Death of a 24 week old baby at the hands of his father. Issues around parental mental health, parental substance misuse and family violence. Serious case review undertaken using the SCIE systems methodology. The report contains 10 findings covering issues around: optimistic thinking from professionals; the focus on the child; assessment of men in the family; over-reliance on self-reporting from parents; the need to challenge colleagues and other agencies; the importance of timely pre-birth assessments; the importance of taking into account parental history; assessments as a dynamic process that take into account new information and re-assess the risk to the child. The report includes a response from the LSCB on the findings from the review and details of action being undertaken and planned.
      
 Title:  Serious case review: Baby J LSCB: Lancashire Safeguarding Children Board Author: Alan Bedford and Jane Wiffin Date of publication: 2012  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.                           1                                       SERIOUS CASE REVIEW   Baby J  For the Lancashire Safeguarding Children Board   April 2012    Redacted to protect family anonymity        2  INDEX Chapter  Page 1 Introduction 4  Why was this case chosen for the review   Purpose   Family Members   Case Summary 5  Methodology   The Review Team   The Case Group 6  Family Member Involvement   Structure of  the Review Process 7  Parameters and Mandate   Sources of Data   Methodological comment and limitations   Structure of  the Report 8    2 Appraisal of Professional Practice in this case—Synopsis 9    3 Introducing the Findings: What light has the review shed on our ability to keep children safe? 12 4 The Specific Findings 13  Innate Human Biases 14  Finding 1   The lack of recognition in professional practice of the potential for unfounded optimism in work with families with a history of parenting failures makes child-focused decision making unlikely.    Family Professional Interaction 20  Finding 2 The inadequate assessment of the role of fathers, in high risk cases allows judgements to be uninformed or insufficiently deep   Finding 3   An overreliance on self-report from parents and a lack of challenge to them, leaves risks to children inadequately ascertained 23  Longer Term Work 24  Finding 4  Interagency and intra professional relationships that lack challenge minimise the safeguards that working together is aimed to achieve   Finding 5   Professionals need a good 28    3  understanding of the impact of domestic abuse, parental substance misuse and parental mental ill health to provide an effective safeguarding service.  Management Systems 32  Finding 6   Pre-birth assessments that are started at predetermined points are not sensitive to risk in particular cases and can lose valuable time in assessing and planning.   Finding 7   An acceptance of poor quality assessments makes timely and appropriate help for families unlikely and can undermine child safety and well-being. 35  Finding 8   Providing family support and child protection as separate services, with distinct management and supervision arrangements, creates obstacles to responsiveness to families evolving situations, and runs the risk that complex cases are left with staff who are insufficiently skilled and experienced. 40  Response to Incidents 44  Finding 9  Acceptance of delays and lack of substance in response to incidents, in part related to predetermining the risk in Child in Need cases, can lead to crises and escalations being poorly evaluated   Tools 47  Finding 10  Using the same meeting category on the ICT system for more than one type of meeting creates confusion and misunderstandings  5 Summary of Recent Changes 49     Appendix 1  References 52  Appendix  2 Case Review Group 54  Appendix  3 Types of Documents Examined 55    6 LSCB Response  56     4  CHAPTER 1    INTRODUCTION  1.1 Why was this case chosen to be reviewed?  The review was initiated as a result of the sad death of Baby J at age 24 weeks.   1.2 The statutory guidance “Working Together to Safeguard Children” (HM Government, 2010), says that when a child dies ….and abuse or neglect is known or suspected to be a factor in the death, the Local Safeguarding Children Board (LSCB) should always conduct a serious case review (SCR) into the involvement of organisations and professionals in the lives of the child and family. The LSCB is the commissioner and owner of this report.  1.3 Redaction: This report is in redacted form, in line with the national guidance that SCRs are „appropriately redacted and anonymised to protect the privacy of vulnerable children and their families‟.  The LSCB believes that in this case there are „compelling reasons‟ to limit some detail about the family.  1.4 The purpose of such reviews is:  establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children;    identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;   and improve intra- and inter-agency working and better safeguard and promote the welfare of children.  1.4    This case uses the SCIE systems methodology (Fish, Munro & Bairstow 2008). In a systems review, the key purpose is to look at professional practice, rather than what happened in the case itself. In this Review, it was the professional practice in one District within the County concerned, although as some of the staff covered a broader area there may be some wider implications to be considered.  1.5    Family Members:  In this report the following titles are used:  Mother:   Baby J‟s mother  Father:   Baby J‟s father Baby J, or J:   child of mother and father and subject of the review             (The mother has other children who were adopted)        5  1.6 Case Summary:          This case involves professional efforts to support a mother and her new partner in their parenting of Baby J, against a background of mother having previous children subject to care proceedings because of neglect (one removed close to birth) and later adopted, a long history of drug and alcohol misuse in her adult life, poor mental health and an extensive criminal history.  Professionals knew little about the background of the father who later killed J, except that he was a relatively recent partner who did not have a history of drug use. The agencies involved during the pregnancy and birth included probation, drug and alcohol services, Children‟s Social Care, and a substance misuse midwife.   1.7 After Baby J‟s birth, the home situation was marked by a number of domestic disputes and violence between father and mother (some pre-birth) and then mother‟s increasing problems with alcohol. The extended family were involved at times of crises, but this was not recognised by those working with the family.   1.8 Methodology:  This SCR used the SCIE systems methodology, by a special dispensation from the Department of Education as a pilot. The dispensation allowed some changes from  the rules set out in “Working Together  2010”, for example  the requirement  for agencies to prepare individual management reviews (IMRs), and for the LSCB SCR Panel to oversee the preparation of  the SCR. The latter is because the Review Team (see para1.10) conducts some similar functions.  1.9    The focus of a case review using a systems approach is on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the deeper, underlying issues that are influencing practice more generally. It is these generic patterns that count as „findings‟ or „lessons‟ from a case, and changing them will contribute to improving practice more widely. Data comes from structured conversations with the involved professionals, case files and contextual documentation from organisations.  A fundamental part of the approach is to talk with staff to understand what they thought and felt at the time they were involved in the case, avoiding hindsight as much as possible. It is vital to try and make sense of what factors contributed to their understanding at the time and to the decisions they made. This is known as „local rationality‟. Any appraisal of practice is then made in the context of those contributory factors.   1.10    The Review Team:  Under the leadership of two reviewers trained by the Social Care Institute for Excellence (SCIE), the review was conducted by a team of senior representatives from local agencies who had had no direct dealings with the case. They shared in the conversations, the analysis of documents, the identification of key practice episodes and contributory factors. This report is the shared responsibility of the Review Team in terms of analysis and conclusions, but was written by the joint    6  lead reviewers.   Name Job Title Organisation Alan Bedford  Lead Reviewer Independent reviewer Jane Wiffin Lead Reviewer Independent reviewer  Directorate Safeguarding Manager Lancashire Children's Social Care  District Manager  Lancashire Children's Social Care  Review Officer Lancashire Constabulary  Det. Inspector Lancashire Constabulary  Associate Director Safeguarding NHS Lancashire  Consultant Paediatrician Acute Hospitals Trust  Safeguarding Lead Nurse Lancashire Care Foundation Trust – Mental Health  Safeguarding Officer Early Years, Lancashire County Council  Senior Probation Officer Lancashire Probation Trust  Assistant Director, Alcohol and Drugs Directorate  Greater Manchester West, Mental Health NHS Foundation Trust  Chief Executive Domestic Violence Service  Head of Safeguarding  County 2  1.11  The Case Group:  The members of the Case Group are the staff who worked with or made decisions about the family, and who had individual conversations with members of the Review Team. The Case Group comprised of over 30 people. They were collectively briefed on the methodology and then met with the Review Team for two further sessions to share in the analysis, the identification of contributory factors, and to comment and contribute to the final report. This degree of participation by all those in the case is new to SCRs.  1.12  Family Member Involvement:  A number of family members were willing to have a conversation with Review Team members. Contact with them was very helpfully facilitated by a Police Review Team member and a family liaison officer. Those seen included the mother, her parents, father‟s mother and sister, and one adoptive mother.      7  1.13 Structure of the Review Process:  The Review Team met on 9 occasions, including three times with the Case Group, and worked on the information from conversations as it was refined into a „professionals‟ story‟, key practice episodes and the contributory factors, and then into key learning points. These formed the working out process towards the identification of key learning points and issues for LSCB consideration. This means that local agencies understand, for their own learning, more than is in this redacted version. The process took from November 2011 to March 2012.  1.14 Parameters and Mandate:  Although some historical information was relevant, the time period, the review appraised was from June 2010  until September 2011. The methodology does not require formal terms of reference so that the review can follow whatever emerges from documents and conversations, and what was important for professional and the family at the time.   1.15  The Review did liaise with the County 2 where an adopted child lived.  1.16 Sources of data:    The semi-structured conversations between members of the Review Team and over 30 members of the Case Group. The roles of those on the Case Group are listed in appendix 2. Also the conversations with family;   Documentation:  All necessary documentation was made available to the review ranging from case files, procedures, legal files (with client permission) and police attendance records;  The  types of documentation are listed in appendix 3;  No significant documents were unavailable to the review.  1.17 Methodological comment and limitations: As the first SCIE systems methodology SCR, the process will be subject to a range of evaluations on completion. As a preliminary test (although still a statutory SCR) of how the method works in cases that meet the SCR criteria, there is an expectation that any difficulties faced in the process will be reflected on and learnt from for the future. The test conditions themselves created some draw backs, namely the main part of the work involving the Case Group and Review Team was limited to 4.5 months to meet the original deadline. Of that, the majority was taken with gaining an in depth understanding of what happened and why in the particular case, actively involving the Case Group in the process. This left less than adequate time to explore with the staff involved, as much as we would have liked, the extent to which the practice issues within this case represented more extensive systemic patterns. The LSCB will form a view on this as part of their response.    8  1.18 The area studied in this report was one District within the County. There should be no automatic assumption that any appraisal or finding relates to any other District, although some of the services involved are County wide or beyond. 1.19 Structure of the Report:  The Report that follows begins with an explanation of the method used to organise   the Review Team‟s thinking into Findings. There is a Synopsis of the professionals‟ response to the case summarising key Review Team‟s appraisal, and then ten Findings. Each specific Finding that then follows have matters for the LSCB to consider SCIE reviews do not have recommendations, but issues and questions for the LSCB to consider as it prioritises responses. There is a Summary of Recent Changes achieved by the end of the SCR process, which are also referred to briefly at the ending of each Finding where relevant.  The responses from the two LSCBs are contained in a separate document,  in a format described in Chapter 6.   1.20 References are to be found in appendix 1                       9  CHAPTER 2: APPRAISAL OF PROFESSIONAL PRACTICE IN THIS CASE -SYNOPSIS  The appraisal relates largely to what was seen in one part of the County, but the LSCB is invited to consider to extent to which the appraisal might apply in other areas. The appraisal relates to professional practice rather than the outcome of the case. 2.1    Following the „Case Summary‟ in 1.6, this synopsis looks at how the case leads to a number of findings about local systems and their influence on professional practice. The LSCB, and the staff in member organisations, should be congratulated for participating in this methodology that throws up challenging issues, both for individuals who were so open with the Review Team in helping understand why they acted as they did, and for organisations who hold overall responsibility. It is through this openness and willingness to consider the systemic implications in the findings that improvement can be made. This report centres on the professional response to the case, rather than the case itself. If we are to improve safeguarding practice it is essential that we learn systemic lessons rather than focus on individual practice. This can be more challenging for organisations than a focus on individual responsibility.  2.2 The case review has at its heart a series of conundrums, which start at 2.6 below. Reviewing cases after the event often throws up professional actions and decisions that seem, with the benefit of hindsight, hard to explain, or inexplicable. This can be dispiriting for professionals and agencies who intend to do a good job.  Looking at the systemic context can cast light on not just what happened but why it happened.  2.3   There were a consistent group of workers who tried hard to be supportive and give advice, and many were persistent in difficult circumstances. However, their efforts were not always child focussed and did not have a positive impact on the parents‟ deteriorating personal circumstances, and in general terms their approach did not change, or address worrying events occurring in the family.   2.4    The Review confirmed what was already known, internally and to external inspection, about the fragility at the time of Children‟s Social Care in the District concerned. This was characterised by instability at team leader level, a need to re-establish thorough supervision processes, the capacity to carry out good quality assessments, and delays in recording. These issues had begun to be addressed at the time of the death of Baby J, but this did not impact on the quality of decision making and staff support in this case.  2.5    The professionals did not recognise that doing more of the same was not helping over time. They (professionals)  seemed blinkered  by their hope that this mother, whom they liked, would succeed this time, be a good enough parent, and improve her life, alongside her hoping to  regain a role with one  of her  adopted children. This contrast between effort and impact can be summarised through the four conundrums below.    10   2.6   The first conundrum is, how was it considered possible, without challenge, that these parents would be able to meet the needs of a new baby? There were historical concerns about the mother's seriously neglectful parenting which led to the removal of three children and their adoption. She had experienced mental health problems, a heroin addiction maintained until 4 months before the baby‟s birth, and there was a new partner about whom there were concerns of controlling behaviour. This was in the context of no multiagency pre-birth meeting to assess the risks, and led to the baby being managed as a 'Child in Need' without consideration of child protection processes. There was also a lack of consideration of the role that the extended family could have played, if they had ever been contacted or considered as part of a potentially protective network.  2.7    Secondly, despite growing evidence of a number of risk factors which were likely to impact negatively on a young baby (including 9  post birth domestic abuse incidents attended by the police, physical tussles over the baby, mutual allegations of violence, both parents arrested during disputes, and evidence of the mother‟s increased misuse of alcohol) it is hard to understand why the case was not subject to any child protection inquiry (section 47), or any comprehensive multiagency meeting or review.  2.8     How was it also that, despite that evidence, no agency either queried decisions made in the management of the case or whether appropriate processes were followed? No agency understood or exercised their right to call a case conference, or even suggest meeting informally to share views about the continuing and increasing family unrest. This was despite the existence of evidence that would normally lead to such questioning or meeting to share information.  2.9    The final conundrum relates to mother‟s being in touch with one birth child who was removed from her care when she was a toddler. No one took a critical approach to the renewed contact between the two. Why were no arrangements made to monitor the adopted child‟s connection with her birth mother, or to keep her adoptive (and legal) parents informed? This was despite a growing number of domestic incidents.   2.10   Surrounding these puzzling features were other areas of practice that the Review Team judged as problematic. The detail is used to illustrate the Findings that follow, but in summary, the Review found that the core assessment, which was intended to assess the parents‟ ability to look after a baby, was seriously flawed, and had insufficient multiagency involvement and challenge.  This led, in part, to J being assessed as a „Child In Need‟ and there being confusion about who was leading the case, at times being a joint role between a Social Worker and a family support Worker, and with short notice it becoming the sole responsibility of the family support worker. This led to confusion about case and management accountability.     11  2.11 Professionals developed a pattern of working relationships which were characterised by optimism and a belief in permanent and enduring change, despite growing evidence to the contrary. This led to insufficient attention and speed of response to domestic incidents, and the impact on a very young baby of the chaos in the family seems to have been lost.  The unchanging optimistic approach was seen by all agencies which shows that this is not a simple matter of individual error but something needing a systemic approach to guard against it.  2.12 The systems approach leads to caution about any conclusion as to whether an incident was predictable or preventable – hence it is not attempted in relation to Baby J‟s murder. What is clear from this review of professional practice is that Baby J was not adequately safeguarded given what was known and knowable at the time about his parents‟ situation as it developed. The appraisal of the Review Team would still have held even if the tragedy of his death had not occurred as it did. We have to look at the way in which professional decisions were made regardless of the long term outcome, because the causal links are not possible to pin down with certainty. In this case, the decisions were poor and the outcome was poor, but that does not imply a causal link.  2.13 We go on in our Findings to describe the underlying patterns of working identified through this case. In many ways this case is a unique tragedy for those involved. Yet having to work with parents expecting and having another child after having previous children removed is a not uncommon experience for professionals. Reviewing this case in detail therefore has provided an invaluable opportunity to shed light on what are problematic areas, so we might better keep children safe.                12  CHAPTER 3: INTRODUCTION TO THE FINDINGS What light has this case reviews shed on the reliability of our systems to keep children safe? 3.1 A case review plays an important part in efforts to achieve a safer child protection system, one that is more effective in its efforts to safeguard and protect children. Consequently, it is necessary to understand what happened and why in the particular case, and go further to reflect on what this reveals about underlying gaps and inadequacies in the child welfare system that may reappear in other cases. The particular case acts as „a window on the system‟ and so the findings need to say something about the LSCB area/agencies and their usual patterns of working. They exist in the present and potentially impact in the future. 3.2   The systems model that SCIE has developed includes 6 broad categories of these underlying patterns.  The ordering of these in any analysis is not set in stone and will shift according to which is felt to be most fundamental for systemic change:  Innate human biases   Family-professional interaction  Longer term work  Management systems  Response to incidents  Tools 3.3  There is a brief explanation of the meaning of these headings at the start of each Finding. Each category may have many subcategories and it is the subcategories that are elaborated in this report. There is, of course, overlap between categories.        3.4  The Findings start by looking at how the issue manifested itself in the case, and attempts as far as possible to say in what way it is an underlying issue, and what the review has gleaned from those involved about its prevalence. They end by summarising the issue and raise questions for LSCB consideration.      13  CHAPTER 4: SPECIFIC FINDINGS Innate Human Biases  Finding 1:  The lack of recognition in professional practice of the potential for unfounded optimism in work with families with a history of parenting failures, makes child-focused decision making unlikely.  Family – Professional Interaction Finding 2: Inadequate assessment of the role of fathers in high risk cases allows judgements to be uninformed or insufficiently deep. Finding 3: An overreliance on self-report from parents and a lack of challenge to them, leaves risks to children inadequately ascertained. Longer Term Work Finding 4: Interagency and intra professional relationships that lack challenge minimise the safeguards that working together is aimed to achieve.  Finding 5:  Insufficient understanding of the nature and impact of domestic abuse, parental substance misuse, and parental mental ill health makes child-focused decision making unlikely. Management Systems Finding 6: Pre-birth assessments that are started at predetermined points are not sensitive to risk in particular cases, and can lose valuable time in assessing and planning. Finding 7: An acceptance of poor quality assessment makes timely and appropriate help for families unlikely, and can undermine child safety and well-being. Finding 8: Providing family support and child protection as separate services, with distinct management and supervision arrangements, creates obstacles to responsiveness to families evolving situations, and runs the risk that complex cases are left with staff that are insufficiently skilled and experienced. Response to Incidents Finding 9: Acceptance of slow and insufficient response to incidents, in part related to predetermining the risk in Child in Need cases, can lead to crises and escalations being poorly evaluated. Tools Finding 10:  Using the same meeting category on the ICT system for more than one type of meeting creates confusion and misunderstandings    14  INNATE HUMAN BIASES Are there common errors of human reasoning and judgement that are not being picked up through current case management processes?  Finding One: The lack of recognition in professional practice of the potential for unfounded optimism in work with families, with a history of parenting failures, makes child-focused decision making unlikely.   4.1.1 A key finding from this case is the extent to which professionals developed a pattern of working relationships which were characterised by optimism and a belief in permanent and enduring change, despite growing evidence to the contrary. This led to insufficient attention and speed of response to domestic incidents, and the impact on a very young baby of the chaos in the family seems to have been lost. The unchanging optimistic approach was seen by all agencies which shows that this is not a simple matter of individual error but something needing a systemic approach to guard against it. The picture with father is more complicated. There were early positive views about his role in mother‟s life, he was considered to be a protective factor because he did not use drugs. However, concerns about his controlling behaviour were not acted upon, and evidence of issues about his mental health went unacknowledged. The view of father did change over time, and this is covered in Finding 2.  4.1.2  Research (Burton 2009) suggests that the human brain struggles to make sense of contradictory data, and the more incremental it is, the harder it is make sense of that data.  Coupled with the importance of making relationships with parents, and the emotional component of the task, human errors in reasoning are considerably more likely. In this case, this was manifest in three ways:  A rule of optimism  Failure to revise judgements  Overlooking the lessons of history  4.1.3 These are dealt with together in one large finding as these tendencies are often inter related, and for staff working with complex families they can all be at play at the same time. Threads of this are seen in most Findings. The rule of optimism 4.1.4 The Rule of Optimism has been recognised as a critical element in a number of serious case reviews (Burton 2009) and refers to the process of rationalising any evidence that contradicts a professionals view of progress. This was apparent in this case. All professionals were optimistic about mother and her ability to change, despite evidence to the contrary.  The core assessment was strongly influenced by the engagement of mother and father. They were willing to take part, and engaged in a    15  way that was seen as open and honest. This was not considered at the time to be a version of “disguised compliance” (Reder, P, Duncan, S and Gray, M, 1993) where parents engage fully, but there is no evidence of change. The parents attended nearly all meetings and passively agreed about concerns raised, but this was in the context of a deteriorating situation, and their reassurances that they could manage the difficulties they were experiencing were believed. Contradictions in what was said at that time were never questioned, which was important as parents may try to 'control' the information that is known and shared.  4.1.5 This optimism influenced the approach towards domestic abuse and the increasing levels of incidents. Each one was treated in isolation and was explained away by the couple, and the professionals uncritically believed that this meant they were addressing the issues raised. The fact that this was not effective, the gaps between incidents got smaller, and mother‟s drinking got more problematic, did not influence thinking.   4.1.6 This was an issue for all professionals. The fact that it was so widespread suggests that this is a systemic issue, not simply one of individual error. It highlights the critical importance of supervision by reflective and critical supervisors so that these „human biases‟ can be identified and addressed.  Failure to revise judgements 4.1.8 Munro has highlighted that one of the most common problematic tendencies in human cognition is the failure to review and revise judgements and plans once we have formed a fixed view. “The single most pervasive bias in human reasoning is that people like to hold on to their beliefs” Munro (2008: p137) 4.1.9 There is considerable evidence from research (Burton 2009) SCRs (Brandon et al 2008, Dale et al 2002; Reder and Duncan 2004;) that fixed views are influential in decision making about a child or young person‟s circumstances. Professionals were found to have disregarded, dismissed or ignored contradictory information including parental behaviour if it did not confirm their original view of the family circumstances. This natural human tendency needs addressing through critical reflection and challenge, using supervision, management oversight and challenge from the multi-agency perspective. None of these conditions were consistently present during the period that professionals worked with Baby J and his family.  4.1.10 In this case, a fixed view permeated all decision making with regard to Baby J and his family. The increasing number of domestic abuse incidents did not cause any professionals to think that a different approach was necessary or a reassessment was warranted. When the police reported mother‟s chaotic drinking and father made    16  allegations of alcohol and drug misuse, this led to no new appraisal or action. There was no sense that any professional working with mother understood that she had an escalating problem in managing her alcohol use, and was starting to use other substances, because this did not fit with the notion that “she was drug free” a quote which appeared in much of the paperwork.  There was a substance misuse professional working with mother, but she was not consistently invited to any Child in Need reviews and attended none, and did not know of the increased levels of alcohol misuse.   4.1.11 Mother was open about being in touch with one adopted child and she told professionals that she would take this slowly because she wanted to concentrate on proving that she could be a good parent to Baby J. This led to a fixed understanding that mother was taking a mature and child focussed approach to this issue, and this view never changed significantly, despite evidence to the contrary The father (see Finding 2) did try and alert professionals to his concerns about mother‟s drinking– but because of fixed views about him as the aggressor in domestic disputes, these allegations were never taken seriously, and County 2 were not informed of his worries.   4.1.12 As with optimism, the tendency to retaining fixed views crossed agency boundaries and was not identified or challenged in supervision across any of the agencies.             Overlooking the lessons of history  4.1.13  Evidence from SCRs (Brandon et al 2008) and research suggest that history is an important part of assessing current and future parenting capacity, and should be considered as a potential risk factor. It is apparent that “the past is the best predictor of the future” (Reder and Duncan 1999).   4.1.14  In this case, knowledge about the extensive history appears to have operated in the opposite way. Professionals were impressed with mother‟s commitment to make changes, despite her past and those changes were considered to be dramatic in nature, despite them being of short duration. This was seen as mother‟s fight against adversity. There was a lack of critical analysis of the evidence from history, and the short term nature of encouraging progress.  4.1.15 The specific reasons for three prior removals of her children were not well known therefore could not influence an analysis of whether her past difficulties with parenting might impact on the present. The removal of mother‟s children because of her neglect of their care became characterised as her “losing her children to the care system”. This manner of describing previous parenting history was manifest in many of the records viewed, and seem to imply no responsibility on mother‟s part. It was her lifestyle, rather than her parenting ability that was being questioned in assessments, as if the two were easily separable. Many SCRs have noted the concept of “natural love” (Dingwall 1983)    17  and in this case mother‟s desire to be a successful parent was translated into a belief in her ability to be a good parent.  4.1.16 Brandon (2008) has described professionals‟ capacity to put aside knowledge of the past and to focus on the present as the “start again syndrome”. In the Biennial Review of SCRs in the many cases where mothers had children removed due to neglect, professionals disregarded this knowledge and moved the focus to the present and to support for these mothers to “start again”. Parenting history was not fully analysed to consider the current capacity to parent.  4.1.17 The compassion that professionals felt for mother had an impact on their critical faculties and their ability to focus on the needs of Baby J. They saw their role as helping mother to “start again” with Baby J and to start a new relationship with one adopted child. Without rigorous and in depth supervision, this was never understood as a central part of the decision making in this case.   4.1.18 In conclusion, then, there are connecting threads in these illustrations of the human biases that can take over a professional‟s approach. Working in the child welfare context with people and children/young people requires professionals to form relationships in often difficult and complex circumstances. This desire to work collaboratively is a core part of professional practice and is also implicit in much of the guidance and legislation related to child welfare practice. In this case all the professionals worked very hard to build relationships with adults, and there is evidence of a great deal of effort in this regard. The building of relationships, however, should not be at the expense of a healthy degree of “respectful scepticism” (Laming 2003: pp159, 205, 322) and appropriately authoritative practice, combining as it does both demand and support. To achieve this, reflective supervision, front line support and sympathetic management oversight are necessary. These conditions were often lacking for those professionals working with this family and it is therefore unsurprising that there was evidence that human biases had an impact on professionals‟ decision making in this case.  4.1.19 It is a core part of professional practice in safeguarding and family support to help families who have had difficult lives make changes and improve the quality of their and their children‟s lives and to be enabling and supportive of that change. This desire to improve lives can become a bias which has an impact on critical thinking and professionals judgements and there is a need for there to be strong systems to be in place to identify it when it happens, support professionals with it, and minimise any associated misjudgement. This particular case suggests that they are not as effective as required.       18  4.1.20 See the „Summary of Recent Changes‟ in Chapter 5 to see recently audited improvements in supervision in the District.     FINDING 1: The lack of recognition in professional practice of the potential for unfounded optimism in work with families with a history of parenting failures makes child-focused decision making unlikely. In this serious case review it is apparent that professionals adopted an overly optimistic stance towards a mother whom they liked and admired and wanted the best for. This caused all those involved to downplay the messages from mother‟s history and to fail to revise plans in the face of a number of risk factors which indicated that the care of Baby J was likely to have been compromised.  These natural human tendencies of over optimism, a reluctance to change a professional view, and the need to feel hope for those you work with have been found in a number of previous serious case reviews. Given that it is not possible to police one‟s own cognitive biases, minimising their impact requires organisational strategies to increase the likelihood they are picked up and addressed. Such strategies include good quality supervision and multi-agency processes which invite challenge. Without such processes being given adequate value or priority across all agencies, professionals can be seen as being in a work environment that is not conducive to good quality work with families.   Issues for  the LSCB to consider For the LSCB, and its member agencies, the challenge is to consider whether these risks are adequately recognised and minimised at all levels in organisations.  Issues to consider include:   Is there rigorous support for quality supervision across member agencies   Does the Board have a means of hearing from the workforce about what gets time and attention within supervision sessions and what does not?   Is the evidence around these human biases and associated risks, well understood by the Board and member agencies?   Does the workforce currently have a language with which to articulate these kinds of issues or are they hard to air and talk about?   Do agencies have anything in place to support professionals when working with families who have had previous children taken into care and adopted, which helps them to mitigate against a falsely optimistic stance?  Do agencies have anything in place which recognises the importance of sharing and discussing new evidence around high risk families?  How can the LSCB help create a culture where openness to challenge, to    19  minimise the chance of new information being undervalued, is more common?      20  FAMILY PROFESSIONAL INTERACTION What patterns are discernible in the ways that professionals are interacting with different family members, and how do they help and or hinder good quality work? FINDING 2: Inadequate assessment of the role of fathers in high risk cases, allows judgements to be uninformed, or insufficiently deep.  4.2.1 A striking feature of this case is that the central player in the tragic outcome - the father - was not assessed adequately by professionals when they were working with the family. He was insufficiently understood in three different ways.   4.2.2 Firstly, concerns that were held about his being controlling of mother were effectively minimised. They fell in the shadows of the narrative of positive change that professionals created around mother. For example, the probation officer began to feel concerns about father‟s controlling nature, shared this with the substance misuse worker, concerned the mother might be entering another worrying relationship. The drugs worker was concerned the mother would pick a partner whose controlling behaviour would set off her strong reaction to being controlled. The mother‟s good progress on giving up drugs seemed to camouflage these concerns and by the time of the core assessment the drugs worker did not mention it in her report.  The Probation Officer did, but he described many positive features about mother‟s progress which seemed to focus the reader there. The father, not being on drugs and apparently without a criminal record, with a long prior marriage and step children, was seen as different, and a protective factor for the mother.  4.2.3 Secondly, the father was barely included within the focus of the core assessment undertaken before the birth of Baby J. In the same assessment, mother‟s positive view of him was recorded, as were her views that his „bossiness‟ could be handled, but there was no assessment of how the pair related or how they might care for a new baby, and it was thought by professionals at the time that to scrutinise this closely ran the risk of destabilising mother‟s recovery.  4.2.4  Thirdly, when professionals become aware of the domestic violence, he was categorised as the perpetrator, and the strong concerns he had about the capacity of the mother to provide adequate care and protection to their child were not taken seriously. So after J was born, and the series of domestic incidents started, the father was seen as the aggressor, and this fitted the earlier perception of him being over-controlling. However, the fact that his concern was how mother‟s problematic drinking and behaviour was impacting on her ability to look after the baby, was never subject to any  real examination in terms of the nature of the relationship and what this might mean for the baby‟s safety . In other words, the idea that he might have been a bully, violent and controlling, but also right about risks to the baby was not considered. This sort of subtlety in assessment was never made (even when mother was found by police to be drunk and the baby moved to father‟s relatives overnight). In the latter part    21  of J‟s life he made several requests to Children‟s Social Care to protect J from his mother, but this never led to any re-assessment.  4.2.5 Child protection systems require that professionals routinely engage and assess men well given their role as fathers or partners is so important. Yet many SCRs have found that fathers or male partners (both referred to in this finding as „father‟) have not been understood well and therefore the risks assessed inadequately. In some cases, the father might be a shadowy figure, hardly seen with little known about him, in others a strong controlling character hard to engage or even frightening, with many variations on those themes. This case highlights the danger of superficial understandings that can treat fathers as heroes or villains, rather than being sensitive to the nuances and subtleties that mark most relationships. It highlights the particular need for such nuanced thinking in cases where there is a history of poor parenting, and the mother being in abusive relationships. It illustrates for other cases the risks from not assessing new relationships, and not going beyond self-report in the interests of the child/ren.  4.2.6 Professionals are not immune from fear, and families where there is violence are frightening places mostly for those in them but also for professionals. For the latter, the fear can be around not just particular personalities but about the consequences of not getting interventions right.   4.2.7 As can be seen in other Findings, we learned from the Case Group that there were few processes in place at the time to help workers identify when they were getting stuck in dealing with this controlling and at times aggressive father, or simply out of their depth.  It is likely that similar dynamics might be at play in work with other families and there must be risk that that other cases might drift as this one did without really understanding the role of the father.  4.2.8 To do this kind of assessment of men in new relationships is not an easy or straightforward task. It requires skill, expertise and determination.   FINDING 2:  The inadequate assessment of the role of fathers, in high risk cases allows judgements to be uninformed, or insufficiently deep  This case indicated a pattern whereby assessment of parental relationships is inadequate, and highlighted the particular danger of incorporating only a one-dimensional interpretation of the role of the father. For children to be effectively protected there has to be a skilled effort to understand the nature of relationships between mothers and the men in their lives. This is especially so if relationships turn violent, when it becomes important not just to  rely on earlier characterisations,  nor to assume that is what continues to happen despite new evidence. It means    22  triangulating the view of all professionals with knowledge of the person concerned.  It also means ensuring that front line workers have the maximum support in dealing with fathers, particularly those who are known to have been violent, or appear frightening, and that staff feel free to seek help. Supervision and support are particularly important in this context.  Given the important part that men play in children‟s lives, both good and bad, if staff are not adequately equipped or supported to engage with them, they are in effect only able to do half  their job. The risks for the children concerned are clear.    Issues for the LSCB  to consider   Is the LSCB aware of the degree to which professionals are prepared for understanding the nature of the relationships of parents they are working with, and of engaging with the men involved?  Does the LSCB consider that agencies give and model sufficient support to staff when facing potentially hostile or distant fathers?   Does the Board know whether it is culturally acceptable for workers to ask for help and that this is seen as a strength not a weakness (This applies especially to staff who work on their own in family homes)?  How could the LSCB promote such a culture?       23  FINDING 3: Overreliance on self-report from parents, and a lack of challenge to them, leaves risks to children inadequately ascertained. 4.3.1  Consistently in this case, professionals relied on self-report from the parents without challenge or without a search for corroborative evidence. (A similar dynamic between professionals is described in Finding 4). This was seen across all organisations. Three areas where accepting self-report hampered case management were identified for local staff to learn from, and two can be described here.   4.3.2 Firstly, when mother retracted to social work staff what she had told the police about being afraid of father, and worried that he would take Baby J and harm her, this was taken at face value, and the explanation that it was just a matter of tiredness accepted. Another time mother was alleged by father to have stabbed him, but when seen by Children‟s Social Care staff he said that he had been misquoted by the police. This was not checked, and went unchallenged.  Both mother and father once again reassured professionals that these incidents would not happen again, and in the next CIN meeting this was accepted uncritically. A planned Section 47 inquiry was abandoned. Throughout the case, self-reports that matters had calmed would end any serious consideration of future risk.  4.3.3 Secondly, when the mother tested positive for opiates (for the first time since the previous autumn) when J was 4 months old her explanation of the result coming from strong medication was accepted without further exploration. A relapse is not an uncommon event for addicts, but it was not considered in the context of known domestic abuse in this case, more analysis was needed of its significance.  4.3.4 In discussions with the Case Group, it became clear that staff were anxious to maintain a good  working relationship with mother, were hopeful  that she should do well and be „rewarded‟ for her efforts on coming off illicit drugs. (See Finding 1). The Case Group described how this positive approach lowered the perception that challenge was necessary, and made it harder for them to make any challenge to self-report for two reasons. One, in case it made the mother feel undermined in her efforts and possibly lose commitment, and two, because they wanted to continue to have the good relationship with her that they saw as important to her success. Supervision processes robust enough to identify this happening were not in place.  4.3.5 A dictionary definition of challenge includes „summons to engage in a contest‟ and „demand an explanation‟. Often it can be the fear of coming over as engaging in a contest that stops professionals demanding explanations. This can apply to work with families (like not challenging mother too much in case it lessened her motivation to do well). Also, it can be hard for workers to challenge parents, when certain of their answers might lead to life changing decisions about the family such as the removal of a child, and the consequential pain for parents.     24  4.3.6 Given the importance of hearing what parents say, but doing so with professional judgement and scrutiny, this is an important area for further consideration. The Case Group and Review Team confirmed that difficulties accomplishing this are likely to be an issue beyond this case, and therefore a systemic issue to be addressed.  4.3.7  See “Summary of Recent Changes”  in Chapter 5 for audited improvements in supervision which should support greater challenge of self-report    FINDING 3 An over-reliance on self-report from parents and a lack of challenge to them, leaves risks to children unascertained  It is much safer for children, young people and their families if challenge of what is reported by parents is built into processes such as supervision and decision making, but also into cultural expectations which recognise that asking questions and seeking explanation from parents  is something to be valued.  A high reliance by staff on self- report by parents brings with it significant risks of proceeding on false information.   Arrangements put in place to recognise when there is insufficient challenge, and to increase the value given to challenge, are in the interests of families and staff. Such arrangements can include ensuring time for in depth supervision, ensuring an independent uninvolved voice at key decision making meetings, managers modelling that challenge is acceptable, and showing how it can be done in a constructive way so that workers have more confidence in challenging parents.  Issues for the LSCB  to consider  Is there a collective view at the LSCB about the prevalence of this issue and the scale of change needed around challenge with families?  Is enough known about the perspectives of the workforce on this issue? Is there a view that to challenge parents is to be judgemental?   How could the LSCB promote a culture where staff are supported to be challenging when necessary?  LONGER TERM WORK Were any good or bad patterns identified about ways of working over a longer period with children and families? FINDING 4: Interagency and intra professional relationships that lack challenge minimise the safeguards that working together is aimed to achieve    25  4.4.1   The fourth finding from the review of this case is a pattern within the way that professionals communicate and collaborate together in longer term work, which is marked by a lack of challenge. The lack of challenge between professionals and parents described in Finding 3 was mirrored in the lack of challenge between agencies, and between managers and staff, across the whole timeframe of this case. This was characterised by four features. Agencies not resolving interagency tensions so they continued. Agencies not challenging, or even questioning, each other and assuming what the other did or thought. Supervision arrangements relying on family self-report as relayed by workers, and accepting worker views without exploration.  Finally, there were no multiagency meetings to discuss risk to J in his lifetime, and almost no informal meeting between professionals. All four features created risks in the management of the case, as illustrated below, neutralising the kinds of safeguards that working together is designed to accomplish. (Such as making good use of all available information and spotting when the handling of the case is going off course in order to be able to rectify it in a timely fashion).    4.4.2  The absence of the substance misuse practitioner from all bar one of  J‟s Child in Need meetings arose from a situation where Children‟s Social Care understood substance misuse staff to be too busy to attend such reviews, while  substance misuse staff felt left out by not being invited. This meant crucial information was not shared or tested out in a meeting that the Review Team believes would have made a difference to case management.  The Domestic Violence Service (DVS) believed Children‟s Social Care did not value them as equal partners, and sometimes this led to DVS being unclear on what they needed to share.  Neither area of tension was, at the time, confronted and resolved.  4.4.3  When several agencies were expecting that there would be a full pre-birth assessment and a case conference to decide what to do about the new baby, none challenged Children‟s Social Care when neither happened. Whilst partly because they tended to share a positive view of mother‟s progress, it was also due to the assumption that Children‟s Social Care must have made the decision on the best available evidence, or they could not have decided to take the Child in Need route. No one raised this or tested it out.  4.4.4  Supervision arrangements in Children‟s Social Care, challenged by the high workloads, backlogs of work, and instability at team manager level, were not thorough so reports by the Social Worker were unchallenged. On one occasion the view of a worker that the severity of a particular domestic incident had been exaggerated was accepted by the manager although it was based on parental self-report alone. As a result, a Section 47 inquiry that had previously been ordered by the manager but not carried out by the Social Worker was allowed to pass.     26  4.4.5  The fourth area was the lack of face to face meetings.  There was no meeting of agencies in the core assessment, no strategy meeting or case conference at any time, and Child in Need reviews after J‟s birth never contained more than Children‟s Social Care staff and the health visitor. This stopped full information being shared, but also prevented a chance to test out professional assessments and views.  There were no face to face meetings relating to the adopted child who was in touch with her mother..  4.4.6 Very similar factors lie behind the lack of professional challenge as with the lack of challenging families. There was a specific reason around the poor supervisory challenge which stemmed from supervisors not having time for in depth supervision in the highly pressured and struggling Children‟s Social Care office, and a hope that cases could be managed with least resources, given caseload pressures.   4.4.7 Finding 3, referring to the definitions of challenge said how „demanding  an explanation‟ can be avoided for fear that it appears like a „summons to engage in a contest‟  This can apply to relationships between agencies where challenge might be seen as being uncorporate, or adding to interagency tension. When this issue was discussed with the Case Group, they described the reluctance for professionals to challenge each other in terms of the common fear that it might be seen as indicating a lack of trust or respect exists between them. Challenging someone else is something many people find hard in any walk of life, so it will certainly be hard in settings where complex work is undertaken.   4.4.8 In this case, the absence of challenge and facing up to agency tensions weakened the ability of services to protect Baby J. While it is individuals who do not make the challenge, this has to be seen in the systemic context of the degree to which challenge is valued and the structures and norms within which it can take place. The fact that its lack was evident throughout this case, and across agencies, raises the important question of how widespread it is across the child care system in this area. There was nothing in the input from this particular group of staff in the course of this case review that suggested the lack of challenge and facing up to inter-agency tensions was extraordinary or reserved to this particular case alone.   4.4.9 See “Summary of Recent Changes” in Chapter 5, quoting the recent Ofsted review which refers to staff reports of more challenging supervision.    27   FINDING 4 Interagency and intra professional relationships that lack challenge minimise the safeguards that working together is aimed to achieve  This finding is connected to that in Finding 3 relating to lack of challenging parental self-report in that challenge with families and between staff need a culture which supports it.  Working together across professional and organisational boundaries forms the foundation of our child protection system. The obligation to do so, and the processes of professionals meetings that support doing so, are designed to work crucial safeguards into the system. It is intended to increase the chances that a correct and holistic picture of the child‟s situation is gained and maintained, and a linked plan of help can then be generated and updated accordingly.  So the finding of a pattern of less than forthright relations and ways of working together between professionals and agencies introduces serious risk into the system.   Issues for the LSCB  to consider   Does the Board have a good understanding about the extent to which challenge between professionals is currently seen as expected, or not?  To want extent do formal processes build in challenge between professionals and agencies?  Are there ways that these could be strengthened to increase the value perceived to be given to challenge and make it harder to avoid asking or being asked questions that challenge sense and decision making?   Are arrangements put in place to recognise when there is insufficient challenge What recourse to support do staff have such as time for in depth supervision, or ensuring an independent uninvolved voice at key decision making meetings?  To what extent do staff across agencies think that their managers model that addressing conflict and posing challenge is acceptable, and show how it can be done in a constructive way?   How will the LSCB work to support a culture, within which, challenge between professionals is seen as both wanted and valued?  Does the Board, and the County 2 LSCB, need to review the clarity of cross boundary working arrangements?       28  Finding 5: Insufficient understanding of the nature and impact of domestic abuse, parental substance misuse and parental mental ill health makes child focused decision making unlikely.  4.5.1 Research (Cleaver et al 2011) and Serious Case Reviews (Brandon et al 2008) has consistently found that there is a significant impact on children and young people‟s development and safety from living in households with domestic abuse, parental substance misuse, and poor parental mental health.   4.5.2  Each of these factors can bring their own challenges to the task of parenting, family life and children‟s needs, but it is the co-existence of all three which can be particularly harmful. Baby J grew up in such a household.   4.5.3  The review has indicated an underlying issue of the professional network having insufficient understanding of these issues to assess or address them effectively either as individual issues or in their interaction and cumulative significance.   Domestic Abuse 4.5.4 There were allegations of domestic abuse about both father and mother during the whole of Baby J‟s life, including when he was in–utero. There were serious concerns about father‟s controlling behaviour from the early days of mother‟s pregnancy, which was also early in their relationship. There were two incidents of domestic abuse whilst mother was pregnant, where she said she had been physically assaulted and then retracted these statements. Later on mother talked of father‟s physical abuse and controlling and emotionally blackmailing behaviour. There were also incidents where father alleged that mother had been physically abusive, including stabbing him, which were then withdrawn.  4.5.6  Professionals were aware of these concerns and there was evidence that appropriately both parents were asked to consider the impact on Baby J as he grew up,  but professionals were reassured that both parents understood the concerns and would address them. There was never an assessment or analysis of the dynamics of the domestic abuse, who was a perpetrator, who was being consistently harmed and what power and control dynamic was being played out. This meant that no one understood what was happening, and therefore what would help to make it stop. Without this understanding, the reassurances from parents were meaningless. The Case Group said that although they were aware of the importance of domestic abuse, they did not always feel confident to asses or it address effectively.  What impact there could be on the adopted child, who was in contact with the birth mother, from the domestic abuse was never explored. 4.5.7 There was a good assessment carried out by a voluntary organisation, but these practitioners were never incorporated into the Child in Need process. In fact, they felt    29  they were marginalised from it, and therefore their knowledge and expertise was never used to inform the Child in Need approach. These practitioners said this was not unusual.  4.5.8 The voluntary organisation made a referral to Multi- Agency Risk Assessment Conference (MARAC), but this seemed to have little effect on the overall approach to this family, and left the Case Group and Review Group with questions about the role and purpose of this meeting which is intended to address the needs of those who experience domestic abuse.  4.5.9 See “Summary of Recent Changes”, Chapter 5, for recent progress on domestic abuse arrangements.  Parental Substance Misuse  4.5.11 Parental substance misuse has the potential to have a serious impact on a parent's ability to provide appropriate care, and has been associated with negative outcomes for children of all ages (Hidden Harm, Advisory Council on the Misuse of Drugs 2003). In this case there were historical concerns about mother‟s long term use of heroin which remained until around 5 months into the pregnancy, when after detox she was maintained on a methadone programme. This success meant that the practitioners involved with her considered her actually to be “drug free” and the regular drug screening appointments confirmed this. The information about her growing chaotic alcohol misuse does not seem to have been recognised as an issue, despite this leaving Baby J caught in the middle of physical tussles between the parents, and late night moves for the baby.  4.5.12 Early practice was good, provided by a specialist substance misuse midwife, who supported mother and made a referral to Children‟s Social Care. There was a consistent and supportive substance misuse worker involved with mother during the whole period under review, but she was marginal to the Child in Need process, and so was never able to add in her knowledge and expertise. It is clear that there are more general difficulties in substances misuse services and other agencies working together which go beyond this case.    Parental Mental Ill Health  4.5.13 Although it is clear that many children are unaffected by parental mental ill health, this issue can have an impact on parent‟s ability to provide effective care and has the potential to have a negative impact on children‟s outcomes (Cleaver et al 2011).      30  4.5.14 In this case mother had a history of depression and self-harm, and there were concerns raised by father about her self-harming behaviour during pregnancy. She sought help for depression, and was referred to mental health services by the GP when Baby J was 4 months old.   4.5.15 Mother reported that she had concerns about father‟s mental health, that he had tried to harm himself whilst she was pregnant and that he had made threats to do so again if she left him. These concerns were never discussed or assessed at the time.  4.5.16 The need for improved understanding of issues relating to parental mental illness was seen in the GP regarding his referral as urgent, but mental health services deciding from what he wrote that it was not. Mental health services told the Review Team that the referral described the baby as a „protective factor‟ and this lessened their perception of the urgency. This was an inaccurate analysis, and demonstrated a lack of child focussed practice.  4.5.17 Many on the Case Group were surprised by the information about the mother and father‟s mental health issues, and they recognised that these concerns had been hidden or unacknowledged. It is clear that there are national concerns about how well self-harm in the context of parenting is assessed and incorporated into planning of children‟s needs so all areas need to be prepared for it.  4.5.18 The review found that not all professionals were equipped to understand these three issues individually, and so it is unsurprising that they were also not assessed or addressed effectively as co-existing and interacting concerns, which were likely to have a detrimental effect on Baby J and  anyone else in the household.    F FINDING 5:  Insufficient understanding of the nature and impact of domestic abuse, parental substance misuse and parental mental ill health makes child-focused decision making unlikely.  Assessing family situations, parenting capacity and how children experience these are tasks that are complex, time consuming and dependent on practitioners being sufficiently knowledgeable, skilled and experienced. The co-existence of domestic abuse, substance misuse and parental mental health issues, raises particular challenges to effective assessment and response. This case review suggested that the knowledge of staff across agencies in this area was insufficient. Addressing the absence of adequate professional understanding of child neglect is therefore of fundamental importance to the reliability with which children and families are provided appropriate protection and support.     31                   Issues for the LSCB to consider.   Is the LSCB aware of the adequacy of professional knowledge of domestic abuse, substance misuse and mental health individually, and particularly where these parental capacity concerns co-exist?  How is appropriate development for staff in these areas being encouraged and supported?    Is the LSCB aware of whether these issues get routinely addressed through good quality supervision and management oversight?    32  MANAGEMENT SYSTEMS Are elements of management systems a routine cause for concern? FINDING 6   Pre-birth assessments that are started at predetermined points are not sensitive to risk in particular cases and can lose valuable time in assessing and planning. 4.6.1 When a mother who has had previous parenting problems (especially when these have led to statutory removal) becomes pregnant, an opportunity is presented to work closely with the family to assess future capability and to help plan. In this case, the main professional workers involved (substance misuse, probation and the substance misuse midwife) all continued with their own roles when the mother‟s pregnancy was identified. In those roles, they offered appropriate support and, for example, a place was found where the mother could detox (successfully) from drugs to help her be able to parent.  The staff also liaised with each other. Even though it was known that the mother had had her previous children removed and adopted, that she had a significant number of convictions, and she was still using large amounts of drugs, there was no meeting of workers, Children‟s Social Care were not informed, no background checks were made about her past parenting, and there was no meeting of involved professionals to make a joint plan.  4.6.2 This was because the workers considered this to be work that started much later in pregnancy. The midwife intended to make a referral to Children‟s Social Care so that there could be a proper pre-birth assessment but understood that they would not accept referrals until 20 weeks of pregnancy had elapsed so planned to do it nearly three months later.  (Children‟s Social Care want to be sure that a pregnancy is viable so as not waste scarce resources). The Lancashire Multi Agency Pre-birth Protocol ratified in 2009 said there were circumstances when it may be appropriate to refer earlier. The then LSCB procedures said that referrals should be made at about 20 weeks, but also said “When a pregnant substance misuser is in contact with services and there is no perceived need to instigate procedures, it is good practice to convene a multidisciplinary meeting to establish a care plan at the earliest opportunity and ensure that all appropriate agencies are involved”. (In the current procedures in  the section about drug using parents it says if there is a risk of significant harm „ a referral to Children‟s Social Care must be made as soon as concerns are identified‟ but this was not in the version in use in 2010). However, so powerful was the agency experience that  Children‟s Social Care would not accept referrals until much later (and this was the common practice) that the notion of either referring earlier or even having a multiagency meeting was not considered.  4.6.3 The outcome was that there was no joint plan, no pooling of information about the family, or agreement of what needed to be assessed or monitored until over three months after the pregnancy was known. In fact, there was never a multiagency meeting about baby J. When the mother came out of detox there was still no plan as the referral to Children‟s    33  Social Care had yet to be made, and the involved agencies continued their separate work.  4.6.4 The Review Team believe, with such a troubled background that included three children being permanently removed, multiple offences, a history of domestic disputes, drug taking throughout adult life, and some violence, that it would have been good practice to engage Children‟s Social Care early, so that planning support and guidance could be given throughout pregnancy in such a high risk position.   4.6.5 Without such a multiagency focus at that early stage a vicious circle applied, whereby in the absence of fuller information (that would have come from multi-agency sharing) limited knowledge and that limitation itself made it less likely there would be an identified need to meet and discuss.   4.6.6 The issue of „20 weeks‟ was reported by Case Group members as of one of general relevance to pre-birth planning as it governs when planning is done. The pre-birth protocol is now embedded in the LSCB procedures, and the discretion to refer early is clearly stated in more than one place, but the Review Team and Case Group identified that the conventional wisdom is still that 20 weeks is close to an absolute, and that to try earlier would normally be fruitless.  4.6.7 Even if other agencies‟ view of the Children‟s Social Care stance is correct, it does raise the issue of how other agencies can be encouraged to be more forthright if they have a clear view on what timing is most helpful, rather than just accepting the conventional wisdom.  4.6.8 The 20 weeks guide (it is longer in some parts of the County) , runs the risk that by the time assessments are completed and a case conference arranged in complex cases there would be little time left to put full plans in place after the decision. Timing relating to the nature of each case is more appropriate.  4.6.9 Families like this, where the past parenting has consistently been found wanting, need the maximum support and assessment throughout pregnancy, both as good practice, but also to gain information over a good length of time about the parent‟s individual stability, and the strength of their relationship. Leaving involvement to the later stages of pregnancy can prove to be a false economy.  4.6.10 See Chapter 5 for an update on current improved arrangements on pre-birth assessment.       34   FINDING 6   Pre-birth assessments that are started at predetermined points are not sensitive to risk in particular cases and can lose valuable time in assessing and planning.  There will be many other occasions when decisions have to be made when a mother becomes pregnant with an extremely poor history of prior parenting, where early assessment, planning and support will  be in the interest of the child and parent/s. It is important for future cases that staff across the agencies feel confident to requesting/ organise meetings, whether formal or informal, to discuss  with Children‟s Social Care such cases. Also, that they do not feel constrained about when to ask for involvement, that Children‟s Social Care take the flexible stance the procedures allow, and that professional perceptions are shared and tested out to make sure the very best assessment of risk to the unborn child is identified quickly. Pre-birth planning is an area of high risk and needs the most robust arrangements.  Issues for the LSCB  to consider   How will the LSCB assess the degree to which pre-birth referrals are currently assessed at the appropriate time?  How will the LSCB review on-going adherence to the flexibility needed?  Is the LSCB satisfied that there is sufficient knowledge about the right time to start assessment so that pre-birth work starts at the right point?                       35  Finding 7: An acceptance of poor quality assessment makes timely and appropriate help for families unlikely, and can undermine child safety and well-being.  4.7.1 The design of multi-agency child protection systems in England has assessment at their very heart. The assessment process is the foundation to any help provided to families. It produces the understanding of the circumstances of the child and family that underpins planning for the kind of help provided. Yet this case review identified that the process and quality of assessment was weak in a number of specific and important ways. There were fundamental weaknesses in regard to:   child focus   pre-birth framework  inclusion of appropriate information from all relevant agencies  involvement of extended family  clarity of focus – what is to be achieved through the assessment  analysis  multi-agency participation and ownership  re-assessment   4.7.2 These are detailed below. They give a graphic picture of professionals in some ways going through the motions of the assessment process, but with the attention to detail required to make that process meaningful, lacking.   4.7.3 The Core Assessment conducted before J‟s birth was not sufficiently child focussed.  Its emphasis was on self- report from parents about their plans and their ability to meet the needs of a new baby. Particularly missing was a real discussion about mother‟s own responsibility for her children coming into care around concerns of neglect, and how and why things would be different this time. Mother had a long history of putting her own needs first, before the needs of her children, and this should have been subject to further analysis and professional judgement. Father was not asked about his experience of parenting, and how prepared he was to look after a new baby. There was also no real discussion about the link between substance misuse and management of stress, in the context of a new baby and in the early stages of a new relationship. Within it there was also confusion about how much consideration should be given to mother‟s contact with one adopted child.  4.7.4 The Assessment was undertaken using a prescribed format, contained in Lancashire‟s computerised system. It did acknowledge that this was pre-birth but did not contain many of the elements of good quality pre-birth assessments (Hart 2010)   4.7.5 The assessment lacked a clear focus, describing past parental history, rather than considering the needs of the baby and questioning the capacity of the parents to meet    36  Baby J‟s needs.  This issue of focus is critical to the quality of assessments. If as professionals you are unclear what you are hoping to achieve through the assessment process, then the analysis is likely to be unclear.  4.7.6 Crucially the assessment did not include the extended family or an understanding or analysis of the role they might play in Baby J‟s life. This was an important opportunity to engage the wider family directly in considering what part they could play and what support and help they could provide.    4.7.7 The Assessment was not sufficiently multi-agency. The professionals who worked with mother were asked to provide a written report for the assessment, but they were given no specific guidance about the purpose of this or what was needed and so they wrote about their contact with mother from the perspective of their agency, not from a parenting or child perspective. One agency did seek clarification, but this was not responded to, but overall the agencies who contributed were not sufficiently aware of the Assessment Framework and their responsibilities within it. They also gave no professional view of what should happen, and in the Case Group a view was expressed that non-social work professionals do not always feel empowered or qualified to do so.  4.7.8 The specialist midwife for substance misuse was not asked to provide a written report for the assessment because of confusion about the role and purpose of CAF. She had used the CAF form to make the initial referral to Children‟s Social Care, which she considered to be the required process.  It was received mistakenly as a brief assessment, and therefore taken as written information for the Core Assessment, despite its brevity and that it had been written some months earlier. This meant that she was not able to contribute her specialist knowledge around issues of substance misuse in pregnancy or to share current health related information .This was a significant oversight given mother‟s history and her pregnancy. This confusion between assessment processes is a national issue and research (White 2008) has highlighted the incompatibility of the two fold function of the CAF as an assessment tool and a mechanism for referral.    4.7.9 Information was sought from the Police and was received after the assessment had been completed. (It was sent promptly, having been requested late, but the assessment was finished early before its arrival and did not report that some information was missing). This information was very full and detailed about the past, but contained only a sentence about mother being a victim of domestic abuse in August and December 2010 whilst pregnant, and separately that father had been the perpetrator of domestic abuse in August and December 2010. Further details about the suicidal ideation and parental conflict were not provided, so this information was not seen, and was not incorporated into the Assessment.      37  4.7.10 The analysis at the conclusion of the assessment was unhelpful. It related to the history, the views of mother about her hard won progress, the views of other professionals that she had done well in becoming illicit drug free, and mother‟s views about the adopted child.  But it provides no professional view from the Social Worker about issues of likely risk or pressure points, given the history, and does not  prioritise the needs of the new baby. The lack of analysis was also hindered by the multi-agency group not being actively involved in an analysis of the information, or in any action plan. This was compounded by the lack of a multi-agency assessment meeting. This is an agreed process in Lancashire, but the Review Team heard during the case review process that it tends to only take place in about a third of cases, due to work commitments.    4.7.11 The assessment was signed by the Social Work Team Manager, but in light of the weaknesses detailed above, it is unclear what if anything lay behind this process and so if the signature meant anything at all. Nevertheless, it gave a misleading signal to the rest of the network that this was a comprehensive and full assessment, which it was not. The Case Group reported that they thought the  decision making process was underpinned by a clear analysis of the needs of Baby J, but no one in the network received a copy of the assessment or its conclusions and they were therefore unable to make an informed judgement.  4.7.12 The final weakness to highlight is that there was never any re-assessment of Baby J‟s circumstances, despite escalating concerns about domestic abuse, alcohol misuse and parental conflict. Assessment should be an on-going dynamic process, where children needs are considered, actions taken in a timely way to address those needs, and for these plans to be reviewed and re-evaluated over time ((Munro 1999).  The emphasis on fixed timescales, linked to auditing systems and Performance Indicators has nationally had an impact on the way that assessments have been viewed.  Research (Turney et al 2011) suggests assessments are seen as a fixed and definite process, which has to be completed within the timescales prescribed in the Guidance (Framework for the Assessment of Children in Need and their Families 2000). This timescale is rigidly set by the computerised system used in Lancashire Children‟s Social Care. This end date drives the assessment process, and suggests that once it has been achieved the task is over. There is no prompt for reassessment, and in terms of the computer system there would need to be a whole new assessment.  4.7.13 It is important to acknowledge the particularly difficult situation that the Children‟s Social Care of the District within Lancashire where J lived was in, at the time that this Assessment was being undertaken. There was a back log of recording and a lack of managers. The Social Worker did not receive adequate supervision and management oversight. The weaknesses in management and supervisory arrangements meant that there was not a counterbalancing force to these assessment process constraints. However, input from the Case Group and Review Team suggested that many of the    38  issues the Review Team judged as weak in this particular case are reasonably usual in day-to-day practice locally. The Review Team and Case Group recognised that there are weaknesses in the involvement of the multiagency group, and confusion about their roles and responsibilities across the whole assessment process. This is replicated nationally. The provision of appropriate information was also considered a local issue, which has been replicated in a number of SCRs nationally.  The Case Group considered that those professionals outside Children‟s Social Care lacked confidence in asserting their professional views, and also lacked expertise in knowing what was needed to inform assessments effectively. The Case Group also agreed that there was confusion about the role and place of the extended family in assessments, and again this is replicated nationally. This was raised by the family members interviewed in this review. They felt excluded from the formal processes of support, whilst being part of an informal support network. Finally, the Review Team and Case Group also reported that there were local issues about the process and procedure for a re-assessment of a child‟s circumstances, and this is also a key finding from a number of other SCRs.  4.7.14 See Chapter 5, “Summary of Recent Changes”, and the March 2012 Ofsted conclusion about improved initial and core assessments.      F FINDING   7: An acceptance of poor quality assessments makes timely and appropriate help for families unlikely and can undermine child safety and well-being. The case review on the basis of the views of the Case Group and Review Team (and written material) has indicated that there is an acceptance of poor quality assessment, which lack a clear child focus, are one off processes, without clear multi-agency ownership around analysis or professional judgement and a lack of involvement of extended family networks.  If these weaknesses are prevalent, it seems unlikely that assessments can achieve the function they are intended to in the multi-agency system. Keeping children safe and considering their needs effectively, requires a clear process by which all agencies understand the part that they play, and that extended families are included, and there is an adequate rigour to the analysis. Issues for the LSCB to consider  Is the Board confident in its knowledge about the quality of assessments?   Are there means of ascertaining which if any elements of assessment        39     processes that need to be addressed? Namely: o multiagency participation in assessments and reviews o involvement of extended family o timely re-assessment  o child focus  How would the LSCB know that change has been made?  How will the LSCB be sure that there is clarity on the appropriate function and use of CAF forms?    40  FINDING   8:  Providing family support and child protection as separate services, with distinct management and supervision arrangements, creates obstacles to responsiveness to families evolving situations, and runs the risk that complex cases are left with staff that are insufficiently skilled and experienced.  4.8.1  A key feature of this case was that the early categorisation of the baby‟s circumstances as „in need‟ rather than at „risk of harm‟ did not change when the circumstances merited it. Many of the findings express different patterns of the way in which the child protection system is working, which made it more difficult for the professionals involved to act differently. One critical feature of the work environment that had a major influence was the very structure of teams in Children‟s Social Care. This structure and accompanying management and supervision arrangements are the focus of this particular finding.   4.8.2 In the early days of the referral regarding mother and father and the unborn baby, it appeared that a child protection case conference was likely, in order to establish the safety and well-being of the baby, and to provide support to the parents.  All professionals were informed of this and for many this was either a welcome or inevitable outcome.  After the assessment, appraised in finding 7, this changed to universal support and a Child in Need/Family Support Framework. This approach was further embedded into thinking by the decision that it was a „child in need‟ case made at an internal „care planning‟ meeting without other agencies present. This was to have a profound impact on thinking about the case and its management. What is apparent is that once this decision was made there was a rigid adherence to it, regardless of circumstances and the division of the family support team from the child protection team inadvertently encouraged this.  4.8.3 Nationally, the separation between child protection and family support as distinct areas of practice has been problematic.  This characterisation means that child protection has been considered as exclusively concerned with the risk of significant harm, which can overlook a child‟s wider needs. Family Support can be considered less important, and not about risk, but only about need. The label of „family support „–which can become synonymous with „child in need‟ can set a frame of reference, where tasks are narrowly defined. There is a danger therefore that professionals become narrow in their focus and engage in tunnel vision (Fish, S., Munro, E. and Bairstow, S. 2008).  4.8.4   In the District Children‟s Social Care, case responsibility was held by a Family Support Worker because it was considered in the context of “Child In Need”. The management and supervision of the work was overseen by the Family Support Service within Children‟s Social Care. However, In this case, whenever there was a crisis, the case was reallocated to a Social Worker and this happened on up to four occasions in a six    41  month period.  When this happened, case management passed to the Social Work team, and the supervision reporting requirements went over to the Social Work Team Manager. This meant that the supervision and analysis of the Family Support Worker was not recorded on the computerised system, as this became the responsibility of the Social Worker, and she only recorded her own work. This constant change caused uncertainty and a lack of consistency in approach. The separation of the services led to the two Children‟s Social Care workers not spending time together planning their respective roles, and their supervision and management oversight arrangements were managed separately. This meant that there was no overall joint planning or analysis of the constantly evolving nature of the family‟s circumstances.   4.8.5 There were times when the Family Support Worker and Manager felt that the case should not be held at a „Child In Need‟ level, but the lack of inclusion in joint planning meant that these differences of opinion were not shared and also the Family Support Team were aware of the pressures that the social work team were under and did not want to further burden them.   4.8.6 The Family Support status also meant that the Child in Need meetings happened informally in the family home. There appears to have been little real analysis of how the plan was actually working, looking at crises rather than overall progress, with the distraction from J of having to consider other challenges mother was facing.  4.8.7 This desire to locate services in a Child in Need context also links to professional‟s attitudes to mother. The Review Team heard from Case Group members that there was an influential view- that being considered in a „child protection‟ context was “sometimes a punishment for parents” especially if parents were seen to be cooperating. No one wanted mother to feel that the efforts she was making were not being noticed, and there was a consequent reluctance to consider the necessity of child protection processes.   4.8.8 A major consequence of this issue, and one that the Review Team were most concerned about, was the acceptance of the Social Worker not carrying out a requested Section 47 inquiry, and not being appropriately challenged about not doing so. There was a second occasion when a Section 47 inquiry was considered an appropriate course of action, but the case management got lost between the Family Support and Social Work team manager debates.    4.8.9 The plan of work, which was not clearly outlined in the Child in Need records, seems to have been halted by the many crises, and so despite this approach not being successful, it was not changed or challenged. This left the Family Support Worker with a great deal of responsibility and competing demands which she described in conversations as overwhelming and unmanageable.      42  4.8.10 The Review Team understands that the strategic plan of using Family Support Workers in complex Child in Need cases remains current within the District. It is therefore an underlying issue of significance to more cases than this particular one. To the knowledge of the Review Team, the types of challenges created by the separation between Family Support and Social Work services remain unresolved. The Review Team view is that this represents a significant vulnerability to achieving a safe system.   4.8.11 See Chapter 5 “Summary of Recent Changes”, and the recent work to align social work and family support    FINDING 8   Providing family support and child protection as separate services, with distinct management and supervision arrangements, creates obstacles to responsiveness to families evolving situations, and runs the risk that complex cases are left with staff that are insufficiently skilled and experienced.  In the context of children‟s services, the potential demand is so high that all agencies have to prioritise as they allocate a finite amount of resources. It makes good financial sense therefore that tasks and roles are allocated in such a way as to ensure a suitable match of skill and expertise. Using overqualified staff for reasonably straightforward tasks can be seen as wasteful. However, the question of how cost effective strategic decisions are, hinges on whether there is an accurate match between the complexity of the task and the professionals skills needed to carry it out. This is a particular challenge in the field of child protection, because family‟s situations are not static but continually in flux. Designing systems that are flexible and responsive is therefore vital.  This finding shows how the separation between family support and child protection can limit thinking and actions on a case, and can unhelpfully prescribe a rigid approach to planning, action and decision making, with various unintended consequences.  This artificial separation can also cause confusion of roles between social work and family support, as well as confusion about management responsibilities and oversight. The Review Team‟s analysis suggests that this introduces important risks into the system, making the giving of appropriate help for children and families less reliable.  Issues for the LSCB  to consider   How does the Board assess whether appropriately qualified staff are managing complex Child in Need cases?   Is there a role for the LSCB in assisting Children‟s Social Care in a review of    43  the criteria that sets out when the allocation of a Social Worker is required and what the arrangements will be when joint work is undertaken?  What might help professionals, whether qualified Social Workers .family support workers  and or others, feel able to challenge fixed views which leave children‟s circumstances being considered in one of  an „ in need‟ or a „high risk‟ context, where both need to be present?  How might the LSCB and member agencies tackle the professional perception of the Child Protection system as a punishment, rather than a way of thinking about both the risks to children and the needs of their parents, in a multi-agency context?     44  RESPONSE TO INCIDENTS Are there particular good or bad aspects to the patterns of how professionals respond to specific incidents e.g. allegations of abuse? FINDING 9   Acceptance of slow and insufficient response to incidents, in part related to predetermining the risk in Child in Need cases, can lead to crises and escalations being poorly evaluated 4.9.1   A feature of professional practice in this case was that responses by agencies and their staff often seemed both slower and less serious than the situation merited. The issues behind this response relate to previous Findings, for example,  led to original less risky conclusions  being held on to despite new information, (see Finding 1) weaknesses in management systems (Findings 6-8) and an insufficient knowledge base around domestic abuse or substance misuse ( Finding 5) . The Review Team wanted this finding to be seen in its own right because it can characterise cases where assessments have not been updated, but also because of the wrong message that slow responses can give to professionals and families about how seriously things are seen. The mother for example told Case Group members that Children‟s Social Care were not worried, when she herself knew how fraught were family circumstances. 4.9.2   The Review Team found a number of instances of this pattern of response. Whilst many visits, especially by the Family Support  Worker were diligent, on several occasions after domestic incidents, which involved allegations of violence or tussles over the baby it would have been reasonable given the parenting history for immediate  Children‟s Social Care visits to be undertaken to be sure the baby was well and to assess the likelihood of reoccurrence. On several occasions such visits were delayed by up to 4 days if a long weekend intervened, when had they occurred earlier in the week a speedier response would probably have occurred. There were also gaps before health visitor and Children‟s Social Care staff would clarify events.   4.9.3   At perhaps the highest risk period of domestic disputes, there was a 10 day gap between visits. The Case Group identified that there was less expectation of immediate responses because of J‟s status as „child in need‟. Waits to visit were therefore not seen as unreasonable as it was not a „safeguarding‟ case. Professionals also felt they would not have much chance of getting scarce out of hours‟ staff to respond.  4.9.4  The „standard‟ (lowest) grading of each domestic dispute visit by the police, even after numerous such visits, also promoted a reaction which seemed slow given the frequency of disputes. 4.9.5 In one period where there were both domestic abuse incidents and mother was referred by the GP to mental health services for depression, the Health Visitor did not visit, but the baby was seen in clinic by a nursery nurse.  Health Visitor guidelines would not have required an automatic visit. The Review Team are raising this not as    45  criticism, but so expectations in crisis periods of Health Visitors, whose role is essentially developmental, can be clarified.  4.9.6 In terms of the substance of the response, as described in other Findings, no domestic incident, even those involving disputes over the baby, or the mother‟s alcohol use ever led to a new assessment process, or a multiagency review of child safety. Similarly, decisions to withdraw the Social Worker from the case varied over the baby‟s life with the Social Worker being withdrawn on three occasions, sometimes not long after renewed domestic incidents.  4.9.7 The decisions on the speed and gravity of responses are symptoms of the systemic issues, described across many of the other Findings, and are not simply matters of individual judgement by practitioners in this case. For example, lack of clear supervisory instructions, and the pattern of maintaining earlier views because an over optimistic perspective has become embedded and been unchallenged, can affect response times.    4.9.8 The Finding does provide an opportunity to think again about how decisions are made about the level and speed of response, how those decisions are known to match the potential risks to children, and how colleagues across agencies can work together to be sure respective roles are clear.  4.9.9 This is needed both to ensure child focussed decisions on responses, and to ensure that families clearly understand the risks that professionals see. The fact that in this case, workers by and large did not actually appreciate the risks involved, and may have seen responses as proportionate, does not disprove the Finding. It rather highlights the risks that can be created when the system works in a way that leads to under reaction to serious events.   FINDING 9:  Acceptance  of slow and insufficient  response to incidents, in part related to predetermining the risk in Child in Need cases, can lead to  crises and escalations being poorly evaluated  In cases where there is cumulative risk over time from what is (seen to be) a sequence of low risk issues there can be a slow or insufficient response. This case review has also highlighted a hierarchy of response to incidents themselves in which cases that are being treated on a Child in Need basis are assumed to be less serious than incidents that occur in cases where there is a Child Protection Plan. Clearly this logic is circular and creates significant risk that escalating situations in families will not receive a response appropriate to the seriousness of the situation.   There is also a lack of certainty about who should respond how quickly when events such as domestic abuse occur where children are involved. This is not an easy issue    46  for the LSCB to address as in most cases workers believe they are responding according to events, or according to the perceived risk level of the case.   Issues for the LSCB  to consider   Does the LSCB know how widespread is the possibility that „child in need‟ status can reduce response regardless of the incident?  What, beyond procedures, might facilitate a better understanding of what is a reasonable response to family crises?  Do agencies work together to optimum effect in these situations? How can teamwork around crises be more coordinated?  Are there adequate resources to provide a consistent child protection service out of hours, and a culture that sees a 7 day service as appropriate if the case demands it?     47  TOOLS   What has been learnt about the tools and their use by professionals? FINDING 10: Using the same meeting category on the ICT system for more than one type of meeting creates confusion and misunderstandings  4.10.1 Traditionally, people have tended to see tools as passive objects that help professionals do the same tasks as before, but do them better or faster. However, the experience from other fields emphasises how tools become active agents in shaping practice so that they are best seen as co-agents, altering the nature of the task the human does. An assessment framework, for example, is more than a neutral format for organising data but offers a framework for organising the assessment that influences the way the family is conceptualised and hence alters the final picture of them that is acquired. The structure of forms with their differently headed boxes, similarly, have  transformative effects both on the sense-making process of the form filler and the „interpretive demands‟ (White et al, 2008: 12) it places on subsequent readers.  4.10.2 Nationally there have been concerns about the impact of tools such as the assessment framework and those related computerised systems introduced to improve recording. It is clear that these tools have an impact on practice and that for people that use them there can be a number of unintended consequences. This case review shed light on problems created when IT systems do not keep up-to-date with developments in practice, specifically the creation of new types of meeting.  4.10.3 In this case, decision making about future support for the family after the Core Assessment took place in a „Care Planning‟ meeting.  In Lancashire, this is a new meeting structure within Children‟s Social Care which we saw minuted as “Internal Supervision” and is intended as a way to ensure appropriate oversight of complex decision making.   4.10.4 As this meeting is new, it has no code on the computerised system, and has therefore been coded as a „strategy meeting‟. This has led to confusion about the nature of the meeting in both Children‟s Social Care and the multi-agency group. The Social Worker understood that current policy in her area was that this meeting had replaced the need for a strategy meeting and was multi-agency because it considered the information provided by the other professionals, it just did not have those professionals present.   4.10.5 This meant that there was no opportunity at this early stage for professionals to see the information provided by others, and to contribute to an effective multi-agency plan. Yet its coding means that it appeared as if multi-agency meetings were taking place when they were not. Also a „real‟ strategy meeting would have had police present and that would have introduced the information about the domestic incidents in pregnancy,    48  which was not considered at all. It impacted on the whole multidisciplinary process, which had a lesser role in the decision making than might have been the case.  4.10.6 Input from the Review Group and Case Group suggested that the misunderstanding of the nature and focus of such „care planning‟ meetings was common beyond the particular group of workers involved in this case. Misunderstandings that resulted in this case are therefore likely to impact more widely.    FINDING 10:     Using the same meeting category on the ICT system for more than one type of meeting creates confusion and misunderstandings  The quality of the work that staff are able to accomplish is significantly affected by the appropriateness of the tools that they are given to use. What this case review has highlighted are particular difficulties that are created if the computerised options are not updated in a timely fashion so as to ensure a good match with the working practices of professionals, but the obligation to log all work continues nonetheless. Compromises such as using the same category for two different meetings may meet the management demands of logging activity, but they can inadvertently create obstacles to good working together between professionals, and therefore good quality work with families. Specifically, through this case we learnt of the lack of a category in the computer software for a new type of meeting and saw how the work around social care staff had invented, impacts negatively on the understanding of internal meetings, and runs the risk of creating a false sense of multiagency participation that confuses those participating and not participating.  Issues for the Board to consider  Is a multi-agency view needed on the role and purpose of „care planning‟ meetings, and are changes needed?  Should new categories of meeting which impact on the multi-agency group be created by Children‟s Social Care?  Can arrangements be made so this is done more clearly in the future?   Is any remedial work needed to facilitate clarity in the workforce about the defining features and function of a strategy meeting?      49  Chapter 5: Summary of Recent Changes (at time of SCR completion 30.4.12) 5.1 The methodology for this SCR concentrates on understanding how things were at the time, and identifying systemic issues for consideration.  The LSCB and its members will determine the current priority needed on the points raised in the Findings, and outline their joint plans for future action and progress on action underway. This section gives some examples of the positive steps, already taken in three key areas reported to the Review by the involved agencies.  Children‟s Social Care robustness  Addressing domestic abuse  Pre-birth planning   5.2 The District Children’s Social Care: The case concerned was managed within one District of Children‟s Social Care in Lancashire which is a large County with twelve districts. The Review understands that this was the District that was described in a December 2010 Ofsted unannounced Inspection of Contact, Assessment and Referral. “There are significant challenges at one office staff vacancies, team deployment issues, use of agency staff and high staff case loads, leading to deficits in the timeliness and quality of assessments, transfer of cases and quality of supervision. However appropriate management arrangements and a robust action plan are in place to address the immediate deficiencies”. (Ofsted did not give any notice to improve in the report).  5.3 Lancashire Children‟s Social Care reports that considerable management action has been applied to improving the District concerned.  The Local Authority told us they took this Inspection very seriously, and as well as putting in additional investment, they created additional management oversight of the District. The improvements began to take effect during 2011. The use of agency staff was stopped in April 2011, capability issues were addressed, and by August 2011 the department was fully staffed. Children‟s Social Care were confident that the corner had been turned in the summer of 2011, and this was confirmed by an internal audit in October 2011. An internal audit of supervision before the external review (below) found supervision to be „high quality and satisfied the requirements of the supervision policy‟.   5.4 The County was subject to an Ofsted Inspection of Safeguarding and Looked-after Children Services in January/February 2012, and a report in March 2012. The District was one of four within the County sampled for the full Safeguarding and Looked-After Children Inspection. Children‟s Social Care informed the SCR that the inspectors remarked on considerable progress being made. Ofsted reported the following about Lancashire, having inspected the District concerned.     50   It „has taken effective action to tackle areas for development identified in the previous unannounced inspections of its contact, referral and assessment services‟.   „Social care staff report that they receive good quality supervision which is appropriately challenging‟.  „The quality of initial and core assessments has improved….‟  „Early intervention and preventative services are good‟„. The quality of recording has improved and is now good overall‟.  5.5 The report does identify some issues as still needing further improvement, but the capacity to improve is rated as „good‟.  5.6 Children‟s Social Care also report that work has been undertaken to align the work of family support and social work staff through development days, co-location, and joint allocation meetings. There is also now  in place within the District, a Learning and Development Senior Practitioner who will assist the district in developing practice, mentoring, coaching and supporting staff in complex cases.  5.7 Pre- birth planning:  Work was already underway by the LSCB and partners to review the current pre-birth protocol before this SCR commenced, and a revised protocol (making it very clear that early referrals will be accepted when the case warrants this) and a pre-birth assessment tool, are planned to be implemented by May 2012.  5.8  Lancashire Teaching Hospital NHS FT, which covers midwifery in this case, has been feeding back learning to staff about referral and assessment processes of pregnant women.  5.9 Lancashire Children‟s Social Care has confirmed that referrals, as previously outlined in the policy, will be accepted before 20 weeks when appropriate.   5.10  Domestic Abuse:  In order to improve risk assessment and communication around domestic abuse a MASH (multi agency safeguarding hub) pilot started in January 2011 and was fully operational, and co located with Children‟s Social Care from May 2011. The risks to children, including in utero, involved in incidents attended by the police are assessed and shared with other agencies. They are referred to Children‟s Social Care where the threshold for referral is met, and in any case after 3 standard assessments using the DASH risk assessment framework.  The NHS is informed of each such incident and information passed on to appropriate health professionals. Where a pregnancy is involved midwifery is informed. All risk assessments are quality assured by the Police Public Protection Unit (PPU) Compliance Unit. PPU sergeants have had additional training about the need for early assessment of risk to unborn children.    51   5.11 The March 2012 Ofsted report on Lancashire Children‟s Social Care (see para 4 above) noted „there are good arrangements for managing domestic abuse in place. Joint work with the police who are co-located in the contact and referral team has already had an impact leading to improvement in the identification of risk and appropriate referral for assessment.‟  5.12 Lancashire Care NHS FT revised its training strategy in January 2012, including domestic abuse training, and its level 2 training includes case studies on domestic violence, substance misuse and mental health. Greater Manchester West Mental Health NHS FT has been rolling out additional domestic abuse training across its staff since April 2011.                       52   Appendix One References  Advisory Council on the Misuse of Drugs (2003) Hidden Harm: Responding to the Needs of Children of Problem Drug Users. London: Home Office. Brandon, M., Belderson, P., Warren, C., Howe,D.,  Gardner,R., Dodsworth, J and  Black , J. (2008) Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? A Biennial Analysis of Serious Case Reviews 2003-2005. Report, DCSF–RR023. London: Department for Education and Skills (DCSF) Burton, S.(2009) The oversight and review of cases in the light of changing circumstances and new information: how do people respond to new (and challenging) information? C4EO Safeguarding: Briefing number 3 (PDF). London: Centre for Excellence and Outcomes in Children and Young People's Services (C4EO). Cleaver et al (2011) Children‟s Needs – Parenting Capacity Child abuse: Parental mental illness, learning disability, substance misuse, and domestic violence. 2nd  edition. London TSO Dale, P., Green, R. and Fellows, R. (2002) What really happened? Child protection case management of infants with serious injuries and discrepant parental explanations, London: NSPCC Department of Health, Department for Education and Employment, and Home Office (2000): Framework for the Assessment of Children in Need and their Families.  London: The Stationery Office. Dingwall, R., Eekalaar, J. and Murray, T. (1983) The protection of children: state, intervention and family life, Oxford: Blackwell. Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews, London: Social Care Institute for Excellence. Hart, D (2010) „Assessment before birth‟ in in Horwath, J. (Ed) (2010). The Child‟s World: The comprehensive Guide to Assessing Children in Need.  London.  Jessica Kingsley, publishers.  HM Government (2010) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London: The Department for Children, Schools and Families. Munro, E. (1999) „Common errors of reasoning in child protection work‟, Child abuse and neglect, 23, 8, 745–758. Munro, E. (2008) „Improving reasoning in supervision‟, Social Work Now, 40, 6.    53  White, S., Hall, C. and Peckover, S. (2008) „The descriptive tyranny of the common assessment framework: technologies of categorization and professional practice in child welfare‟, British Journal of Social Work, bcn053. Reder, P., Duncan, S. and Gray, M. (1993) Beyond blame: child abuse tragedies revisited.  London: Routledge. Reder, P. and Duncan, S. (1999) Lost innocents: a follow-up study of fatal child abuse, London: Routledge. The Lord Laming (2009) The Protection of Children in England: Progress Report. London: The Stationery Office. Turney, D., Platt, D., Selwyn J. and Farmer, E.  (2011) Social work assessment of children in need: what do we know?: messages from research: executive summary London: Great Britain. Department for Education.    54  Appendix Two The Case Group names and specific organisations are not included to ensure the anonymity of the case. This list therefor indicates the numbers and breadth of staff who had conversations with the Review, most of whom served on the on-going Case Group  Organisation Roles   Children’s Social Care  Social Worker Senior Family Support  Worker Social Work Team Managers 3 Family Support Managers  District Manager Children‟s Centre Manager Children‟s Centre Outreach Worker Extended Services Manager County 2 Children’s Social Care Social Worker Team Leader Police Det. Inspector, Public Protection Unit Det. Sergeant, Domestic Violence Team PCs 2 Resource Officers 2 Domestic Violence Service Coordinator Worker Probation Services Senior Probation Officer Probation Officer Mental Health NHS Trust Substance Misuse Practitioner Senior Substance Misuse Practitioner Primary care Mental Team 2 Community NHS Trust Trust Lead Nurse Safeguarding Health Visitor Team Coordinator Community Nursery Nurse Designated nurse Acute NHS Trust Specialist Substance Misuse Midwife Community Midwife 2 Support Nurse Consultant Drug Rehab Unit  3 staff  There were also phone discussions with lawyers and Cafcass    55  Appendix Three Types of Documents Examined This is not an exhaustive list but gives an indication of the depth on inquiries made. All case files were available 1. Lancashire Children‟s Social Care : IA and CA records, CIN Review notes, care planning meeting notes, supervision notes, chronology 2. County 2 Children‟s Social Care :  Case conference and core group minutes, chronology 3. Police domestic abuse attendance records, criminal records disclosure, information sharing protocols and guidance, chronology 4. Domestic abuse service: chronology 5. Probation Service: chronology, assessment reports, court report, chronology 6. Substance Misuse: drug testing  record, assessments, correspondence with detox unit, chronology 7. Cafcass: civil court records, correspondence 8. Solicitor: Mother‟s file re non molestation application ( with her permission) 9. NHS: maternity and mental health referral letters. Case notes available. Midwifery,  health visiting, mental health paediatric  chronologies 10. MARAC note on family discussion 11. Policies/Procedures: LSCB ( old and current), CAFCASS, Lancashire domestic abuse guidance and protocol, MARAC  Final Draft J SCR Redacted 27/9/12           56     Serious Case Review  Baby J   LSCB Response to Findings       June 2012      57  1. Introduction  2. Lancashire Safeguarding Children Board (LSCB) is grateful to the Department for Education for being given the opportunity to take part in this pilot of the Learning Together model. LSCB is also grateful to the Social Care Institute for Excellence for supporting them during the course of this process.   3. LSCB has completed several Serious Case Reviews during the last few years, as have LSCBs nationally, and there has been a tendency to find similar 'learning' in these cases locally and nationally. This pilot provided a welcome opportunity to identify more constructive learning that could really make a difference to how professionals safeguard the safety and wellbeing of children locally and nationally.   4. LSCB was hopeful that this review would identify new and different learning to that identified in other serious case reviews and would provide the LSCB with direction to change practice permanently for the better in Lancashire. The findings in this review however have been very similar to the findings that have emerged for some time across the country. Issues about the role of fathers or lack of challenge for example, have been identified numerous times in serious case reviews nationally.   5. It seems to the LSCB that what needs to change is the way practitioners come together to undertake critical reflection of practice and how the findings are responded to by the LSCB and its partner agencies. This review has presented the findings in an open-ended way, which has encouraged the LSCB to be more creative in their response to them. However, this has made identifying actions to be taken very difficult, and guidance and advice nationally about how to tackle some of these common issues would have been helpful in the report.   6. The other issue that is difficult for Lancashire is that because it is such a large and diverse authority, it is not clear whether the findings apply more widely than for the particular teams involved in this specific case. The LSCB will need to complete a significant amount of work to be clear about whether these issues are systemic beyond these specific teams at that moment in time. If the review had been able to state with more confidence that the issues were broader than the specific teams or not, and indeed that they remained an issue to date, that would have been extremely helpful.   7. The LSCB has some anxiety that this method of completing reviews will be difficult in an authority the size of Lancashire. There are more than 280,000 children and young people in Lancashire, making up almost a quarter of the total population of the county. A quarter of Lancashire's children, almost 32,000 0 to 15 year olds, live in some of the most deprived parts of England. An index of child wellbeing published by the Department for Communities and Local Government in 2009    58  placed Lancashire 64th out of 149 upper tier local authorities. However, levels of child wellbeing vary markedly across the county. In the same index, Ribble Valley was ranked 2nd out of 354 districts nationally whilst Burnley was ranked 323rd. Lancashire Children's Social Care receive an average of 1175 referrals per month. The purpose of this report is to identify systemic issues, and large authorities may not be clearer at the end of the process.  8. A problem that is going to be faced by any LSCB in the future is the very significant change that is taking place in the way that safeguarding services are delivered as a consequence of the changes implicit within Working Together. An example of this would be the major changes that have happened in Lancashire since this death. The implementation of early Support, and the whole system change approach that is being implemented through our 'Working Together strategy, that incorporates the Government's Troubled Families programme, mean that services to children in need are no longer delivered in this way.. This family would potentially go through a different referral system (Multi Agency Safeguarding Hub) be referred to a Working Together With Families Team for intensive support, and benefit from a lead professional who has access to a budget to innovate in helping the family to manage their circumstances. The retrospective nature of serious case review undertakes root cause analysis of the services and professional ways of working at that particular moment in time. Detailed learning may therefore become difficult to apply to a service way of working that has radically changed and becomes more of an exercise in establishing only whether this could happen under the present system   9. That said, the process has generated some creative discussion by the LSCB, and this discussion will continue beyond the formal written response to the report. This report details the LSCB plans to date. Finding One: The lack of recognition of the tendency in professional practice of undue optimism, disregarding history and reluctance to revise judgements and plans in work with families who have complex and difficult lives makes child-focused decision making unlikely.  10. The LSCB acknowledges that there may be a natural human tendency of over-optimism. Dingwall (Dingwall et al 1983) detailed a 'rule of optimism' that has been reflected in several serious case reviews over recent years, and the reasons for this tendency are complex and numerous. Professionals are sometimes keen to acknowledge success, even when small or temporary, and this has been reinforced by an emphasis on strength based approaches to working with parents and children. Small improvements can be seized upon as significant progress, and the often detailed and lengthy history of concerns can be minimised by very recent improvements. It is also the case that the original Children Act intention was that    59  professionals should do all that they can to ensure that children remain with their families and over time, it would be fair to say that this may have a produced a bias for optimism to fulfil this requirement.  11. Conversely, the issue of rigid or fixed thinking by professionals has been identified on a national basis (Brandon et al 2009). Sometimes professionals can form a view about the nature of a family's issues and then struggle to review those decisions in the light of new information. This can mean that a picture of increasing concerns does not lead to a re-assessment of risks to the child. This can be especially true when children are 'categorised' as being either a child in need, or a child in need of protection.   12. The structure of national guidance, such as the Assessment Framework, along with the performance indicators that are routinely collated about assessment timescales can lead to practitioners seeing assessment as a one-off event, rather than a tool to determine needs and risks within families on a continuous basis. This leads to changes in need or risk not being identified and acted upon. The focus on timescales, which are performance managed nationally, may have lead to the quality and depth of assessments being compromised.  13. The LSCB accepts the finding in this case, and also that it seems to be a natural tendency for all professional practice, although the prevalence across Lancashire has not been established. It is very difficult to manage and control people's natural tendencies, but the LSCB can ensure that the organisations within Lancashire have the best strategies to try and help people recognise these tendencies and address them.   14. How will the LSCB take this forward?  15. There is a great deal in place already within Lancashire to attempt to minimise over-optimism and rigid thinking. This work has developed over the last eighteen months as the issues have become apparent, and is still work in progress.   16. The multi-agency training in place in Lancashire already uses a variety of tools to assist professionals to reflect on their practice e.g. 'thought interrupts' are promoted on all multi-agency courses. These tools help practitioners and managers across agencies identify when they need to revisit their conclusions and findings about children and helps them to identify when they should have concerns. Hypothesising tools were identified in a recent serious case review as being helpful, and they are promoted on all LSCB courses and briefings and in newsletters.      60  17. The LSCB already promotes the message about the importance of historical information in assessing risks to children. This is done in many different forums that already exist; such as briefings, training and newsletters. This will be reinforced further in light of this serious case review, and will particularly build on the issue of families who have had children removed previously. The LSCB welcomes the fact that the newly launched consultation document to replace 'Working Together 2010' is proposing a shift in focus from performance measuring timescales for assessment, as this could lead to a refocus on quality.   18. Best Practice panels are being developed across Lancashire. They are case specific multi-agency forums where practitioners discuss a particular case and identify what has worked well or what could be improved on. The LSCB is building on these, by using the model of practitioner-led focus groups to examine practice in cases that do not meet the criteria for serious case reviews.  19. The LSCB is currently considering proposals to change the format of its Locality Safeguarding Children Groups – LSCB subgroups that operate to interact with practitioners more locally. It is proposed that they become large practitioner workshops, where front line practitioners and senior managers can come together to listen to one another. It is hoped that thematic workshops will be part of this structure, and the emphasis will be very much on hearing front line experiences and listening to how managers can better support staff. The findings from serious case reviews, including this one, would be a key theme in this process.  20. The LSCB has developed a new quality assurance framework which is now operational. The framework incorporates views from practitioners across many different agencies on subjects such as supervision, and how effective it is. This includes the opportunity for practitioners to rate how reflective their supervision allows them to be. The QA framework also collates quantitative data about supervision, and will report on how frequently supervision takes place across the key agencies. In conjunction with this, the LSCB is due to launch new multi-agency guidance about safeguarding supervision standards.   21. The LSCB is aware that Lancashire County Council is introducing a new supervision audit tool that will assess how reflective supervision sessions are for social workers, and the findings from these audits will be of great interest to the LSCB.  22. LSCB recognises the finding and is keen to try and assist agencies in mitigating natural human biases when they could impact on the safety and well-being of children. However, this is an issue for agencies across the country, and the LSCB would like to draw it to the attention of the Department for Education to ensure that agencies nationally are addressing the issue.    61    23. Finding 2: Inadequate assessment of the role of fathers in high risk cases allows judgements to be uninformed or insufficiently deep  24. LSCB acknowledges that in this particular case the father of the child was somewhat sidelined, and also that it seems to be a natural tendency in some professional practice, although the prevalence across Lancashire has not been established. In this case, the concerns about the child's mother were more well-known, and the father was not a central figure for the professionals involved.   25. The role of fathers, or male partners, in professional support or intervention with families can sometimes be overlooked. Once again, this is an issue that has been previously recognised on a national level. Brandon (Brandon et al 2009) found four primary themes about men in serious case reviews:  i. the dearth of information about men in most serious case reviews, ii. the failure to take men into account in an assessment iii. rigid or fixed thinking about men as „all good‟ or „all bad‟ iv. the threat posed by men to workers  26. Brandon felt that this reflected a wider problem of the lack of information and engagement with men in child health and welfare. Once again, there are many complex reasons for this phenomenon, which include fixed-thinking about men, or sometimes a fear of men by professionals.   27. There is a substantial amount of literature available about fathers and family-support services, and indeed the issue has arisen previously in serious case reviews in Lancashire and nationally.   28. How will the LSCB take this forward?  29. The LSCB already builds the issues of fathers and male care-givers into its multi-agency briefings and training. The SCR briefings that the LSCB run offers a slot about the 'Invisible Man', and gives real examples of cases where fathers or male care-givers have killed children. Previous SCR newsletters have focused on the role of fathers and male care-givers and how professionals can sometimes minimise their involvement. All multi-agency training the LSCB delivers incorporates the role of fathers and male care-givers.   30. The LSCB understands that the Department for Education is currently funding a project about engaging with fathers, and is keen to consider how the findings from this project could inform the work of LSCB partner agencies.     62   31. The LSCB has three 'Locality Safeguarding Children Groups' that meet to ensure more local communication between the LSCB and practitioners. LSCB is proposing to change how those groups run, to turn them into regular practitioner-manager forums. The proposal is that they are run three or four times a year in each of the three localities, and will offer workshops for practitioners to talk to managers about themes and issues. We are intending that the focus of these workshops will be about practice, and how difficult issues such as engaging fathers, or working with hostile people really is for practitioners.   32. The LSCB is determined that the practitioner forums will be more than an opportunity for managers to talk to front-line practitioners, as has been the case historically. They aim to be events at which managers can listen to practitioners, and hear about how they can better support them in working with these incredibly difficult issues.   33. FINDING 3: Overreliance on self-report from parents, and a lack of challenge to them, leaves risks to children inadequately ascertained, and 34. FINDING 4: Interagency and intra professional relationships that lack challenge minimise the safeguards that working together is aimed to achieve.  35. Accepting reports from parents without sufficient questioning links with many other issues that emerge on a regular basis in serious case reviews nationally. Professionals not taking sufficient notice of parents' histories for example or accepting 'disguised compliance' by parents.   36. It is acknowledged that there must be an element of trust in family and worker relationships in order that they can be successful. However, these must be accompanied by a 'respectful uncertainty' (Brandon et al 2009), and this is a difficult balance to strike. Coupled with practitioner inexperience the child and his/her needs can sometimes become lost.  37. The LSCB therefore accepts that there may be a tendency for some professionals to rely too much on the self-reporting of parents, and this issue can be found nationally. It can be especially true for parents that may misuse substances, and it is sometimes difficult to challenge self-reports with hard evidence to the contrary. However, the LSCB believes that there are ways to help professionals be more aware of the dangers of reliance on self-reporting and to encourage the necessary uncertainty needed to safeguard children.      63  38. A similar theme is the difficulty practitioners have in challenging one another, and the reasons for this are again very complex. It could be a lack of confidence, or an assumption that other practitioners are more experienced or knowledgeable. Sometimes agencies could assume that Social Workers are the key agency and therefore know more than other practitioners and should not be challenged. This seemed to apply in this case. There needs to be a culture of practitioners feeling able to ask the naïve question, and able to query others' decisions and actions.  39. How will the LSCB take this forward?  40. The LSCB has very recently produced a multi agency risk assessment toolkit that aims to assist all professionals in the assessment of risk to children. This includes stressing the need for full consideration of parental histories and aims to assist practitioners in mitigating the effects of over-optimism and reliance on self-reporting. This tool is now operational and being promoted through various channels.  41. The issue of professional reliance on parental self-reporting is sometimes an issue in cases where parents may misuse substances, which can result in the neglect of their children. The LSCB has recently agreed to pilot a tool that assists practitioners in objectively determining whether children may be neglected. This trial is due to take place across agencies within a specific locality in Lancashire, and if successful, will form part of the LSCB neglect strategy and be rolled out across the county.   42. The LSCB is going to encourage agencies to be more proactive in supporting their staff to challenge parents. There are several ways in which this will happen. The Locality safeguarding practitioner forums that are scheduled to run will adopt this as a theme, and encourage discussions between managers and practitioners about the issue of challenging parents, other professionals and how to objectively make decisions about risks to children. The findings from this case will be used as a discussion point.   43. The issue of challenging other practitioners needs to be demonstrated at all levels within partner agencies. The LSCB recently undertook a questionnaire with its members about how able they feel to challenge other board members, and also how able they felt to be challenged. The responses were reassuring, and the accuracy of them will be monitored over coming months.  44. The LSCB is due to finalise multi-agency safeguarding supervision standards that will set a baseline for all agencies to ensure their supervision about work with children and families is reflective and tests decisions and views appropriately. This will be followed by questionnaires and follow-up sessions with practitioners about    64  how valuable their supervision is, and how it could be improved to assist them in challenging parents when necessary.   45. Finding 5: Insufficient understanding of the nature and impact of domestic abuse, parental substance misuse and parental mental ill health makes child focused decision making unlikely.   46. The Cabinet Office Social Exclusion Task Force published in 2007 a report called Reaching Out: Think Family that detailed how multiple disadvantage can impact on children 'There is a clear relationship between the number of parent-based disadvantages that a family experiences and a range of different ... outcomes for children.' The combination of several parent issues, such as domestic abuse, drug misuse and mental health issues can create a toxic environment for children.  47. LSCB believes that the extent to which child care practitioners and adult practitioners understand this fact is improving, but that in this case there was an issue with this. Practitioners are faced with a difficult balance; to improve the outcomes for children they must assist parents to tackle their own issues, but at the same time they have to keep the child as the focus of their decisions and actions. This is incredibly difficult to do, particularly when families are in a state of chaos, which families with this multiplicity of problems often are. It is difficult not to be drawn into responding in a reactive and 'chaotic' way.   48. There has been significant progress around how practitioners and agencies work together with families in Lancashire over recent months, to try and make support for children as effective as possible. This is being delivered through a commitment by the Children and Young People's Trust and the LSCB to working strategically, operationally and culturally in a more effective way with families to improve outcomes for children and young people. This is a new model of partnership working with families at the heart. A recent workshop provided details about how this new way of working is being developed, and how it links into the Government's 'Troubled Families' scheme: Lancashire Children's Trust - Working Together With Families - Workshop (internet link)  49. Linked to this new way of working with families is the roll out of a Multi Agency Safeguarding Hub (MASH) across the County. This is a proposed service redesign for the Safeguarding referral pathways and the structure through which we deliver both intensive work with families and the Early Support functions across Lancashire. This is part of an overall Transforming Service Delivery Strategy that is signed up to and owned by all partners through the Children and Young People's Trust and the Lancashire Children and Young People's plan.  50. The Transforming Service Delivery Strategy proposes:     65   New common Referral/Request for Service pathways centred upon the creation of a new Multi Agency Safeguarding Hub (MASH)  An integrated model facilitating step up and step down between Safeguarding and Early Support/Intensive work with families  The creation of multi-agency delivery hubs and the co-location of services  New Early Support commissioning arrangements  The refreshing of common assessment processes and structures  51. The aim of these significant developments in how agencies work together with families is that children and their families will receive the appropriate joined up support they need at an early stage. The multiplicity of parental issues will be identified and addressed by practitioners coming together and working together with their relevant skills, knowledge and expertise.   52. Whilst this significant action is being progressed, the LSCB continues to promote the messages about multiple disadvantage and the risks it poses to children and young people. The SCR briefings that the LSCB has been delivering on a regular basis for the last eighteen months have a section about 'The Toxic Trio' (mental health issues, substances misuse and domestic abuse). Practitioners are given real case examples about the impact these issues can have when they co-exist, and are told to seek 'expert' help if they are not sure. They are given advice about how to accurately assess the risks that may be present, and also about how adult issues can divert focus away from the children.   53. The LSCB has also created a new, in depth training course for practitioners this year called 'The Toxic Trio', and this is currently being offered and delivered to practitioners across all agencies. With the addition of the improved reflective supervision standards in Social Care, the practitioner questionnaire about supervision and the planned practitioner forums, the LSCB is committed to addressing the issue of practitioner confidence about multiple parental disadvantages. However, the LSCB recognises that this is a national issue, and would welcome the DfE's plans on how to address the issue on a national basis.   54. FINDING 6   Pre-birth assessments that are started at predetermined points are not sensitive to risk in particular cases and can lose valuable time in assessing and planning.  55. It is not clear in this finding whether the 'pre-birth assessment' being discussed is one that would involve Children's Social Care, or whether it refers to a CAF that may be completed by agencies prior to a referral to Social Care. However, as a statement, it would hold true that a 'one size fits all' timescale for any assessment could be detrimental. The LSCB is not convinced that in this case it had any impact    66  on the work with the family however, and certainly had no bearing on the ultimate tragic events that precipitated the serious case review.  56. There is an issue in starting a statutory, social care assessment before there is a viable pregnancy; not least the impact this could have on parents. The current pre-birth protocol, which details when and how referrals should be made to social care for a statutory assessment, states that the referral should take place at twenty weeks gestation unless there are exceptional circumstances for it to happen sooner; those being exceptional risks to the unborn baby. There is scope within this policy therefore for agencies to refer to social care earlier than twenty weeks. In this case this did not happen.  57. There seems to be a perceived wisdom held by practitioners in other agencies that social care will not accept referrals prior to twenty weeks, and therefore they do not try to refer until that time. It is not clear whether this is based on fact, or whether it is based on a historical fact that has continued to hold true, or whether it is an untrue perception by agencies. What is clear is that the protocol needs to be revised and agreed by all agencies and publicised to all practitioners.   58. The pre-birth protocol was due to be reviewed at the time this serious case review began in any event, and the process of refreshing it is well underway. The issue of timing of referrals to social care has been keenly debated and will be agreed by the LSCB. The new protocol will be widely publicised within Lancashire. There will remain a timescale for referral to social care, as it has to be acknowledged that there must be a system to allow social care to manage the volume of referrals it receives. However, when the MASH comes into being across the County, this may well change again, and will be reviewed.  59. FINDING   7: An acceptance of poor quality assessments makes timely and appropriate help for families unlikely and can undermine child safety and well-being.  60. This finding has two issues at heart; the first that assessments could be of poor quality, and the second that they are being 'accepted' by managers. The poor quality of the assessment in this case was felt to be a lack of focus on the child, a lack of revision in the light of new evidence and a lack of multi-agency ownership. The LSCB accepts that the assessment in this case was not of the quality it should have been, and that it was subsequently accepted by the manager. The LSCB does not accept that there is an issue with this across the entire County, and this is borne out by the recent Safeguarding and Looked after Children Inspection completed by Ofsted.      67  61. However, there are some issues with core assessments generally on a national basis. Local Authority's have to report nationally on performance with regards to timescales for the completion of Initial and Core Assessments. They do not have to report on the quality of those assessments, although obviously this is something Ofsted report on, and is something that Lancashire Children and Young People's Directorate take very seriously. The proposal to end the reporting of timescales to complete assessments should hopefully lead to more of a focus on the quality of assessments. If key pieces of information are missing, assessments will not be 'late' if they remain incomplete.   62. By setting a timescale for completion, the concept of an assessment being something that is completed and not revisited has been strengthened. An assessment is completed, reported on, and then work with the family continues but formal 're-assessment' is not a required element of the national reporting mechanism or indeed the local IT systems. Hopefully the cessation of completion timescales data will encourage practitioners to view assessment as an ongoing, organic process.   63. This concept of continuous assessment and re-assessment is again something the LSCB promotes through its training and briefings programme. But again, it is an issue that is nationally problematic. The DfE published Social work assessment of children in need: what do we know? Messages from research in March 2011, which concluded that the following points describe the organisational and professional climate needed to support good assessment practice:   A knowledgeable, highly skilled and confident workforce, supported by appropriate education, training and continuing professional development;   A clear framework for reflective „clinical‟ supervision (individual and/or group) and other forms of case-based consultation, including support for practitioners working directly with children;   Resources – in terms of time and staffing, as well as services – to allow practitioners to complete assessments and plan appropriate interventions in a thorough but timely manner;   Good intra-organisational and inter-professional working relationships;   An organisational culture that supports reflection and learning (not a „blame culture‟);   Electronic information management and recording systems that „work with‟ practice, are reliable and not unnecessarily time-consuming; and   „Organisational health checks‟ or audits of the quality of assessments undertaken.   64. The LSCB and its partner agencies are continuously making efforts to try addressing these points. The training and professional development we offer to practitioners on a multi-agency basis has already been detailed to an extent, and    68  individual agencies also deliver a myriad courses and developmental opportunities around assessment. Details of proposed improvements to reflective supervision have also been described. The issue of resources is addressed in every case review undertaken by the LSCB and has not been identified as an issue; nor was it felt to be an issue in the very recent Safeguarding and Looked After Children Inspection completed in Lancashire.   65. Working relationships and cultures are being developed on a continuing basis and the proposed practitioner forums and current Best Practice Panels will hopefully develop this. As these relationships develop, it is hoped that practitioners will feel more confident to contribute to multi-agency assessments and also to challenge one another when appropriate.   66. Social Care in Lancashire are currently in the process of commissioning a new electronic case recording system, which can provide an opportunity to improve on the electronic assessment tools available for social workers. The LSCB has regular updates about the progress of this, and multi-agency partners have the opportunity to comment. However, it will remain the responsibility of social workers to input these assessments onto the electronic record and therefore the possibility of other agencies feeling that social care 'own' the assessments cannot be completely removed. It remains a statutory responsibility for social workers to complete the assessments.   67. Prior to the completion of a social work assessment, there is usually a CAF completed by all agencies involved with the child and the family. The appropriate use and function of the CAF is an issue at times as there is sometimes a view from other professionals that the CAF is a referral form, rather than an assessment tool to assist their work with families. This has been exacerbated by the necessity of the CAF for a social care referral.  68. There is currently in place a project board that is addressing the issue of CAF and Lancashire's 'Continuum of Need', to decide whether there need to be changes to processes and tools. This is a multi-agency group that the Children and Young People's Trust and the LSCB have signed up to. The conclusions of this group will form the basis of future work around CAF, and will link into the Transforming Service Delivery and MASH developments.   69. FINDING   8:  Providing family support and child protection as separate services, with distinct management and supervision arrangements, creates obstacles to responsiveness to families evolving situations, and runs the risk that complex cases are left with staff that are insufficiently skilled and experienced.      69  70. This finding relates to the organisational structure of Children's Social Care within Lancashire County Council, and as such the LSCB has asked them to comment and respond to this finding. The LSCB is keen to note the response to this from children's social care, and will be expecting its multi-agency partners to have a view too. Any issues that emerge from this response will be discussed with the Local Authority. However, it has to be noted that a thorough Safeguarding and Looked After Children Inspection of Lancashire was completed by Ofsted in January 2012, and they found no evidence to support this finding. The review Team in this case felt to be an issue, but it may not be that it is an issue in the current day. The response from Children's Social Care will be carefully considered by the LSCB.  71. FINDING 9   Acceptance of slow and insufficient response to incidents, in part related to predetermining the risk in Child in Need cases, can lead to crises and escalations being poorly evaluated  72.  This finding seems to link to finding 4 about lack of professional challenge and finding 1 about the reluctance to revisit judgements, and details about the LSCB response and the proposed and current actions have already been provided within this report. However, this report identified two other specific queries in relation to responding to incidents.   73. The first was how teamwork around crises could be more coordinated, and the current development of the MASH and the Transformation of Service Delivery is planned to deliver exactly this. The LSCB and partner agencies in the meantime continue to deliver training and briefings about how agencies and practitioners can coordinate their responses to best effect. They also continue to help practitioners understand how to recognise risk.   74. The second specific issue identified was about providing a child protection service 'out of hours' and a culture of a 7 day service as appropriate. Lancashire children's social care has an out of hour's child protection service that deals with any urgent child protection matters that may arise, and this is being developed further. Other agencies also offer emergency support as necessary for example urgent health queries. Children's social care family support service also works with families at weekends too. However, the issue of offering a 24 hour a day 7 day a week routine service from all agencies has not been considered, and would require a significant investment at a time of diminishing resources. This will be an issue the LSCB will discuss further.        70  75. FINDING 10: Using the same meeting category on the ICT system for more than one type of meeting creates confusion and misunderstandings   76. This finding relates to two separate issues. The first is that the IT system did not allow for a specific social care internal meeting, called a 'care planning meeting' to be accurately recorded on the IT system. There was no specific template for it to be recorded and therefore it was recorded as a strategy meeting. This conferred onto the meeting a meaning and purpose that it did not have; most specifically, that it was multi-agency. It was a single agency meeting. The children's social care IT system is being replaced and therefore the issue of recording onto it will be addressed.   77. However, the more pressing element of this finding is that an internal single agency meeting was used as a decision-making forum, and led to a lack of multi-agency involvement in important decisions. The decision not to go into Care Proceedings or to convene a Child Protection Case Conference was made in this single agency meeting without the relevant information and practitioners having involvement. The LSCB has asked for urgent reassurance from children's social care about the function, role, occurrence and multi-agency practitioner understanding of these meetings. It has also requested assurance that they will not take the place of multi-agency forums for information sharing and decision-making, as it did in this case.   78. Conclusion   79. The findings from the review have caused the LSCB to review the activity it is currently engaged in to address the themes that have been identified. A number of these have been recorded nationally as well as locally and we will think creatively how we might supplement and refresh our already considerable efforts to address them.  80. The SCIE Learning Together model is being evaluated independently and the current national consultation around Working Together will also be collating feedback about the process. Lancashire LSCB is heavily involved in the national feedback and therefore has not commented further about its feelings on the process or this particular case and final report in this response.         71  References: Dingwall, R., Eekelaar, J. and Murray, T. (1983) The Protection of Children: state intervention and family life. Oxford : Blackwell. Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C. and Black, J. (2009) Understanding Serious Case Reviews and their Impact: A biennial analysis of serious case reviews 2005-07. Department for Children, Schools and Families. DCSF-RR129. Social Exclusion Task Force, Cabinet Office (Crown Copyright 2007) Reaching Out: Think Family. Analysis and Themes from the Families at Risk Review  Lancashire Safeguarding Children Board June 2012   