2016-2017. 13 ‘Those local authorities providing the strongest evidence of the most comprehensive action to tackle neglect were more likely to have a neglect strategy and/ or systematic improvement programme across policy and practice, involving the specific approaches to neglect’: In the child’s time; professional response to neglect. Ofsted (March 2014) 12. Missed opportunities: indicators opportunities: indicators of neglect – what is ignored, why, and why, and what can be done? Marion Brandon, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lustoy and Harriet Ward- Childhood Wellbeing Research Centre (Nov 2014) MSCB Child H1 Serious Case Review Page 15 of 40 there is no common tool or risk assessment used.  However, the Board has been working on developing a new Neglect Strategy, which is nearing completion and will be discussed at MSCB in February 2017. Community Health Services use a tool called CANDO (Child Assessment of Neglect and Disability Overview). The training is currently being rolled out across the city to support community staff in evidencing neglect and the impact on a child’s health.  (iv)   How prevalent and widespread is this issue? The findings of other Serious Case Reviews show that professionals may individually have concerns about a neglected child, but all too frequently the concerns do not trigger effective action. Research suggests that potential obstacles for effective action includes: professionals lack of knowledge, resource constraints influencing professional’s behaviours and professional ‘mind-sets’ that hamper professional confidence and action.14  Research on biases in human reasoning finds that recall is stronger for very vivid or emotive material, such as visible injuries to children (or significant weight loss) but less so in relation to signs of neglect. ‘Clearly it is important to give priority to less obvious signs and symptoms of harm, or the risk of such harm, to children and young people’15.  Neglect has been described as the ‘most serious type of child maltreatment and the least understood’ (Dubowitz, 1999 p.67). It is the most common reason for a child having a child protection plan in the UK (45% in March 2015 DfE). The percentage of children in Manchester under the category of neglect is continuing to rise. In 2014 -2015 it was 50.5% rising to 61.4% in the 2015 -2016 year and the figure for the first quarter in 2016 -2017 has jumped up to 69.8%.  If there is undue focus on processing these cases through the system, there are a lot of children who stand to come back into it, as happened here.  (v) Why does it matter?  Dealing with neglect can be difficult and at times overwhelming. A safe safeguarding system recognises these challenges and supports practice decision making based on an understanding that neglect is characterized by a cumulative pattern, rather than discrete incidents or crises. If this is accompanied by management support that is readily available, this pattern can be seen and responded to. When plans are reviewed regularly, and change measured in terms of positive outcomes for children then children are more likely to be safeguarded. In such a system, the ‘start again syndrome’16 will be averted and potential case drift less likely. In the absence of these features and when the pressure on services is high, cases of neglect will not receive the same time and attention necessary to understand and work with causal factors and therefore professionals stop seeing and identifying neglect. In these circumstances, the focus becomes practical support and moving families between services. This results in families ‘bouncing’ up and down thresholds without any clear measurable change or progress in the lives of children.                                               15 Ten pitfalls and how to avoid them. What research tells us Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln. September 2010 www.nspcc.org.ukinform. 16 Change of practitioner and insufficient attention is paid to the past and work starts afresh (Brandon et al 2008) MSCB Child H1 Serious Case Review Page 16 of 40    Finding 1: When the provision of practical support is prioritised over understanding the root cause of neglect, the danger is that neglect is left unaddressed. Summary  Neglect is a complex safeguarding issue that requires a complex response. Being able to respond effectively to cases of neglect requires professionals to be confident in their understanding of all aspects of neglectful parenting. When cases of neglect are managed by a plethora of short service interventions that focus on practical support and outcomes that can be readily demonstrated, there is a danger that the underlying cause for professional involvement is diminished and the cause and impact of the ongoing neglect is lost.  Questions for MSCB    Does the Board understand how multi-agency professionals currently work together with neglect and are the barriers understood?  How will services be supported in implementing the new neglect strategy and how will progress be measured?   Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development?  How will MSCB be best informed of progress and consider how challenge will be provided?  How will planned improvements be integrated into the MSCB Learning and Development plan?   3.2.2 Finding 2: Insufficient attention within a child protection plan of how a service might benefit the individual needs of children may result in the wrong service provision.  (i) Introduction   All services work within a delivery framework dictated by legislation, duties and responsibilities, a preferred model of delivery and increasingly by resource availability. In a time of austerity, it is perhaps unsurprising that services apply a model of service delivery that often dictates the terms of engagement with a family and how a service will be provided. Added to these pressures, is a further pressure to provide services constrained by time within a ‘window of opportunity’, in a desire to move need out of the higher levels of multi-agency intervention. The unintended consequence can be an increasingly rigid construct of service delivery that applies a model of ‘one size fits all’, negating a bespoke model of service delivery that is flexible enough to adapt to individual need and difference.  (ii) How did this issue manifest in this case? There are several examples within the case illustrating how this issue manifested. The examples chosen to illustrate this finding are the two referrals made to the Families First (FF) Service in March 2015 and in June 2015. The family were referred to this service in line MSCB Child H1 Serious Case Review Page 17 of 40 with a recommendation made at the ICPCC, and after the SW had been unsuccessful in their attempts to escalate the case to legal proceedings.  The Families First (FF) Service provide intensive intervention to families for a period of six weeks to support families: ‘to make positive changes so your family can live together safely’17. The service provides ‘intensive evidence based interventions’ and has clearly provided some much-needed support to families in crisis. However, there was a question whether this service was the right service for this family; the primary issue was one of chronic neglect, the family had received an array of different services for several years and periodic improvements had been achieved but not sustained. Mother was a single parent with five children; isolated, depressed and living on a low income, it was unclear how solution focussed brief therapy and brief intervention was going to help this family. In addition, mother was frequently regarded as disengaged from services she had previously made it clear that the intervention of the Family Intervention Project (FIP) had not been welcomed. It was recorded: ‘(Mother) does not want such intensive support, she finds it intrusive’. Critical to success of the FF service was engagement from families, although there was a clear pattern of non-engagement the SW was stuck; there had been an unsuccessful attempt to escalate the case to a higher threshold of intervention and referral to a new service seemed the only option.    The involvement of FF was not discussed with mother; equally it was not discussed with the FF service. Despite the concerted efforts of the workers, attempts to engage mother in the work were unsuccessful and the service quickly closed their involvement. Two months later, a second referral was made, again the FF service attempted to work with the family but again they were not able to engage mother and so closed their involvement. Just over five weeks later, the critical incident that prompted this SCR occurred.      (iii) How do we know it is an underlying issue and not unique to this case? When discussing this with the Case Group and the Review Team, these issues seemed to resonate across several services. From the perspective of the practitioners in the Case Group, their experiences were of a multi-agency system attempting to cope with the volume of need within finite resources, where there was constant pressure from within the organisation to identify need and move cases on; ‘to step down (or across) the case’ (starting at the front door of provision and out the other end to a lower threshold of intervention). It was their view that this pressure took precedence over proper consideration of whether the service being referred to would be the best fit for the needs within the family, this was said to be compounded by the need to comply with performance indicators and during times when the organisation was under strain.   Members of the Review Team agreed with this view sighting as an example: ‘the constant pressure to get children off a CP plan’. They spoke about how the pressures on services (such as resource constraints, restructuring, impending Ofsted inspection etc.) significantly influenced the need to move families quickly through services. Members of the Case Group and Review Team also spoke with some feeling about the emergence of new projects in Manchester (because of restructuring, new policy drives or national initiatives - such as FIP and others), who deliver services ‘within a rigid construct of service delivery’ (such as an                                             17 Families First Information Leaflet (MCC)  MSCB Child H1 Serious Case Review Page 18 of 40 alignment to a particular model and rigid timeframes) and can result in ‘pushing families through a cat flap, when delivering services off menu is not allowed’.      (iv) How prevalent and widespread is this issue? Research completed by ‘Locality’ in association with Professor John Seldon, is relevant to this finding. The report: Saving money by doing the right thing - Why ‘local by default’ must replace ‘diseconomies of scale’18 describes research conducted into public service systems in an attempt to understand the challenges faced by services at a time of austerity cuts, mounting demand and rising expectations. Messages from this research resonate with the experiences of this family, and that of frontline professionals and managers in Manchester.  ‘High volumes of re-presenting demand illustrate that demand does not go away because it is screened out of a system. When a person’s problem isn’t resolved (which is most of the time), he/she just re-enters the system through another of the bewildering array of doors a referrer can choose from. Decisions about where to refer applicants are dictated by what services exist rather than what individuals need.’   ‘If a service has been commissioned that vaguely relates to presenting needs, people will be referred there. Each time a new service is commissioned it creates yet another referral door to add to the list. The thinking behind referral is: ‘this isn’t for us, so it is up to someone else to help them’. What actually happens at the next transaction point is that the assessment (screening) process starts all over again.’  Data on children subject to child protection plans in Manchester shows that of the 953 children subject to a plan in December 2016, 8.1 % have been the subject of a plan for a second or subsequent time, this equates to 77 children who have been the subject of assessment and child protection planning for a minimum of two cycles.     The report describes a system that is unable to understand people in context or respond to their needs; ‘People quickly learn that when they ask for help what they will get is assessment and referral. Some feel so overwhelmed by the many professionals now managing their life that they give up trying to help themselves. Such users are usually labelled difficult or non-compliant and sometimes visited with sanctions or refused further service. The overall consequence, however, is the same – a failure to solve the original problem, which as a result becomes worse or more complex. People with problems continue to place demands on, or be referred between, multiple services, inevitably consuming more resources across the system as a whole.’  (v) Why does it matter?  Every day across the country19 children receive support from multi-agency professionals to safeguard them from harm, and improve their lives. Critical to the success of this work is the timeliness and appropriateness of the services that are provided. This complex multi-agency system works well when needs are responded to as they emerge, services are provided to match the level of need, and the system is flexible enough to provide a bespoke model of                                             18 Locality in partnership with Professor John Seldon (Vanguard Consulting) March 2014 19 During 2014-2015 390,000 children received support from Children’s Services: Department for Education (2015) Characteristics of children in need in England 2014-2015   MSCB Child H1 Serious Case Review Page 19 of 40 service delivery that accommodates individual difference. This is a complex and difficult task where there are no quick fixes; one size will not fit all, but if there is room for individual difference to be recognised and responded to (and clear contingency planning), children and families will receive support at the right time, in the right way, and in the right place, resulting in timely and efficient interventions that allow children to be safeguarded and positive outcomes realised. Within a context where choice cannot be infinite and resources are fewer in number and often in scope, this is far from easy to achieve.  Finding 2:  Insufficient attention within a child protection plan of how a service might benefit the individual needs of children; may result in the wrong service provision.  Summary  In a system that prioritises efficiency over reliability, where little attention is paid to how services will best meet the individual needs in a family, children’s needs will not be met and the risks to children will increase. If this is accompanied by an absence of contingency planning, delays will inevitably occur, pressures on services will continue to escalate and the opportunity to make a difference for children will not be realised.  Questions for MSCB    MSCB are invited to consider the Locality & Vanguard20 report and consider how Manchester might adopt a systems approach to change for the benefit of children, families, and service providers.   Where will accountability be held for monitoring and evaluation of the learning and development?  How will MSCB be best informed of progress and consider how challenge will be provided?  How will planned improvements be integrated into the MSCB Learning and Development Plan?                                                 20 In outline, the Vanguard Method provides the means to study services end-to-end, understanding service-user demands, following the demands through the services to understand how and how well the services work and identifying the system conditions that help or hinder achievement of purpose from the service users’ point of view (Locality in partnership with Professor John Seldon - Vanguard Consulting March 2014). MSCB Child H1 Serious Case Review Page 20 of 40 3.2.3 Finding 3. When services are configured for adults and children separately there is a danger that the impact of risk within the whole family is not fully understood or even considered, which can potentially leave children and adults vulnerable.  (i) Introduction Currently, Health and Social Care services for children are not fully integrated. Adult Mental Health and Children’s Social Care have separate legal frameworks, separate guidance on policy and practice, separate management and separate lines of accountability As a result, the chances of a whole family assessment with care plans to promote the needs of both the child and the adult becomes much more challenging for all professionals. The ‘Think Family’ agenda was introduced to help professionals working in adult and children services to understand the importance of a whole family approach.  Although ‘Think Family’ is not a statutory requirement (and relatively old in policy terms as it was published in 2009), many providers of services have embraced it to support staff to try and minimise the number of cases where risks were not considered from both the adult and child’s perspective. This case has shown that despite initiatives that encourage services to think about the needs of all family members, the continued separate configuration of services mitigates against this approach.    (ii) How did the issue manifest in this case? There are several examples in this case illustrating how professionals involved with the family concentrated on identifying individual risks to the children but did not consider the needs of the whole family. The example used to highlight this is the lack of partnership working in relation to mother’s depression.  Mother had been registered with the same GP for 13 years, and was well known to the practice. She attended the GP practice two to three times a month, and spoke candidly to the GP about how she felt. The GP had a good understanding of her mental health (including nightmares and flashbacks to the trauma she experienced in Rwanda) and appeared to have a good relationship with her. The GP made three referrals to secondary care mental health over a period; none of which the mother took up. When mother missed her appointments, the surgery appropriately followed these up.   However, there was little (if any) communication with secondary mental health, the GP was unaware that the children were the subject of child protections plans, did not know about the other services supporting the family and despite existing guidance,21 there seemed to be no formal liaison between the family health visitor and the GP. The surgery is a ‘paperless’ practice and although the information pertaining to the children was recorded in their electronic notes, including the fact that they were the subjects of child protection plans under the category of neglect, the mother and children’s electronic records were not linked on the Information Technology (IT) system.   The other professionals working with the family had little understanding of the mother’s mental health and at times assumed that mother was being ‘difficult’, ‘resistant to help’, or displaying ‘childish behaviour’ when she turned her back on practitioners, why she was doing                                             21 Communication between General Practitioners and Health Visiting (2012) Health Visiting Task Force, partnership Task and Finish Group. MSCB Child H1 Serious Case Review Page 21 of 40 this, and the possible significance of her depression, was not thought about. Mother was never seen as having needs in her own right or regarded as a vulnerable adult by any of the professionals working with her and her family. Professionals assumed mother was compliant with her medication for depression, but again did not check this out with the GP, had they done so they would have been furnished with a very clear account of mother’s mental health and why: ‘she went to sleep for 16 hours’22, it was understood by the GP that this was: ‘in the hope that she could forget her past experiences’.   (iii) How do we know it is an underlying issue and not unique to this case? Within any system there is a reliance on information systems containing the right information and professionals being able to access the information in a timely manner. Currently, IT systems in Manchester are not integrated across service providers and even within health there are several different IT systems in use. When IT systems do not ‘talk to one another’ the emphasis is on professionals communicating, and sharing information in a timely way.  The Case Group and Review Team told us that this was incredibly frustrating and time consuming; messages left on voicemails and time taken to respond meant that ‘nothing moved on’. When this also coincides with high volumes of cases, high turnover of staff and the introduction of new models of care it is hardly surprising the communication and information becomes fragmented.    The Review Team told us that following the Ofsted Inspection there has been a recognition that service provision needs to change to ensure that the support provided by children’s, adults’ and family services is co-ordinated and focused on problems affecting the whole family to improve the outcomes for the children and adults. The introduction of the Early Help Hubs across the city and the adoption of Signs of Safety23 provide a practice framework for all services - with the aim of improving the effectiveness of multi-agency working with families. The co-location of the Adult and Children’s Multi Agency Safeguarding Hub (MASH) also supports a whole family focus and improves information sharing. However, during this SCR the Review Team had many discussions with the Lead Reviewers about service provision across Manchester and whilst they spoke of a ‘Think Family agenda’ within their own organisations, they remained pessimistic about how this agenda has been translated into tangible changes for children and families in receipt of services.    (iv) How prevalent and widespread is this issue? The ‘Think Family: Improving Support for Families at Risk’, was launched in 2009 by the then Department of Children, Schools and Families. This toolkit was based on evidence identifying the lack of integrated practice between services provided to children and adults’ and defined ‘Think Family Practice’ as: ‘Making sure that the support provided by children’s, adults’ and family services is co-ordinated and focused on problems affecting the whole family’. Fundamentally it is about how professionals think, and it is therefore not surprising that professionals who work either with adults or children will have a bias towards how they see and relate to the individuals within the family. When this is put together with a system under pressure, with little time to explore and analyse the risks and possible impact, and combined with a lack of management oversight and robust supervision the likelihood is that                                             22 ICPCC minutes 29.1.15 23 A solution-focused, strengths- based approach to social work practice; Eileen Munro, Terry Murphy and Andrew Turnell MSCB Child H1 Serious Case Review Page 22 of 40 professionals focus on their own area of expertise and do not always consider the bigger picture.   Serious case reviews involving parents who have their own needs (such as substance misuse, mental health difficulties or learning difficulties etc.), often reference the lack of integrated working between adults and children services, and the impact this has on how children are safeguarded: ‘Issues of silo practice have been highlighted in previous biennial reviews, and again were identified in several of these serious case reviews. No single profession has a monopoly of knowledge or skills for protecting children. By working in isolation, professionals miss opportunities to effectively support families and safeguard children.’24  (v) Why does it matter?  Families are systems of interconnected and interdependent individuals, none of whom can be understood in isolation. When the focus of each agency starts from the position that whatever needs have been identified can only be assessed by considering each member of the family and the interdependencies that exist, services are provided that meet the needs of the whole family, the needs of an adult are considered in the context of their parenting role and the needs of a child as interdependent on those of the adults and other children in the family.  A shared strategic agenda, integrated services, and strong leadership support this approach across the multiagency network and nurtures a culture of joint working, when this happens children are better safeguarded and families strengthened.    The converse position of individualising family members and providing services in isolation splits the family system; needs will be divided and services provided in a furrow. When this happens, the whole picture will never be seen; assessments and plans will be inherently flawed, the needs of children and adults will be compartmentalised and despite the determined endeavours of professionals, children will not be safeguarded.    Finding 3: When services are configured for adults and children separately there is a danger that the impact of risk within the whole family is not fully understood or even considered, which can potentially leave children and adults vulnerable and without the services they need. Summary Currently, systems and services designed to support families are highly complex and often fragmented, resulting in an uncoordinated and inadequate response to chronic, multi-faceted needs. As a result of this, the ability to clearly identify the needs and risks within the family as a whole becomes more challenging, there will be a focus on either the child or the adult and little consideration of the interrelated and dynamic context of the family system, leaving children and adults vulnerable and without the services they most need.  Questions for MSCB   How can the Board support multi-agency partners to translate their strategic agendas into tangible change on the front door of service provision?                                              24 Pathways to harm pathways to protection: a triennial analysis of serious case reviews 2011-2014 (Sidebotham, Brandon et al DfE May 2016)   MSCB Child H1 Serious Case Review Page 23 of 40  How would the Board be confident that an integrated approach to working with families is effective?    How will MSCB know whether new initiatives/service configurations (such as the Early Hubs) are providing joined up care? How might MSCB support these services in overcoming any obstacles?   How might MSCB hear the perspective of children and families and frontline professionals about the opportunities and challenges faced when attempting to provide joined up family focused care?  Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development?  How will MSCB be best informed of progress and consider how challenge will be provided?  How will planned improvements be integrated into the MSCB Learning and Development Plan?   3.2.4 Finding 4: When professionals feel uncomfortable asking about a person’s background, culture and belief systems beyond the superficial labels used for demographic data collection, children and families’ needs may remain unmet.  (i) Introduction This finding relates to how the unique self-identity of a parent and/or child is understood and used to inform service provision.  Understanding others fully requires us to try and see others as they see themselves and an appreciation of cultural difference is an element of that. In the absence of this, we just superimpose what we think upon others.  In the context of child protection work this can be a dangerous practice as it means we never fully appreciate what motivates different individuals and therefore how we can help them to change. If this is layered with a misunderstanding that it is intrusive to ask about someone’s background and that everyone should be treated the same regardless of race or culture, then this runs the risk of severely limiting how parents and families are understood and services provided.   (ii) How did the issue manifest in this case? Throughout all the case records, assessments, case conference minutes, plans and interventions it was not possible to gain a complete understanding of mother’s self-identity.  Glimpses of this identity were recorded in the case records and related during conversations with the Case Group: ‘Ms X (mother) was from Africa (maybe Zimbabwe, Nigeria or Rwanda) and had sought asylum’, she followed the Christian faith, ‘she may have been catholic and she had no family or kinship in Manchester or in the UK’, these glimpses of mother’s identity were endlessly repeated but rarely checked out. By examining the full range of multi –agency records (some of which relating to the 11 years’ mother had been in the UK) it was clear that she was from Rwanda, that she left school when she was 10 years old and was 16 when the mass genocide of the Tutsi people occurred (1994).   Practitioners were clear that Mother had strong religious beliefs and after reviewing all the records as part of this review it was established that she was an active member of a local MSCB Child H1 Serious Case Review Page 24 of 40 Christian church, as were the children. She was clearly known well by the congregation (who visited her daily whilst she was in hospital) and at times the children spoke favourably of ‘uncles, aunts and godparents’ (who were thought to be from within this community). When she was challenged about the completion of a task she would frequently say: ‘God will provide’. What mother’s beliefs meant in practice, how this manifested in her internal world and the part it played in her identity, her relationships and in the life of her children was unexplored and so not understood. Instead, assumptions were made and these assumptions found their way into assessments and plans.   (iii) How do we know it is an underlying issue and not unique to this case? During this SCR, multi-agency practitioners were asked about mother’s identity and almost without exception, little was known about her background, her cultural practices or her religious beliefs and practices. There was evident confusion about these areas and there was a distinct lack of curiosity across the professional groups as to why these questions were being asked. Gaining an understanding of a person’s self-identity did not appear to be custom and practice, was not covered within existing assessment formats, and was not seen as core business in how children are safeguarded25.   When this was explored further, beneath what appeared at first sight to be ambivalence was something more. Practitioners spoke about a fear of exercising curiosity about the cultural background of people from BME communities, there seemed to be a fear that recognising difference and diversity by asking these questions might be at best intrusive at worst perceived as racist and this had to be avoided at all costs: ‘we fear asking the question for fear of being seen as racist’. When asked how cultural diversity is understood in Manchester, the routine response was to refer to the statistical collection of data that customarily takes place on each case where boxes are ticked in a menu of demographic variables: ‘it’s about statistical collection rather than understanding how services are provided to the community, so we just tick the box…its collation and meaning is completely outside our work’.  This finding generated substantial discussion and debate amongst the Review Team, there was a strong urge to get beneath what may be inhibiting practitioners, it was strongly felt that the fears about asking the questions about identity may be about something more complex than a fear of being either intrusive or potentially insulting, and the following reasoning was put forward: ‘Understanding of personal identity is a complex issue and professionals need support and education in order to see how this benefits the holistic understanding of families. It may be that working with a culturally diverse population may have a counterintuitive effect leading to assumptions, generalisations and a degree of ignorance in terms of the correct terminology and cultural contexts’.  (iv) How prevalent and widespread is this issue? There is no local or national data that is entirely relevant to this finding. However, the data in relation to Manchester’s demographic profile26 provides some insight into the diverse nature of the Mancunian community. Of the overall population 40.7% are recorded as being                                             25 None of the recording formats specifically covers these areas, and there is no training available. 26 Manchester Migration. A Profile of Manchester’s migration patterns. Manchester City Council March 2015  MSCB Child H1 Serious Case Review Page 25 of 40 of BME identity27.  The report notes: ‘Black African group appears to have grown rapidly over the last decade from 6,655 in 2001 to 25,718 whereas Black Caribbean remains relatively unchanged. There have been many immigrants from countries such as Nigeria and Somalia, and a probable increase of northern and north-eastern African immigrants following the Arab Spring’.28   Relevant research and practice guidance promotes the need to understand the cultural identity of this community so that culturally sensitive services can be provided: ‘Grounding practice in cultural competence is one element in addressing the ‘profound issue’ of practitioners’ lack of confidence. Direct work with families whose language or culture are different can raise anxiety. Practitioners may be worried about causing offence by using the ‘wrong’ terminology or feel uncertain about questioning unfamiliar family practices. Such uncertainty can hamper critical thinking, direct observation and partnership working and undermine professional confidence’.29  (v) Why does it matter?  Valuing the pivotal place of self-identity in the day to day life of a parent and a child and in the life of a family provides an important starting place for getting beneath the surface of assessments of risk by facilitating an understanding of risk and resilience, strengths and vulnerabilities. With this as a starting point, meaningful partnerships with families can be built, engagement facilitated and services designed to meet their needs. Without such an understanding, at best ill-informed services are provided and at worst groundless assumptions can be made. Being fearful of asking curious questions about past experiences, culture and beliefs for fear of being seen as overly intrusive or, in the case of families from BME groups for fear of being seen as racist, has a significant impact on the ability of professionals to make assessments and provide services. It is an approach that seriously hampers the way children from all racial and cultural groups are safeguarded and as this finding has shown, has particular implications for children from BME groups.     Finding 4:  When professionals feel uncomfortable asking about a person’s background, culture and belief systems beyond the superficial labels used for demographic data collection, children and families’ needs may remain unmet.  Summary Individual identity is an internal model unique to us all that gives us a perception of self as an individual and social being. We are all members of numerous social groupings, but we are also distinct in our own individuality from any other member of a given group to which we belong, despite some areas of commonality. Each individual interaction between a child or parent, his or her family, relationships, social context and environment, will be processed into an individual experience. If a child or a parent’s individual identity is not understood or if assumptions are made about this identity,                                             27 This figure includes people of mixed heritage   28 A measure of caution should be applied to this data, the report notes: it is important to be aware that the Black broad ethnic group was estimated to be one of the main types of population undercounted in the 2001 Census for Manchester, so the scale of the rise in the Black African group may be misleading. 29 Confident Practice with Cultural Diversity. Research in Practice 2015 MSCB Child H1 Serious Case Review Page 26 of 40 assessments and services will be of limited value and the safeguarding of children will be compromised.  Questions for the Board   How will practitioners be supported in exploring self-identity and how can this be facilitated?  How well are faith and community groups engaged in the work of the MSCB? What can be done to promote on-going dialogue with these groups?  What is known about non- government organizations (NGO’s)? How might they support safeguarding practice in this area?   Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development?  How will MSCB be best informed of progress and consider how challenge will be provided?  How will planned improvements be integrated into the MSCB Learning and Development Plan?     MSCB Child H1 Serious Case Review Page 27 of 40 3.2.5 Finding 5: Local authority management systems are insufficiently challenging of the custom and practice of social workers not to seek or systematically record informed parental consent for section 20 accommodation, potentially leaving the support needs of parents’ unseen and making case-drift more likely.   (i) Introduction  Section 20 (s20) arrangements happen for three reasons: if a child has no person with parental responsibility for them, they are lost or have been abandoned, or the person who has been caring for them is prevented (temporarily or permanently) from providing them with suitable accommodation or care. The law “does not require’ informed consent for s20 arrangements to be lawful. Statute sets out that a local authority cannot provide s20 accommodation if someone with parental responsibility objects, and can provide an alternative. Use of s20 allows children to be placed away from the home with approved local authority foster carers, with family members or in a children’s home.  In some cases, the use of a s20 can work very well and be to the advantage of the children, parents and local authority in avoiding the unnecessary use of court processes (that can be extremely time consuming and stressful for families). However, good practice guidance that underpins the use of this statute dictates that informed consent is gained for this arrangement (both at the time of the accommodation and for the duration of the arrangement): ‘Consent must be treated as a process that continues throughout the duration of care and treatment, recognising that it may be withheld and / or withdrawn at any time’30. This finding has shown that the good practice principles for obtaining informed consent are not understood.  (ii) How did the issue manifest in this case? The children were accommodated three times under s20 during the review period. The children were initially accommodated using s20 when mother was cautioned and charged with neglect, and the house was deemed unsafe for the children to remain there. Although the mother wasn’t happy for the children to go into care she agreed, and the children remained in care for five months. During this time, she had contact with her children for one hour a week. It is unclear how consent was obtained, how much the mother understood about what she had agreed to, and how far she understood what rights she had under this arrangement. The children were accommodated a further two times during the period under review; the first was short term, when their mother was admitted into hospital for the birth of her fifth child and the second time was when mother was detained in hospital under section 2 of the Mental Health Act (1983).  (iii) How do we know it is an underlying issue and not unique to this case? During the conversations with the Case Group and Review Team as part of this SCR, they said that a s20 is commonly used in Manchester and consent by the parent (with parental responsibility) for the use of a s20 agreement is not routinely recorded. When challenged about how children’s social workers assessed whether the parent had the capacity to consent to the use of a s20 agreement, experienced social workers replied: ‘you just know’. The Review Team and Case Group said that there had been no guidance about how parental consent is recorded. It was also clear from discussions with the Case Group that there is                                             30 A guide for people who work in health and social care. OPG 603 MSCB Child H1 Serious Case Review Page 28 of 40 little management oversight or supervision of how consent is obtained from a parent under a s20 agreement.   Unlike adult social workers and health colleagues, who receive mandatory Mental Capacity Act (MCA) training, there was no formal training provided to Children’s Social Care staff. It was subsequently understood that some training has been offered since this period under review, when it has been clarified that SW’s are expected to use the expertise of colleagues in adult social care or mental health services to carry out a mental capacity assessment, but the low uptake suggests this is not an area that has been prioritised.31    (iv) How prevalent and widespread is this issue? The use of section 20 has increased steadily since 2013 is acknowledged as both a local and national issue. The number of Looked after Children in Manchester as of the 31.5.16 was 1245 of which 172 were accommodated under a s20 agreement; this equates to 13.8%.  Munby states that s20’s ‘are over used and misused’32. Recent judgements by Munby highlight failure of councils to get informed consent. Munby called ‘the misuse not just a matter of bad practice and insisted: It is wrong; it is a denial of the fundamental rights of both the parent and the child; it will no longer be tolerated; and it must stop’. Because of these concerns, Munby set out new guidance for what ‘future good practice requires’:  - Where possible, the agreement of a parent to a section 20 arrangement should be properly recorded in writing and evidenced by the parent’s signature. - The written document should be clear and precise and drafted in simple and straightforward language that a parent can readily understand. - The written document should spell out that the parent can “remove the child” from the local authority accommodation “at any time”. - The written document should not seek to impose any fetters of the parent’s right to withdraw consent. - Where the parent is not fluent in English, the written document should be translated into the parent’s own language and the parent should sign the foreign language text, adding, in the parent’s language, words to the effect that ‘I have read this document and I agree to its terms.’ (Munby 2015).33     (v) Why does it matter? In a safe system, obtaining the agreement of parents to a s20 agreement involves a rigorous process of understanding the legal principles governing this statute, appreciating the vulnerabilities of a parent and ensuring that this consent is a process of appreciative and respectful enquiry, clear recording and the subject of routine discussion and review. This can work particularly well when parents are given access to independent advocacy in order that their human rights and that of their children are independently represented. If used in this way, the arrangement can work well for the child, parent and the local authority in                                             31 Relevant training has since been provided however, it is recognised that the uptake of this training is low and there is a lack of evidence that the training is being put into practice.   32 James Munby, President of the Family Division of High Court England and Wales 33 Recently, the Court of Appeal has ruled that; in strict legal terms consent is not required for Sc20 however, the judge also made it clear     that the Munby good practice guidance should continue to be followed (Community Care 2/2/17).  MSCB Child H1 Serious Case Review Page 29 of 40 providing a short term safe environment that allows a period for a safeguarding plan to be formulated and acted on without recourse to the court system (that has the danger of creating additional stress for parent/s and can risk promoting an adversarial relationship between families and statutory services). In addition, when a parent is helped to understand why accommodation of their children might be helpful and in some cases necessary, they are more likely to engage with services in making any required changes.  However, if parental agreement to this arrangement is not firmly grounded in the principles of good practice, the use of s20 to voluntarily accommodate children could be regarded as potentially deceitful and in the absence of the legal framework in place during care proceedings can lead to drift in care planning and unnecessary delay in the child/ren’s return to parental care. Research has shown that families who are the subject of statutory intervention are often already marginalized and socially isolated, living on a low income and in poor housing. If this is compounded by parental learning difficulties, intellectual impairment, or existing mental health issues and there is limited access to independent legal advice or advocacy, the use of s20 has the potential of breaching the rights of children and families.   Finding 5. Local authority management systems are insufficiently challenging of the custom and practice of social workers not to seek or systematically record informed parental consent for s20 accommodation, potentially leaving the support needs of parent’s unseen and making case-drift more likely.   Summary  Munby has provided clear good practice guidance to Local Authorities about how informed consent by a parent, who has parental responsibility, should be gained and recorded. Despite some training around section 20 for social workers, there appears to be a perception by frontline staff that there is no clear guidance for staff working in CSC about how this good practice should be used.  There is a danger that by failing to support staff in this area, the system is failing to meet the fundamental rights of both the parent and child and inadvertently making successful engagement between family and professionals less likely.  Questions for MSCB   How will the Munby good practice guidance impact on how consent is obtained in Manchester?  How confident is the Board that practitioners and managers understand the legal principles governing how parental consent is gained?  Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development?  How will MSCB be best informed of progress and consider how challenge will be provided?  How will planned improvements be integrated into the MSCB Learning and Development Plan? MSCB Child H1 Serious Case Review Page 30 of 40 3.2.6 Finding 6.  Over-concern about the risks rather than benefits of information sharing is resulting in professionals in Manchester being unsighted as to safeguarding risks to children.    (i) How did the issue manifest in this case? There were six child protection conferences held during the review period. In line with expected practice, policy and procedure, these conferences presented an opportunity to bring the multi-agency safeguarding network together, share information, decide whether the threshold for significant harm had been reached and agree on a plan to protect the children and meet their needs. On reviewing the minutes of these conferences, gaps were observed in the information that was shared; this was particularly noticeable in the RCPCC held on 27th June 2013 when information from the nursery for two of the children and information from the school attended by the eldest child was missing. In addition, when the distribution list of the minutes was scrutinised it was noted that these vital safeguarding partners (who arguably knew the children best) were not sent minutes of the case conference. A statement made in several these conference minutes revealed the following custom and practice: “Anyone who has been invited to this meeting and sent apologies will be sent a copy of the record of the meeting”. Thus, if multi-agency professionals did not send a report and did not send their apologies, they did not receive the minutes.   (ii) How do we know it is an underlying issue and not unique to this case? Discussions with the Review Team and Case Group confirmed that in Manchester this is part of existing custom and practice; if professionals do not attend a CP case conference and do not send apologies regardless of their involvement with a child, they are not sent the minutes. The Lead Reviewers were curious about this, and during the ensuing discussions what emerged was a custom and practice that seems to have evolved in response to an organisational pressure to comply with data protection legislation; if professionals do not attend CP conferences there is no guarantee that they are still involved with a family therefore, sending the minutes to the last known address of the professional is: ‘a shot in the dark’ (the minutes could end up on the doorstep of someone who is no longer involved or worse still, at the address of someone who is not a safeguarding professional). The high turnover of staff in the various agencies and the movement of cases through the different agency systems means that it is very difficult for social workers to keep track of these changes, thus the data base is not always a reliable way of identifying who is currently involved.    Further discussions about how this may affect wider safeguarding systems, revealed that in Manchester the list of children who are the subject of CP plans is not shared with local hospitals. As a result, there is no system within the hospital databases to identify (flag) children who are suffering significant harm who present to A&E/ acute hospital settings. This means that when a child is presented to hospital, knowing that they are the subject of a CP plan/ are suffering significant harm is dependent on clinicians finding out for themselves34.                                               34 It was understood that work is currently underway to link up the local authority IT systems with hospital unscheduled care settings (A&E departments). This is planned to be implemented early in 2017 and should improve the management and information sharing within the safeguarding network - Child protection information sharing (CP-IS) between Local Authority and Central Manchester Foundation Trust. MSCB Child H1 Serious Case Review Page 31 of 40 (iii) How prevalent and widespread is this issue? No data or research could be found on this custom and practice either locally or nationally. It may well be that this specific issue about information sharing in the context of the distribution of child protection minutes, is particular to Manchester. However, the issue of whether data protection is placed at an organisationally higher value (however unintentional) than child protection is not.   Serious case reviews going back over sixty years to Denis O’Neil (1945) have identified concerns about the sharing of information. More recently in 2009, Lord Laming stressed: ‘organisational boundaries and concerns about sharing information must never be allowed to put in jeopardy the safety of a child’. In the triennial review of SCR’s published in 2016, the author’s comment: ‘Our reviews of serious case reviews spanning more than ten years suggest that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals. ……. Data protection legislation is viewed as a set of constraints limiting information sharing rather than a facilitative tool.’  (iv) Why does it matter? When multi-agency case conferences work well, information is shared in a two-way process from the child’s network to the conference and from the conference to the network (in the form of the conference minutes). This allows all those involved with the child to be clear about the risks, to know who is involved with the child, and to be clear about the CP plan and what is expected of them. Conducted in this way, they are a fundamental cornerstone in how multi-agency partners protect thousands of children every day across the country. If fears about data protection prevent the sharing of information and fetters the established child protection mechanisms- these mechanisms will be compromised and children will not be protected.      Finding 6.  Over-concern about the risks rather than benefits of information sharing is resulting in professionals in Manchester being unsighted as to safeguarding risks to children.  Summary  In Manchester, the priority given to protecting human rights to privacy is commendable. However, if this involves an arrangement where data protection is valued over and above the protection of a child a new vulnerability is created in the system.   Questions for MSCB   What support will be provided to partner agencies to address the concerns raised by this finding?  Does MSCB know whether other areas of safeguarding practice are constrained by a misinterpretation of data protection legislation and fears of data breach?  Is MSCB aware of the recent recommendation from the DfE35 ‘Local early help and safeguarding partnerships to develop a strong and coherent approach to making decisions about the balance of risk when sharing information about vulnerable                                             35 Information sharing to protect vulnerable children and families. A report from the Centre of Excellence for Information Sharing (DfE July 2016)  MSCB Child H1 Serious Case Review Page 32 of 40 children and families? ‘How might the board support services in this decision making?  Where will accountability be held for maintaining detailed monitoring and evaluation of the learning and development?  How will MSCB be best informed of progress and consider how challenge will be provided?  How will planned improvements be integrated into the MSCB Learning and Development Plan?     4. Responding to the Research Questions   4.1 Responding to the Research Questions    Not all the research questions that were agreed at the start of this review could be explored in any depth within the scope and time available.  With hindsight, they risked taking the review on too wide a journey. Rather than leave them unaddressed, the Lead Reviewers have considered them in the light of what has been learned from this case and followed each with a recommendation for the Board to consider.  4.1.1 How well do multi-agency services identify and respond to the needs of Young Carers in Manchester, in particular meeting their emotional health and well-being? During the time under review, the professionals who knew the family best identified the eldest child as a Young Carer. At the ICPCC in January 2015, it was reported that: ‘The young carers support service was considered for (name of eldest child), however it was decided that this service was not appropriate because Ms X (mother) is capable of caring for the children’; as a result, this child did not receive a service from Young Carers for the duration of agency involvement. This response by this service that was reported to the conference was surprising, it seemed that a strict criterion had been applied to how services were accessed and even though this child was clearly providing frequent care to the children in the family, she was not regarded as eligible for a service. The Lead Reviewers were told that at the time there were several third sector organisations commissioned to provide services to young people across the city: ‘How services interpreted what constituted being a ‘young carer’ seemed to be applied on an ad hoc basis rather than adhering to informed eligibility criteria’. Following the Ofsted inspection, Manchester’s Children Services introduced three Early Help Hubs across the city: ‘the aim of which is to increase the number of Early Help Assessments and identify the service interventions that a family or young person needs’. There is also work underway to determine how many young carers there are across the city: ‘the age of children caring for adults is falling with some as young as 8 being identified’.  School nurses are an important source of identifying young carers, but in the last 16 months the number of school nurses has been significantly reduced (40%). Alongside this reduction MSCB Child H1 Serious Case Review Page 33 of 40 of school nurses, is a change in the service model with a focus now on: ‘delivering the healthy child programme and immunisation programme within schools’. The impact is that there is very little capacity within the school nurse service to undertake any additional or bespoke pieces of work that they would have historically undertaken, and this includes young carers.    This remains an important area of service provision, the MSCB are advised to continue to monitor and take steps to enable young carers to receive the support they need.  4.1.2 How well do multi-agency partners recognise assess and respond to risk across services with particular reference to males in households, mobile isolated families, immigration status and BME? The issues in relation to assessment and care planning for children and families from within the BME community have been discussed in finding 4. No direct reference has been made to ‘mobile isolated families and immigration status’ within this report. Several the findings contain relevant issues (in particular, Finding 4). However, addressing these issues in detail was not possible within the scope of this review.  In the appraisal of practice, the absence of any checks as to whether the father of the three younger children posed any risk to the family or whether he was supportive and provided stability was discussed. A decision was taken not to have a finding about this, as previous SCR’s in Manchester have identified this as a practice issue requiring improvement. This case suggests that this remains an area for learning and development within multi-agency services. Manchester is not alone in this, the triennial review of SCR’s in March 2016 makes the following recommendation: ‘Efforts must be made to increase the visibility of fathers in practice, policy and research around neglect. Too often mothers are the focus; this can mean that the risks and protective factors that fathers bring to a child’s life may be missed. Local service leaders can enable this through policy review and practice audits.’    It is recommended that the MSCB review previous learning and development plans that have attempted to improve practice in this area, and consider what more needs to be done.    4.1.3 How well is the learning from SCRs implemented on the front line? As outlined above, this case has suggested that the learning in relation to the involvement of fathers has not been implemented on the front line. In addition, the last three SCRs published by MCSB identified similar areas that are found in this case; neglect, history of mental health difficulties and poor engagement with professionals.  Two recent SCRs have covered the same timeframe as this review therefore any learning from these cases would not be reflected in practice.    In terms of poor engagement, professionals dealing with families who are not engaged with services often describe them as ‘hard to reach’ or ‘difficult to engage’ and as seen in this case there is a tendency to close the service rather than explore the reasons behind the MSCB Child H1 Serious Case Review Page 34 of 40 non-engagement. To employ appropriate support and challenge parents when non- engagement or disguised compliance occurs, professionals need to be supported through adequate supervision, training and management oversight. This was identified as an area requiring improvement in the Ofsted inspection.   It is recommended that the MSCB reviews how the learning and development from SCRs is implemented on the front line of service provision.    4.2 Additional Learning: Involvement of GP’s with SCRs and communication pathways within Primary and Community Care 4.2.1 Involvement of GPs  Whilst undertaking the SCR, the lead reviewers were struck by the absence of the services provided by the GP practice in the SCR process. General Practice was not included in the MSCB combined agency report and they were not invited to be part of this SCR. Therefore, the information held by the practice and relationship that the GPs had with the family (in particular with mother) was not known about until relatively late in the process. This issue was highlighted in a previous SCR in Manchester and the Ofsted Inspection (2014) identified that there was a ‘lack of communication within primary care and community services and that this was present in recent completed SCRs in Manchester’.    It is understood that this has now been rectified and General Practice is now considered during the commissioning process for SCRs; the MSCB are invited to monitor this new development.   4.2.2 Communication pathways within Primary and Community Care In 2015, the Citywide Clinical Commissioning Group introduced the Primary Care Link Nurse Programme and part of their agenda was to: ‘strengthen and improve communication between HV’s and GPs’. At each practice visit, the level of contact each GP received from the allocated health visitor was recorded. This piece of work identified that there is still much work to be done on improving communication, only 15% of GPs across Manchester recorded that they have regular and good contact with the allocated health visitor; which would suggest the 85% of GPs did not. It is clear that health visitors and general practitioners need to strengthen their working relationship to improve outcomes for children and families.    The MSCB to review how communication can be improved between Primary and Community Care to further strengthen safeguarding and to consider how best to engage with Public Health (who are responsible for commissioning health visiting and school nursing) to embed improvements in service delivery.    MSCB Child H1 Serious Case Review Page 35 of 40 5 Conclusion  This systems review has had two principal aims: to report and learn from what happened in a case and why, and to consider what this tells us about the wider safeguarding of children in Manchester and how this might be improved.  Overall the review has highlighted the complexity of working long-term with a mother and her five children, who had been voluntarily accommodated by the local authority and subject to child protection plans for neglect, stepped down, and then the cycle repeating itself.  The findings have focused on the learning for Manchester which will improve the multi-agency response to working with children and families, in particular, with families who are perceived as ‘difficult to engage’ and where there is a long history of poor parenting and neglect.  The contents of this report have been the product of the Review Team and Case Group who contributed their knowledge and experience in relation to this case, as well as their wider understanding of how safeguarding systems operate in Manchester.    MSCB Child H1 Serious Case Review Page 36 of 40 Appendix 1 Methodology  This review was conducted using SCIE’s Learning Together methodology (Fish, Munro & Bairstow; SCIE 2008). Learning Together is a systems approach, which seeks to understand professional practice in context. Learning Together reviewers work collaboratively with practitioners and leaders to identify the factors in the system that influence the nature and quality of work with families, using the issues highlighted in the case under review as the primary evidence base. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively.  The methodology is based upon several key principles:  • Avoid hindsight bias: in order to understand why people acted as they did, it is Important to avoid the wisdom of hindsight; the tendency to judge actions from the standpoint of knowing what happened later, when it is easier to see which bits of information were significant and which were irrelevant. • Provide adequate explanations: appraise and explain decisions, actions and inactions in the professional handling of the case, by seeing performance as the result of interactions between the context and what the individual brings to it. • Move from individual instance to the general significance: use a single case to provide a ‘window on the system’ in Manchester, finding out whether weaknesses or strengths in its management are widespread, and so leading to a broader understanding about what supports and what hinders the reliability of the multi- agency child protection system. • Produce findings and questions for the LSCB to consider: Some findings lead to the simple recommendation of a new rule or way of doing something, but others require LSCBs to consider how to balance identified needs with other demands on agencies’ resources. • Analytical rigour: use of qualitative research techniques to underpin rigour and reliability and a very open process so that others can see how conclusions were reached. Data comes from structured conversations with involved professionals, case files and contextual documentation from organisations.  These principles are supported by a suite of SCIE’s analytic tools. One such tool is a typology to help identify which aspect of the child protection system the findings are located within and thereby make it easier to know where to focus solutions. SCIE has developed a typology of 6 broad categories, each of which relate to a different (although linked) aspect of the work and within which it is common to find patterns of practice or behaviour that are systemic:   Multi-agency working in response to incidents and crises  Multi-agency working in longer term work  Human reasoning: cognitive and emotional biases  Family – Professional interaction  Tools  Management systems.   MSCB Child H1 Serious Case Review Page 37 of 40 6.1 Findings: are structured to present a transparent and evidence based account of how the practice issue features in the particular case; in what way, it is an underlying issue – not a quirk of the particular individuals involved and in the particular constellation of one case; how widespread a problem it is perceived to be and/or data about its prevalence both locally and nationally. Finally, each Finding addresses the consequence of not doing anything about it, or why it matters in the context of multi-agency child protection work.  6.2 Organisational learning & improvement: The Findings of Learning Together reviews require debate. They highlight relevant points for LSCBs to consider when deciding upon the most appropriate course of action for local circumstance and do not tend to prescribe specific recommendations at the point of delivery. Considerable learning will have been generated for practitioners and managers as a consequence of their involvement in the review process. The discussions that take place following the completion of a review build upon this and enable the creation of a development plan going forward that is fully owned by the Board and its member agencies.  6.3 Reviewing expertise and independence: Two independent lead reviewers have led the SCR. Ann Duncan and Bridget Griffin have had significant experience of leading SCR’s and are both accredited by SCIE.  Neither has any previous involvement with this case, or any previous or current relationship with Manchester Council or partner agencies. The lead reviewers have received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence.   6.5 The Review Team: The Review Team was made up of senior managers from the agencies involved in the case, who themselves had no direct part in it. Led by the independent Lead Reviewers, they worked as a Panel throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They were also a source of data in themselves, about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure etc.  The Review Team met on six occasions over the course of the review. The Review Team were:  Detective Chief Inspector, Greater Manchester Police  Head of Contact and Referral, Children Social Care  Designated Doctor for Safeguarding Children, CCG.  Designated Nurse for Safeguarding Children, Manchester North, Central and South CCG’s  Named Nurse for Safeguarding Children, Central Manchester University Hospitals   Named Nurse for Safeguarding Children, Manchester Mental Health and Social Care Trust  Locality Manager, Early Help Hub  Education Case Worker  Children’s Social Care.  Supported by:  MSB Interim Business Manager  MSB Co-ordinator  MSB Business Support Officer.  MSCB Child H1 Serious Case Review Page 38 of 40 6.6 Sources of data: Practitioners who were involved with the case at the time formed a ‘Case Group’. Their experiences were captured through individual conversations with Lead Reviewer and members of the Review Team. We held 14 conversations in order to build the base evidence for this review. In addition, the Case Group met on two other occasions- this allowed the Review Team to check factual accuracy, clarify any issues and build on the analysis in the review and findings.   Unfortunately, the attendance at the second Case Group meeting was low (due to sickness and annual leave) and other practitioners attended who hadn’t been at the first. This made it difficult to build any momentum as time was taken up with explanations and discussion as to how we had arrived at the emerging findings.   The Case Group was made up of:  3 Health Visitors Mental Health Ward Manager 2 Child Protection Chairs Pastoral Care Secondary School 2 Social Workers CSC Social Work Manager Head teacher Families First practitioner CIN Team manager Families First Manager CIN worker Nursery teacher School Nurse Mental Health Practitioner In addition to the Case Group members a conversation was held with the family GP but was not included in the Case Group.  6.7 Data from documentation: The Lead Reviewers and members of the Review Team reviewed documentation from a range of sources and agencies including but not exclusive to: integrated chronology, child protection case conference minutes, looked after review minutes, multi- agency reports to case conferences, care plans, case recordings from specific agencies, service specifications and performance management data.    MSCB Child H1 Serious Case Review Page 39 of 40 Appendix 2: References Manchester Migration. A Profile of Manchester’s migration patterns (MCC - March 2015)  Manchester City Council (MCC) Ofsted Inspection Report (Ofsted: September 2014)  Greater Manchester Safeguarding Children Procedures (MCC – updated November 2016)  Greater Manchester Children’s Service – Signs of Safety (June 2016) – Post Ofsted Improvement Plan   Ten pitfalls and how to avoid them. What research tells us (Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln - September 2010 www.nspcc.org.ukinform)  Assessing Children in need and their families: Practice Guidance (DOH 2000).  Confident Practice with Cultural Diversity (Research in Practice 2015).  Research Briefing: Neglect (NSPCC 2012)  Working Together to Safeguard Children, A guide to inter-agency working to Safeguard and promote the welfare of Children (HM Government, 2015).  Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 – 2014 (DfE 2016).  Safeguarding children and Young People. The RCGP / NSPCC Safeguarding Toolkit for General Practice. Dr Vimal Tiwari and Dr Matthew Hoghton (2014  Making decisions, A guide for people who work in health and social care. OPG 603 2009 (4th edition)  Your child, your school, our future: building a 21st century school system (DfE –2009)  Saving money by doing the right thing - Why ‘local by default’ must replace ‘diseconomies of scale’ (Locality in partnership with Professor John Seldon - Vanguard Consulting- March 2014).  Information sharing to protect vulnerable children and families. A report from the Centre of Excellence for Information Sharing (DfE July 2016).  Manchester’s Early Help Strategy 2015 – 2018  Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Marion Brandon, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lustey & Harriet Ward – Childhood Wellbeing Research Centre (Nov 2014)  MSCB Child H1 Serious Case Review Page 40 of 40 Appendix 3: Acronyms and Terminology   CAFA Child and Family Assessment CAMHS Child and Adolescent Mental Health Services CG Case Group CIN Child in Need CINIS Child in Need Intervention Service CPP Child Protection Plan EPO Emergency Protection Order GP General Practice / Family Doctor HV Health Visitor ICPC Initial Child Protection Conference LA Local Authority LAC Looked After Children MASH Multi-agency Safeguarding Hub MCA Mental Capacity Act MCSC Manchester Children Social Care MSCB Manchester Safeguarding Children Board PLO Public Law Outline PPO Police Protection Order PPP Police Protection Power RT Review Team SAR Safeguarding Adult Review SCIE Social Care Institute of Excellence SCR Serious Case Review SW Social Worker WTE Whole Time Equivalent  