Suspected non-accidental injury to a 4-month-old-infant in 2018. Learning themes include: offering families early help; considering the nature of engagement and the refusal to engage with early help; understanding parental risk factors such as parental learning disability, domestic abuse, parental mental health, and parental drug use; considering new information regarding risk including anonymous concerns; environmental difficulties such as housing, homelessness and poverty; neglect and its impact upon child development; seeing patterns of neglect and understanding changes in families in relation to neglect; and communication and information sharing. Recommendations include: consider how to enhance practice and processes to offer the right support to families in cases where early help is refused and unmet need results in repeated contacts being reported; ensure that practitioners respond to new information in the light of the possibility of cumulative harm to a child; revise and refresh the procedures, practice guidance and training in identifying, assessing and making effective interventions where there is suspected parental learning disability or difficulty; ensure that practitioners understand the specifics of the parental risk factors as described in the local neglect strategy when working with any family; when responding to anonymous concerns to any agency, practice should be on a par with other contacts in terms of the scrutiny and weight given to the likelihood and impact of the risk identified by the anonymous referrer and should always be considered within the broader context of what is known about the family; and ensure that information sharing in safeguarding work is effective and serves to support the safety of children.
      
    Serious Case Review No: 2023/C9825  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   Child K –Serious Case Review report v4 30.08.19   1               Serious Case Review in respect of Child K  Independent Reviewer Josie Collier                         Child K –Serious Case Review report v4 30.08.19   2 Index 1.0 Summary of the case _________________________________________________________ 3 2.0 Summary of Learning _________________________________________________________ 3 3.0 Methodology _______________________________________________________________ 4 4.0 Practitioners’ understanding of the family – history and relevance to the period under review. _____________________________________________________________________________ 4 5.0 The context of practice _______________________________________________________ 7 6.0 Theme One: Offering Early Help and responding to the refusal of the offer _____________ 7 7.0 Theme One B: Considering the nature of engagement and the refusal to engage with early help _____________________________________________________________________________ 8 8.0 Theme Two: The specifics of our concern – understanding each parental risk factor and ‘low-level’ concerns. ________________________________________________________________ 9 8.1 Theme Two A: Parental learning disability _______________________________________ 10 8.2 Theme Two B: Domestic abuse and violence. ____________________________________ 11 8.3 Theme Two C: Parental mental health __________________________________________ 12 8.4 Theme Two D: Use of substances – cannabis _____________________________________ 13 8.5 Theme Two E: The specifics of the concerns of others – anonymous referrals, new information and decision-making: ___________________________________________________________ 13 9.0 Theme Three: Environmental difficulties: Housing, Homelessness and Poverty. _________ 14 10.0 Theme Four: Neglect and its impact upon child development - seeing the lived experience of the child. ____________________________________________________________________ 15 11.0 Theme Four: Neglect:  Seeing patterns and understanding changes in families. ________ 16 12.0 Theme Five: Communication and information sharing ____________________________ 17 13.0 Conclusion _______________________________________________________________ 17 14.0 Feedback from practitioners _________________________________________________ 18 15.0 Recommendations _________________________________________________________ 19 16.0 References _______________________________________________________________ 20 17.0 Appendix One – Learning Points for Practitioners ________________________________ 21          Child K –Serious Case Review report v4 30.08.19   3 1.0 Summary of the case  1.1 This Serious Case Review (SCR) was initiated by a Safeguarding Children Board in 2018, following a suspected non-accidental injury to a child aged 4 months old. In order to preserve anonymity this child will be referred to as Child K. Child K was brought by the mother to the GP who sent them to the hospital due to the child’s presentation. Child K was found to have a head injury and there was evidence suggesting similar but older injuries; however, this could not be verified due to a lack of evidence. Practitioners who cared for Child K at hospital described the child’s physical presentation as ‘filthy’ with thick cradle cap and with very sore skin on their neck. Child K’s blanket was smelly, and their dummy was broken. At the time of these injuries the family had three small children, Child K was the youngest and the eldest child, Sibling 1 had just turned two years old.   1.2 The review covers a period of two and a half years commencing from the mother’s presentation to midwifery services regarding the first pregnancy with Sibling 1. The family lived in a neighbouring area (Area 1) but became homeless and moved to the area that commissioned the review (Area 2). The family were known to a range of health and care agencies engaged in preventative and responsive safeguarding in both areas. The family received midwifery and health visiting services throughout the period under review. Sibling 1 was known to Area 1’s Children’s Services. Sibling 2 was born as the family moved from Area 1 to Area 2, and whilst the father, mother and Sibling 1 were staying at the home of paternal relatives. When Sibling 2 was born, the family became known to a range of Area 2 services and their intervention continued for a time when Child K was born.  1.3 In total there were 10 contacts made to social care services in Area 1 and Area 2 and at least an additional 3 calls reporting concerns regarding the children to the police in Area 2. Over this period of time 4 Child and Family (social work) assessments were completed, however it is important to note that at no point did the family receive intervention supported by a multi-agency plan, either as an Early Help plan or under s.17 or s.47 of the Children Act 1989. The family were said to have been referred/notified once to Early Help and Preventative Services (EHPS) in Area 2. Two of the Child and Family assessments recommended that the family could benefit from these services and there were 4 other occasions where early help was suggested to the family. Additionally, there were ‘Concern and Vulnerability’ forms raised by midwifery regarding this family during the first two pregnancies, neither of which resulted in a pre-birth assessment as the mother was not considered eligible under the Area 1 Pre-Birth protocols in place at the time.   2.0 Summary of Learning  2.1 Each agency contributed an agency report regarding their work with this family. There are learning points and recommendations in these reports for the individual agencies to take forward.   2.2 This report provides an analysis of some of the learning themes for multi-agency safeguarding practice in Area 1 and Area 2. In summary these are:  • Offering families early help/ early intervention.  • Managing families that refused early help. • The nature of engagement by the family. • The specifics of safeguarding concerns – understanding parental learning disability; domestic abuse; parental mental health; parental use of cannabis; new information regarding risk including anonymous concerns. Child K –Serious Case Review report v4 30.08.19   4 • Working with homelessness and poverty. • The impact of neglect and the child’s lived experience. • Communication and information-sharing.   There are also a number of learning points for practitioners to consider and reflect on as to the significance to their current practice.   3.0 Methodology  3.1 A total of 11 agencies completed agency reports as required by the SCR’s Terms of Reference. These were submitted and a combined timeline of multi-agency safeguarding work was drafted. There was a practitioner learning event, facilitated by the lead reviewer in order to reflect on practice and develop this analysis of multi-agency practice in the case. Area 1 and Area 2 Safeguarding Children Board’s will disseminate and embed the learning from this case in order to promote effective multi-agency safeguarding practice in the future.   3.2 This report has been reviewed by the Area 2 SCR Panel for the case and was then submitted to Area 2 Board for the learning to be disseminated in practice. The date of publication of this report is not yet known and is dependent on the outcome of the current criminal investigation.   3.3 It would always be the aspiration of the Area 2 Safeguarding Children Board to include the family’s perspective of intervention in the SCR process, however at the time of writing, criminal and public law processes are still underway and so this precludes the involvement of the family in the review.   3.4 This iteration of the report is drafted with publication in mind and thus is anonymised fully. However, some details of the family and events are included in order to emphasise some of the learning points.  This analysis seeks to identify aspects of the safeguarding system which might not work well to promote the most effective practice.    3.5 The independent reviewer is a qualified social worker and works independently as a social work and safeguarding consultant. She has not worked in Area 2 previously.    4.0 Practitioners’ understanding of the family – history and relevance to the period under review.   4.1  4.2 As per the Terms of Reference, agencies were requested to share any known information from the time prior to the start of the review period deemed significant to subsequent agency involvement with the family. The immediate family structure depicted above was known to practitioners in most of the agencies during the period under review, however there was more Mother (aged 24) Sib. 2 (aged 15 months) Father (aged 31) Sibling 1 (aged 25 months Child K (aged 4 months) Child K –Serious Case Review report v4 30.08.19   5 information about the extended family. (N.B. Family members are recorded with their approximate age at the time of the injury to Child K.)  4.3 The agency reports gave details of the father and the mother’s own experience of caregiving as children that potentially impacted upon their own ability to offer care to their children. The extended family and their history were discussed with practitioners – a more fragmented understanding of the family emerged with some agencies knowing about different parts of the family and some agencies knowing nothing. There was information which evidenced the presence of a range of risk factors in the wider family. These factors may have led to ‘cumulative harm’ in terms of the impact on the children.1  There was also evidence to suggest that several relatives had children known to social care. Whilst this might not directly impact upon the quality of parenting in this case it suggests family patterns of maltreatment. It also may mean that the experience of statutory intervention in the wider family network might contribute to how the family regard intervention by different agencies. This historic information was not fully considered together as part of an analysis of risk during the period under review.   4.4 The father was from a minority community and had grown up in Area 2, the mother was  also, from Area 2. Both the father and mother had been known to Area 2 children’s social workers as children, due to suspected neglect and physical abuse. The father was recorded as having received input from Youth Offending Services and Education Welfare Officers as a young person and adult and had 18 criminal convictions for 29 offences, including public order, theft, robbery, burglary, damage and violence towards people including assault on police officers. His last criminal conviction was in 2016.  4.5 Upon request, after queries arose at the Practitioner Learning Event, the Area 2 police agency author retrieved information regarding domestic abuse incidents where the father was the alleged perpetrator. Between 2007 and 2015 he was known to be involved with 5 different women, each of whom had been subject to at least one domestic abuse incident allegedly perpetrated by the father, as well as other behaviours such as harassment. He was arrested on at least 4 occasions and on another was issued a harassment warning.   4.6 Several of these women had had domestic abuse risk assessments (preceding the implementation of Domestic Abuse, Stalking and Harassment (DASH) assessments) or DASH assessments completed around the risk posed by the father.  There were 9 risks assessments recorded: 8 concluded that the woman was at medium risk of harm and 1 recorded a ‘standard’ level of risk. Two of these women were known to be mothers. The first of these women had a child. This child was said to believe that the father was her father. However, the father subsequently told practitioners that this was not the case. The second of these women stated to Area 2 police officers in 2014 that she had agreed with Area 2 SCS in 2013 that she would not let the father have contact with her child. This was not known to the practitioners involved in the review process regarding this child.     4.7 There is information held on agency records that as a child the mother was known by different agencies to have, as variously described, a diagnosed learning disability/a global developmental delay/ learning difficulty. Further information sought showed that the mother had a statement of Special Education Needs from 2002, when she was 8 years old. This showed her as a child to have general learning difficulties, manifesting in cognitive function and an inability to understand information.  During the period under review, the mother informed various practitioners that she had “learning difficulties” which impacted upon her ability to read and  1 Sidebotham and Brandon et al: 2016: 75 Child K –Serious Case Review report v4 30.08.19   6 write. When the mother was 16, a doctor reported that she was not able to fully consent to sexual activity as she was not “fully Fraser-competent”, suggesting her learning needs had a significant impact upon her understanding.   4.8 As a child, the mother was alleged to have been sexually abused by her brother (aged 13). The mother also featured as part of domestic abuse incidents involving the maternal grandmother and her husband. They were both recorded to be alcoholics and from aged 10-15 the mother was alleged to have been subject to physical and emotional abuse and threats from various family members. The mother moved homes between her mother (the maternal grandmother) and her aunt.   4.9 The mother and father are believed to have started their relationship during 2013. In Jan 2015 the maternal grandmother reported to the police that the father had assaulted the mother. The mother did not want to engage with police, however safety planning was considered and offered.  She was assessed as being at medium risk of harm, using the DASH assessment.  The police agency report offered the rationale behind the medium risk assessment was that it was clear from relatives that this was not the first incident of assault or abuse in which the mother was the victim.  No further action was taken against the father due to conflicting accounts and the mother’s refusal to engage with the police.  There were also two reported domestic incidents between the mother and maternal grandmother in 2015, indicating that the volatile and difficult relationship between the two women had continued into the mother’s adulthood. This indicates that the mother, as a parent, may not have had an extended family network to rely upon, which was further exacerbated by a sense that the father was not liked by her family, possibly due to domestic abuse in the relationship.   4.10 In 2013 the father was arrested and charged for an assault on a man whom the father perceived was attacking his partner. This incident took place whilst they were under the influence of alcohol. The mother was on the floor and shouting for help to get up, the victim went to assist her, and the father assaulted him. The father received a conviction for Actual Bodily Harm and a suspended sentence. At the beginning of the period under review, the father was known to the Community Rehabilitation Company (CRC) due to the subsequent sentence.  4.11 From the background information, a picture emerges of a family characterised by a range of challenges. This information was already available in parts of the professional safeguarding system. The family’s experience has elements of all of the list of contributory factors to child neglect as outlined in the Area 2 Safeguarding Children Board Neglect Strategy (published in 2017):  • Parental mental health problems  • Parental substance misuse  • Households where there is domestic abuse  • Unemployment  • Poverty  • Poor parental functioning (including learning disabilities)  • Inadequate housing • Homelessness The analysis will focus on some of these areas in terms of how they were understood in this family during the period under review.   Child K –Serious Case Review report v4 30.08.19   7 5.0 The context of practice  5.1 The socio-economic context in which practice in this case took place is one where there have been significant changes over the past few years in how services are delivered. For example, in this case the midwife only saw the expectant mother in clinic rather than at home. Other challenges in service provision that time also appear to have directly impacted upon the family in that it had been possible for them to become homeless, a situation which hopefully would now be avoided due to the implementation of The Homelessness Reduction Act (2017) and the resultant statutory duty upon key agencies to prevent homelessness.   5.2 From the agency reports there is some information shared by some agencies that reflects the impact of working within a very busy safeguarding system upon practice e.g. taking up opportunities for supervision and reflective opportunities in safeguarding practice; the need to use temporary staff which was shown to impact upon the effectiveness of service provision.   5.3 Conversations with practitioners regarding this case also reveals good practice and effective systems around safeguarding work with this family – for example, there was evidence of the implementation of expected practice frameworks in Health Services; joint visiting during the case between health visitors and social workers and a good handover from Area 1 to Area 2 for Children’s Services, Midwifery and Health Visiting.   6.0 Theme One: Offering Early Help and responding to the refusal of the offer  6.1 This is the defining theme in this case and is one which arises from the legal and statutory safeguarding system. On at least seven occasions, professionals recommended or recorded that the family would benefit with intervention from early help services in order to support their parenting, including at the end of the second and fourth social work assessment. Within the Area 2 threshold document in operation at the time, the application of that threshold between preventative and responsive safeguarding services did not ensure that the family got the right support in a timely way as the family refused, and were not required to, take up the offer of early help. Therefore, the need for parenting intervention was not met. An observation by practitioners was made that it is sometimes difficult to explain what the concept of ‘early help’ means to families and that there is a skill in helping families identify for themselves that they might need such help. The approach to this has now changed in Area 2: a continuum of need and risk is best supported by a continuum of evidence-based support; therefore, the new Area 2 Support Levels appear as a framework which address this learning theme.   6.2 Towards the end of the period under review at the end of the fourth Child and Family assessment, the father researched the requirements of families regarding acceptance of the early help suggested and established that engagement with any early help service was voluntary. This rejection of early help was made at the same time as ongoing positive engagement with health visiting which offered reassurance to the professionals that the family were receiving some support. The health visitor understood from the mother that she was visiting the GP. The GP noted that he was re-assured to hear from the mother that she was seeing the health visitor regularly. There was no discussion between these practitioners to identify what shared support was being offered, only what was reported by the mother herself.  6.3 Due to issues in health intra-agency reporting systems in Area 1, this family also did not benefit from joint working between midwifery and health visiting in terms of receiving early intervention during the first pregnancy. It was felt that this system problem would not occur now in Area 1.  Child K –Serious Case Review report v4 30.08.19   8  6.4 Some decisions were made not to intervene with the family when subsequent safeguarding concerns were reported suggested possible ‘fixed thinking’ in that they were based on the fact that there had been a recent Child and Family assessment completed, even though two previous assessments had also identified unmet need.  6.5 In managing the refusal by a family of an offer of early help, practitioners were fully aware that the family could be re-referred due to that unmet need. When this occurs, there is a need to balance the avoidance of repeated referral and assessments of families with ensuring the safety and wellbeing of children in families. There is also a need to avoid ‘start-again’ syndrome through building an analysis on the existing information. It would not be wise to recommend setting up a new process to monitor families refusing early help which could become a bureaucratic burden; however, some solutions may lie in practice; some practitioners reported that they utilise these already. For example:   • Highlighting unmet need and identifying the ‘weight’ of already known information where there is a refusal of early help. • Recording clear contingencies in responding should new information about the family should be reported within a certain space of time.  • Monitoring re-referrals and unmet need within the MASH/ Front Door. • Reinforcing useful practice frameworks – for example, utilising Signs of Safety in Area 2 or Strengthening families in Area 1 to ensure more effective mapping of strengths/ risks or danger/safety and what might need to change at the point of ending the assessment or updating the Graded Care Profile assessment at the point of case closure. • Pro-actively supporting engagement by families with other services to meet need and sharing with consent the assessment of unmet need with universal services that participated with this assessment e.g. the G.P. and health visiting.    Recommendation One: Both Area 1 SCB and Area 2 SCB should consider how to enhance practice and processes to offer the ‘right’ support to families in cases where early help is refused and unmet need results in repeated contacts / concerns being reported. This will include ensuring that practitioners respond to new information in the light of the possibility of ‘cumulative harm’ to a child or young person. In some families, repeated refusals of help to meet need and risk without evidence of positive change should be seen as a ‘red flag’ by those in practice.  6.6 Overall, it appears as though the support given, and interventions offered made with this family sat most at the ‘right’, but fairly rigid, level within the threshold document given what was known to practitioners at the time, with some need identified. There were at least two decisions made that agencies have identified as opportunities to intervene which were not taken. The family never engaged with any early help service beyond appointments in clinic with midwives; home visiting by the health visitor; and visits to the GP. There is no evidence of any attendance at ante-natal or post-natal groups; parent and toddler groups or parenting groups.   7.0 Theme One B: Considering the nature of engagement and the refusal to engage with early help  7.1 Engagement by the family with health visiting and midwifery was reported as good, practitioners were very committed, and this acted as a protective factor for the children in this family. However, engagement was perhaps more conditional for the family with other agencies Child K –Serious Case Review report v4 30.08.19   9 such as housing and social care. It was reported that on occasion the father was evasive regarding giving requested information to housing services towards whom he had shown some animosity. The health visitor and the social worker did try to explore their refusal of early help with the family but were often met with the response from parents that they would “think about it”. Negative experiences of intervention can often prevent future intervention, and reluctance and blocks to engage can arise from a fear of something new or unknown.2  Examining these areas with families requires a skilled approach by practitioners.  One social worker described how she tried with all families to support their engagement with early help in creative ways which appear as good and tenacious practice.   7.2 Though the family appeared accepting of social workers during the earlier part of the period under review, the social worker involved towards the end of the period under review suggested that the father appeared to dislike her and requested that she was removed from the case. It was also reported by her manager that this social worker had begun to challenge the family a little bit more regarding their lifestyle and parenting. It was also reported that the father had been heard being openly racist about the social worker. Participants suggested that a family’s racist views might be an obstacle to their engagement, but it was also suggested that such behaviour from service users should also be considered as a possible hate crime and should also be considered relevant in terms of decision-making around the safety of the child.    7.3 During the Practitioner Learning Event, practitioners demonstrated some culturally competent thinking in their consideration of the father’s ethnicity, and this is noted in some but not all of the agency reports. They reflected upon his sense of pride in his family, showed their understanding of some of the family’s ‘ways’ and discussed how they had tackled some of these issues sensitively with the family, for example acknowledging the importance for the father of providing food to his children within the context of his culture, whilst at the same time challenging the less than healthy food that he was providing.  Practitioners were also aware that as she did not share the same heritage and so the mother was isolated from some of the paternal extended family and was said not to like them. What is not clear is whether there was any explicit discussion with the father and mother about the father’s cultural background and what that meant for their parenting style and sense of family as well as for the family’s willingness to engage with services.   8.0 Theme Two: The specifics of our concern – understanding each parental risk factor and ‘low-level’ concerns.  8.0.1 This case offers a worrying but very real perspective on the potential for the lack of a shared understanding of risk in the family arising from parental factors, where families present as requiring lower levels of support.  There was historical and current evidence regarding risk factors such as parental mental health, domestic violence, possible parental learning disability 3 in this and the previous generation of this family. All of the contacts regarding concerns about the family made to Area 1 and Area 2 social care services are based on elements of recognised risk factors and appear as appropriate contacts or referrals. The decision to initiate assessments on 4 referrals was appropriate, although there were other contacts where the decision making did not appear to match the reported risks. It is relevant to emphasise the number of concerns raised to social care and police by practitioners (9) and members of the public (4) in less than  2 Ferguson (2011:175) suggests a range of blocks to intervention including a dislike of the system, worker or offer; fear of criminalisation; or personal characteristics in the family arising from their own trauma. 3 Sidebotham and Brandon et al: 2016: 75 Child K –Serious Case Review report v4 30.08.19   10 three years of the period under review. Whilst the family may not have stood out against other families using services, they clearly looked to others like a family that needed help and support.    8.0.2 How much detail about these parental factors might have been expected to be understood or explored with the family by practitioners working at levels 2 and 3 of the Area 2 Inter-agency Threshold Criteria (now replaced) is debatable, although such detail would be desirable in order to inform intervention.  Some agency reports noted a shortfall in meeting agency expectations around understanding these factors, for example the lack of exploration of the wider family with the agency’s Family Health Needs Assessment by Area 1 Community Health or not giving consideration to the father’s family by the CRC.   8.0.3 The family were subject to four social work Child and Family assessments under s17– two by Area 1 Children’s Services and two by Area 2 SCS, and social workers worked with health visitors.  Whilst none of these assessments appear to have led to a ‘Child in Need’ plan, a Child and Family assessment would be expected to deepen an understanding of the family’s needs and the possible risks to a child. In this case, agency concerns around these different family challenges varied, and relied mainly upon the information offered by the family themselves. Some information was ‘checked out’ by social workers but information regarding the family’s history was not fully utilised to assess risk. A social worker at the Practitioner Learning Event noted how much information came to light at the event that they had not been aware of. To develop this learning theme further, this analysis will examine how practitioners worked well with each risk factor or concern in order to identify good practice and what might be done differently in future practice.   8.1 Theme Two A: Parental learning disability  8.1.1 The father was known to have had low educational attendance, which some practitioners attributed to a cultural norm of not attending school in adolescence. He was thought to have a diagnosis of ADHD, although this was self-reported. The mother was variously described in agency reports as having some form of learning disability. There was no shared understanding of this as a possible challenge to parenting capacity. The GP reported having no information about this diagnosis on his records.  An Area 2 social worker recorded their concern regarding mother’s cognition and level of understanding after the first home visit in 2017. She was accompanied by a friend or relative to nearly all of her ante-natal appointments when pregnant with Sibling 1.  What is unclear is the extent to which the historical information regarding this type of diagnosis might be expected to ‘travel’ as a child becomes an adult without a formal transition from children to adults’ service or without support from the family for it to do so.   8.1.2 Practitioners identified that there was clearly some level of impairment to the mother’s understanding and described their sensitive and intuitive practice, both in pitching the advice they gave at a particular level so the mother could understand it and in ‘checking back’ to ascertain her understanding of their advice. In response to this, practitioners noted that the changes that they had suggested were often made quickly, indicating some understanding on the part of the parents. The GP said that the mother was able to follow his advice around treatment. Practitioners did not feel that the parents ‘stood out’ in terms of their cognitive functioning. However, there is also some evidence regarding how parents may well have misunderstood some of the advice or information shared by practitioners. Examples include not understanding healthy eating advice, providing evidence for housing application processes; the father misunderstanding a letter from the council which requested information regarding housing benefits to recover unpaid council tax, but was understood as a demand from the Child K –Serious Case Review report v4 30.08.19   11 bailiffs by the father; and the couple building up rent arrears even with the council’s Floating Support service in place. Additionally, the mother repeated her understanding to practitioners that her children were subject to ‘Child in Need’ plans in Area 1 and in Area 2 on several occasions despite this not being the case.  8.1.3 Although checks were done by an Area 2 social worker to ascertain whether the mother had had input from adult services, it is not clear as to whether practitioners followed the advice of  Area 2 SCB procedures to access sources of information about the mother’s possible learning disability4 and therefore the possible limitations on her parenting and so the resultant risks appear as only vaguely understood.  Learning disability can impact different areas of functioning to varying degrees and so understanding a parent’s strengths, needs, relationships and barriers they face is vital5. The efforts of practitioners to make improvements to parenting may not have been appropriate to the mother’s learning disability. The concept of families moving through a system of intervention from having a problem to resolution and positive outcome might not have been helpful for this family where the parents have a learning disability.  National practice guidance suggests that long term support may be required6 – firstly as a cognitive impairment does not go away and secondly because the needs of children change as they develop and so the parent may need to learn new parenting skills to respond to these needs.   Recommendation Two: Area 2 SCB to revise and refresh the procedures, practice guidance and training in identifying, assessing and making effective interventions where there is suspected parental learning disability/ difficulty.  8.2 Theme Two B: Domestic abuse and violence.   8.2.1 From the agency reports and the practitioner learning event, it is apparent that the level of risk to the children from domestic abuse does not appear to have been understood or shared across the professional network in terms of the father’s behaviour. The mother was open that there had been some domestic violence in the past.  During the period under review there were no reports to the police of incidents between the couple. The second Child and Family assessment was initiated by a police notification that father had been released from prison and was a ‘known serial domestic abuse offender’ and so the Area 1 social worker identified that she had checked his history as a perpetrator. There was a wider range of information held by Area 2 Police about the father’s violent behaviour as described at paragraphs 4.5 and 4.6.   8.2.2 Practitioners identified that the ‘vague’ terms to describe the assessed risk in several different agencies (i.e. low, medium and high) did not support developing a shared understanding of risk amongst practitioners both between and within agencies, and probably would mean nothing to the general public. There was also a shared view at the practitioner event that the CAADA DASH risk assessment could give a subjective picture of possible harm. The police had put warnings on the father’s record as he had been the subject of more than one call out to more than one victim. He was also known for aggression towards police officers, but this was not known by other agencies. This could have compromised the safety of practitioners from other agencies visiting the family home.   8.2.3 This evidence of father’s propensity to violence more broadly was not considered as possibly symptomatic of an inability to self-regulate and manage his anger. There are incidents where  4 (Area 2 SCB Procedures 2.2.14 Parental Learning Disability) 5 Working Together with Parents Network (WTPN) 2016. 6 Ibid. Child K –Serious Case Review report v4 30.08.19   12 father’s anger and hostility are clearly visible and aimed at practitioners. The period under review is ‘book-ended’ by an incident at the beginning where the father is arrested after criminal damage upon being breached for failing to comply with his community order. Towards the end of the period under review, the police are called to an occasion when the father was smashing property at the family home whilst the children were in his sole care. The father reported to police that he was ‘venting his anger’. These instances appear to have been considered in isolation and thus as ‘low-level’ but should have appeared as more significant when considering that the father was caring for his infant children during some of these times.   8.2.4 Despite little understanding across agencies of the previous severity of risk to women arising from domestic abuse by the father, practitioners were mindful of evidence of past domestic abuse in the couple’s relationship and were able to evidence their activity and resultant rationale for not feeling that domestic abuse by the father to the mother was a risk during their involvement. There appeared to be a number of appropriate direct conversations or ‘safe enquiries’ conducted by practitioners in several agencies, with the mother on her own, regarding the risk of domestic abuse. The agencies where practitioners did not speak with the mother about domestic abuse have identified this as learning.   8.2.5 Practitioners, especially the health visitor, saw the couple together on home visits. This helped to develop a deeper but still partial understanding of the couple’s relationship e.g. how they communicated; that mother had a fear that the father would leave her; that the father was proud of his family and spoke of their plan to marry. During the course of visits to the home there were no observed changes in the mother’s behaviour when the father was absent or present. It was described that on visits when the father was there, he tended to ‘take over’, however, this may have been a cultural behaviour whereby the men in the family tended to lead on working with ‘authority’ figures. There may well have been a difference in intellectual capacity which might have led to a dependency by the mother upon the father. There is also the possibility of the mother not recognising abusive behaviour. A challenge in understanding the risk of domestic abuse is in balancing what a practitioner sees in front of them versus less tangible evidence, for example, historical information or concerns reported by family members.      8.3 Theme Two C: Parental mental health  8.3.1 Currently there is no information available to this review regarding the father’s mental health. It is confirmed that there was no engagement by the father with mental health services or the GP regarding this.  8.3.2 The mother was very open with practitioners regarding her anxiety and depression and cooperated fully with the standard screening and assessment activity with each new birth regarding her post-natal mental health. Mother told the health visitor about her engagement with the GP regarding her mental health and around her use of prescribed anti-depressant medication. She also informed the health visitor when she had unilaterally stopped taking medication during pregnancy. The mother refused suggestions that she access counselling and some agencies did not have knowledge of the vulnerabilities arising from the mother’s childhood. The mother’s openness about her depression during the period under review seems to have led to an over-reliance on the mother’s self-reporting rather than an assessment of how her mental health impacted on her capacity to care for her children which drew on multi-agency information and professional judgement. The lack of communication by the health visitor with the GP treating mother for depression may have been useful at the point of the end of the Child K –Serious Case Review report v4 30.08.19   13 targeted regular visiting by the health visitor as the mother had reported an increase in her medication to the health visitor.   8.3.3 The GP reported that the mother attended surgery twice in early 2018 regarding her mental health. Mother reported herself to be ‘stressed out and moody’.  She also reported being stressed about the break-up of her relationship with the father, a fact which was not known by other agencies. On the first visit there had been some confusion with her receiving the right medication and so she wanted her prescription to be altered. The GP described his thorough approach in exploring how her mental health impacted upon her, asking her about possible self-harm and any ideation of harm towards the baby. It appears as though the mother was able to appropriately seek help and manage her medication for depression.   8.4 Theme Two D: Use of substances – cannabis  8.4.1 The father’s use of cannabis and any resultant risk to the children was the focus of proportionate professional inquiry by staff from a range of agencies. The father was very open about his use of cannabis and when practitioners responded to reports made to the police and to social workers regarding cannabis, the father explained to attending officers that he had smoked away from the house in the garden. Some practitioners examined the specifics of the extent of his use with the father and the effect it had on him (e.g. he felt that cannabis calmed him down) and were specific in how they established that this did not pose a risk to children, for example the frequency, location and intensity of his use of cannabis. It was noted that his use of cannabis cost £40 a week, which could present a challenge to a family with limited financial resources.   8.4.2 More broadly, there are some instances and descriptions of an often-busy household from practitioners. Some of these also include examples of social drinking and from the perspective of a neighbour who made reports, the misuse of alcohol and drugs which posed a threat to the children of the household. However, the practitioners in this case were clear that they did not see signs of the use of substances influencing parental capacity in this case, comparing this to other cases where substance misuse is more obvious and clearly harmful. Practitioners asked mother about her use of substances: she does not appear to have used cannabis or other drugs.  Recommendation Three: Area 2 SCB should ensure that practitioners understand the specifics of the parental risk factors as described in the Neglect Strategy when working with any family. Understanding some of these unwanted behaviours or situations in terms of severity (frequency, intensity, duration, and onset) and their impact on children is important.  8.5 Theme Two E: The specifics of the concerns of others – anonymous referrals, new information and decision-making:  8.5.1 During the course of intervention there were several anonymous contacts made to the police and to social care regarding alleged parenting behaviours which potentially could have added to professional understanding of already identified concerns. There are anonymous referrals which are malicious and those which do prompt an appropriate safeguarding response – for example, a welfare check by police. But in this case, there were instances where anonymous referrals were perhaps not examined with the same degree of rigour as other referrals and were considered in isolation from existing knowledge of the family. Some referrals were felt by practitioners not to have had a robust enough response. These include allegations that the dog was sleeping in the child’s cot in Area 1, and that there was a neighbour who had seen a baby Child K –Serious Case Review report v4 30.08.19   14 being dangled from the family’s balcony in Area 2.  New information, even when reported anonymously, can add to the professional understanding of the risks in the family.  8.5.2 In this case, there are instances where the rationale for the decision to close the contact / notification/ referral made regarding new concerns to the police, to both social care services and to the maternity hub in Area 1 was that there had been a recent Child and Family assessment completed. This is despite the identified need for early help input being refused.  Risk is dynamic, circumstances do change and asking the question about what might be different in that instance as compared to the information already known is an important one, especially where there is identified unmet need and the presence of risk factors. In the example of the referral regarding the father’s anger and destruction of property, the Out of Hours service made a decision not to progress the contact based on the recent Child and Family assessment, a decision that was reviewed the next day and approved by the team who had most recently worked with the family.  Recommendation Four: Area 2 SCB should assure itself that practice in responding to anonymous concerns to any agency is on a par with other contacts in terms of the scrutiny and weight given to the likelihood and impact of the risk identified by the anonymous referrer. This should always be considered within the broader context of what is known about the family.   9.0 Theme Three: Environmental difficulties: Housing, Homelessness and Poverty.  9.1 This family were homeless or living in less than suitable accommodation when Sibling 1 and Sibling 2 were born. There were occasions where the father was said to be at work very early in the morning, but it is not clear that his employment was regular. The family were known to struggle with debt. The family’s homelessness was the key concern for practitioners when the family moved to Area 2 from Area 1 and prompted the third Child and Family assessment (the first assessment by Area 2 SCS). During the period under review, the family lived in two different addresses in Area 1 and the tenancies were in the mother’s name only. The second of these tenancies was terminated whilst the mother was pregnant with Sibling 2.  Area 1 Strategic Housing were candid in sharing that despite it not yet being a statutory duty at the time of their involvement, their housing officers were expected to prevent or relieve homelessness.  In this case the housing officer had not made efforts to do so. The family were then seen by practitioners whilst they lived at two different homes of family members in Area 2; then moved to a temporary address for just under 3 months before moving to a permanent address. Research findings suggested that homelessness is potentially harmful to an infant child’s development. 7   9.2 Descriptions of the 2-bedroom property on the second floor of a housing development that became the family’s permanent tenancy were that it was a challenging environment for families. Practitioners reported that the floors were hard and there was damp and mould in many of the flats. There was no lift. There was no outdoor play space for children. The efforts of practitioners were often focussed on ensuring that the family had enough of some of the  7 ‘An Unstable start for Babies’ (NSPCC 2015), the NSPCC and Anna Freud centre note that “homelessness and temporary accommodation during pregnancy are associated with an increased risk of preterm birth, low birth weight, poor mental health in infants and children, and developmental delay. All of these factors are, in turn, associated with the risk of poor outcomes in later life” (p17-8).  Child K –Serious Case Review report v4 30.08.19   15 basic items required through making referrals to local charities. In this case, it appears as though practitioners showed sensitivity and kindness and were sympathetic regarding the challenges that the family faced regarding housing and poverty and were supportive in trying to access practical resources on their behalf. What is not clear is how the family coped in this environment with two, then three small children, and how they overcame potential isolation.    10.0 Theme Four: Neglect and its impact upon child development - seeing the lived experience of the child.  10.1 The key risk that practitioners are managing when working to safeguard children is that a child’s development will be impaired or significantly harmed by the behaviours of others. In the case of infants that are seriously physically harmed, this is most likely to be within the family setting. 8   10.2 The injury to Child K is believed to have arisen from physical abuse through shaking. There was also some evidence identified in the hospital of Child K failing to thrive, however the trajectory of this failure is not clear, as the work of practitioners in monitoring physical signs of this appears as robust during their intervention.  From the outset of professional involvement, a main concern for the children was the possible developmental impact of neglectful parenting and some practitioners gave detailed accounts of observations they had made regarding parent-child interaction and around the physical care and presentation of the children. The parents were seen to be warm towards the children and on the whole, the children were clean. The GP reported that the mother was attentive to Child K, and able to follow the treatment advised for nappy rash and presented the child for a follow-up appointment.  On only one occasion did the health visitor in Area 2, who visited on a monthly basis for over a year, note her concern regarding Sibling 1 appearing as ‘lost’ amongst adults in a busy household. She described the parents missing basic cues and signals from the child e.g. failing to respond to the child being thirsty and more generally needing their attention. On two other occasions, the police may have witnessed an angry parent on their last visit during the period under review; and a temporary housing provider had reported the father as mishandling Sibling 1.   10.3 There was not always a consistently positive assessment of the children’s development – Sibling 2 was slow to grow after having tummy bugs, possibly arising from poor hygiene around feeding at around 8 weeks old. The weight of Child K did not give cause for concern during the first two months of life although the infant had dropped one centile at the 6-8-week health visiting review (a drop of two centiles would prompt concern and action).  After this point, there is no evidence that Child K was weighed for 11 weeks prior to the injury, and upon admission to hospital as a result of that injury, there were signs of poor weight gain/ weight loss. Sibling 1 was noted as showing signs of developmental delay in his communication and fine motor skills towards the end of the period under review.   10.4 Some agencies noted that there were limitations in their practice in understanding the child’s lived experience in this case.  This included social workers having limited time to observe parent-child interaction and the frontline police focussing on the physical signs of neglect rather than gaining an understanding of the emotional impact on children of maltreatment. However, there was also some very good practice in making joint observations of the children in this family by health visitors and social workers.  Particularly striking was the in-depth description  8 Sidebotham and Brandon et al 2016: 65. Child K –Serious Case Review report v4 30.08.19   16 of aspects of the children’s presentation that the social worker and health visitor observed on the last joint visit that they made.  10.5 In summary, most practitioners were looking in the right direction when trying to  understand the children’s lived experience, but again the intermittent nature of some agencies’ case involvement and the refusal by the family to engage in further intervention meant that the opportunity to really understand the child’s lived experience was not taken.  11.0 Theme Four: Neglect:  Seeing patterns and understanding changes in families.  11.1 As outlined in the previous section, there were developmental indicators that when looked at together appear indicative of repeated patterns of impairment to development arising from parenting, where suggested changes by practitioners were not sustained. In this case it is not clear whether agencies were thinking about change in and changes to the family which had an impact. In most agencies the purpose of intervention is to bring about some form of positive difference – whether that is assisting parents to help a child move through the series of developmental tasks in order to progress9 or to ensure that parental behaviour changes in order to reduce harm.   11.2 There were patterns in the signs of neglect in this family which could have been recognised. All three children developed a flattening on the back of their heads (plagiocephaly) and with each child this was addressed by giving the same health messages about how to give the child ‘tummy time’ and not leave them lying down too often in a buggy or bouncy chair, however flattening was evidenced in each child. This is suggestive of a lack of ability to apply the messages around the child’s needs in each successive child. Another example of a pattern not changing appears regarding the need to give subsequent advice regarding hygiene, for example, around baby bottles and cleaning dummies after the birth of Sibling 2 despite this being the subject previous concern when Sibling 1 was born. The broken and dirty dummy features again when the third child, Child K, presented at hospital with head injuries.   11.3 It is acknowledged that it is often hard to stand back and look at these patterns when in the midst of a busy working environment. The use of tools or frameworks that map change and progress in families and their care-giving behaviour across Area 1 and Area 2 differ and the extent to which they are ‘embedded’ in practice are varied between and within these two areas.  A simple tool is a multi-agency chronology, especially around the point of decision making or in resolving professional disagreements. As a reflective tool, the chronology can support recognising patterns and responses to change, and whether change is sustained. The NSPCC suggest that practitioners do not always look for recurring patterns in a family or children’s presentation, rather they look for small improvements that engender optimism as does positive engagement 10. In this case, messages were acted upon after challenges were made to parents by practitioners, thus giving that sign of a small improvement, but one which was not maintained.  11.4 There was a positive change noted by practitioners in that becoming a parent had had a positive effect on the father. It was understood to have stopped him in terms of his pattern of domestically abusive behaviour towards partners and violent to others.  He was reported as a ‘changed man’. This idea sat alongside with the father’s sense of pride in his family as identified  9 Cicchetti, D., & Valentino, K. 2006 10 Infants: Learning from Case Reviews Nov 2017 Child K –Serious Case Review report v4 30.08.19   17 by practitioners. The mother had also been able to identify on several occasions that arguments and violence were not good for children and during the course of intervention there were no reported domestic incidents.   11.5 The birth of a third child is a significant change for any family. There was an indication that the third pregnancy was not wanted by the father or his family, as the mother informed the health visitor when she became pregnant that they had wanted her to have a termination of the pregnancy. There was perhaps not the level of caution by practitioners as to the implications of Child K being the third child born in 20 months and the parents’ ability to cope with this. Services to the family either ended or were reduced less than two months after the birth of Child K.11    11.6 There was a significant change in Child K’s circumstances in the two weeks prior to the injuries being reported. The GP reported the baby generally as being well and observed an “easy baby”. The baby was not weighed by the GP on the last two presentations in mid-April 2018 as there was no cause to do so. In the two weeks after this there was a rapid change in Child K’s experience which is not yet understood. It is not for this review to hypothesise around that, but to draw from this that negative change in an infant’s health and wellbeing can be rapid in the light of the reports regarding Child K’s physical presentation at hospital.   12.0 Theme Five: Communication and information sharing  12.1 Information sharing is repeatedly identified as a challenge to effective safeguarding and deeply entrenched systemic issues can prevent effective information-sharing 12. In this case, there appears to be a real variability in practice regarding the sharing of information between practitioners and agencies. In some parts of the system it worked very well, and in others, perhaps due to the lack of a legal imperative to share, key information does not seem to have been sought or forthcoming around significant risks (see section 8), and perhaps this is to be expected due to the status of the case as ‘low-level’.    12.2 From Child K’s GP records there is no evidence that the GP sought any information with other health staff involved, despite Child K presenting with a condition that the health visitor could have been support the parent in managing. This is despite the fact that Child K had been identified within the GP’s medical notes as a ‘vulnerable child’ and mother was known to have a mental illness which was managed by the GP. However, the GP did not feel that there was the need: the mother’s engagement was seemed to be positive and she followed the GP’s advice and treatment.   Recommendation Five: Given the national evidence and local evidence from previous safeguarding reviews and current practice,  Area 2 SCB should assure itself that information-sharing in safeguarding work is effective and serves to support the safety of children.  13.0 Conclusion  13.1 Whilst the physical injuries to Child K were not predictable, this case has significant learning arising from it for individual agencies around working families where there is the presence of several risk factors. Agency reports on the whole have been candid and informative and there  11 The NSPCC (2016) found evidence in other case reviews that suggest that the birth of a baby “can lead to a tendency to see the birth of a new baby as an opportunity for a fresh start. Sometimes this may hinder practitioners from recognising pre-existing patterns in parents’ behaviour which pose a risk to the baby” 12 Brandon et al 2016: 164 Child K –Serious Case Review report v4 30.08.19   18 is evidence of an impact upon practice from this review. Details of this can be found in the single agency reports and summary of learning and in the ongoing processes within agencies to embed the learning from the agency reports.   13.2 There are some families who despite identified need and professional signposting do not take up the offer of preventative support, from the more structured interventions that might be offered by district services or from more flexible offers that might be on offer through children’s centres or voluntary/ community groups. This type of refusal can in itself be seen as a potential vulnerability and should be explored in order to avoid unmet need and risk to children escalating.   13.3 The evidence suggests that it is more difficult to identify and understand the level of risk in families without formal processes such as CAF/ Team around the Family/Early Help plans/ Child in Need or Child Protection being in place, or shared practice tools being implemented effectively e.g. (Signs of Safety or the Graded Care Profile 2). Different agencies had different understandings of what ‘risk’ meant and the identification and response to risk remains vague without robust assessment and intervention plans.   13.4 This family was not one where there were only emerging signs of risk.  Agencies held information which signified potential significant risk to children, however it was never pulled together in a comprehensive enough multi-agency assessment in order to inform appropriate intervention. This family did not stand out during the period under review, but there was information regarding known risk and vulnerability in the past which was not explored for the relevance to the children in the family. Working with and understanding child neglect appears to pose a series of challenges around understanding the severity and impact of neglect especially where the family composition changes.  13.5 In this case, during the last few weeks of the period under review, something significantly changed for Child K in terms of the caregiving he was receiving. The child’s physical presentation had changed radically from that witnessed by practitioners not long before the injuries were known. Change in families and the circumstances for children can be very rapid and unpredictable.   14.0 Feedback from practitioners  14.1 As part of their contribution to this review, practitioners were asked to give their summary analysis of multi-agency safeguarding practice in this case through answering the following questions: What aspects of multi-agency practice in this case went well? • Good engagement with family and practitioners although it is clear there was selective engagement. However, it was acknowledged that this could be cultural. • Good evidence of joint working between agencies including communication and shared activity between midwifery and health visiting in Area 2; social workers and health visitors in Area 1 and in Area 2; and across the two areas of Area 1 and Area 2. • Triangulation of information when the child presented at hospital. • Referrals and reports of concern regarding this family were appropriate.  Child K –Serious Case Review report v4 30.08.19   19 What might have been done differently in multi-agency practice in this case? ▪ There was a lack of information to some agencies about what was known. Information-sharing continues to be a challenge to effective practice.  ▪ There were several contacts within a short period of time, but the case did not reach the threshold which would lead to statutory intervention. ▪ Applying the thresholds on these types of cases are challenging (NB – these are now known as support levels.  ▪ There was no engagement with services for adults. ▪ There is a gap in service provision when working with families with low level learning difficulties. Parents may not recognise the difficulties that arise. ▪ Decision-making around the last referral.   What might need to change and what need to happen to bring about this change for future practice? ▪ Considerations when working with non-verbal children. ▪ Practitioners working in a multi-agency system should meet following single-agency assessments to pull information together.  15.0 Recommendations  Recommendation One: Both Area 1 SCB and Area 2 SCB should consider how to enhance practice and processes to offer the ‘right’ support to families in cases where early help is refused and unmet need results in repeated contacts / concerns being reported. This will include ensuring that practitioners respond to new information in the light of the possibility of cumulative harm to a child or young person. In some families, repeated refusals of help to meet need and risk without evidence of positive change should be seen as a ‘red flag’ by those in practice.  Recommendation Two: Area 2 SCB to revise and refresh the procedures, practice guidance and training in identifying and making effective interventions where there is suspected parental learning disability/ difficulty.  Recommendation Three: Area 2 SCB should ensure that practitioners understand the specifics of the parental risk factors as described in the Neglect Strategy when working with any family. Understanding some of these unwanted behaviours or situations in terms of severity (frequency, intensity duration onset) and their impact on children is important.  Recommendation Four: Area 2 SCB should assure itself that practice in responding to anonymous concerns to any agency is on a par with other contacts in terms of the scrutiny and weight given to the likelihood and impact of the risk identified by the anonymous referrer. This should always be considered within the broader context of what is known about the family.   Recommendation Five: Given the national evidence and local evidence from previous safeguarding reviews and current practice, Area 2 SCB should assure itself that information-sharing in safeguarding work is effective and serves to support the safety of children.   Child K –Serious Case Review report v4 30.08.19   20         16.0 References  Brandon, M et al 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005. London: Department for Children, Schools and Families, DCSF-RR023.  Brandon, M et al 2011 Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews. London: Department for Education, DFE-RR110  Cicchetti, D., & Valentino, K. 2006. An ecological transactional perspective on child maltreatment: Failure of the average expectable environment and its influence upon child development. In D. Cicchetti, & D. J. Cohen (Eds.), Developmental psychopathology (2 ed., Vol. 3, pp. 129-201). New York, NY: Wiley.   Ferguson, H Child Protection Practice Palgrave Macmillian, Basingstoke, England.  Horwarth, J 2016 ‘Making a difference to the neglected child’s lived experience’ pp 70- 93 in Gardner, R. and Howe, D. (Eds) 2016 Tackling Child Neglect: Research, Policy and Evidence-Based Practice Jessica Kingsley NSPCC (2015) An Unstable start for Babies: www.nspcc.org.uk NSPCC (2017) Infants: learning from case reviews: Summary of risk factors and learning for improved practice around working with children aged two and under accessed on www.nspcc.org.uk   Sidebotham, P et al 2016 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Department for Education  Working Together with Parents Network (WTPN) 2016 Update of the DoH/DfESGood practice guidance on working with parents with a learning disability (2007). Accessed http://www.bristol.ac.uk/media-library/sites/sps/documents/wtpn/2016%20WTPN%20UPDATE%20OF%20THE%20GPG%20-%20finalised%20with%20cover.pdf          Child K –Serious Case Review report v4 30.08.19   21 17.0 Appendix One – Learning Points for Practitioners  Learning point 1 (para 4.3): Whilst many practitioners may not be in the position to gather in-depth information, understanding the wider family and family history cannot be over-emphasised. There are useful tools and resources for practitioners to do so in an engaging and creative way (SCIE communication skills 2008), in order to identify possible risk factors.   Learning Point 2 (para 6.2): In order to understand more fully the experience of the family, practitioners should not rely solely on the family’s perspective of help and services when trying to identify if and how the family are being helped.   Learning point 3 (para 7.2):  Practitioners should utilise opportunities such as professional conversations and supervision to consider the nature of engagement, whether it feels positive or negative. How resistance to intervention manifests itself may have a significant impact on staff and should always be considered in supervision as part of the duty of care for staff.   Learning Point 4 (para 7.2): When possible, practitioners should consider exploring the family’s experience of past intervention with the family. and actively facilitate engagement with another service if they are suggesting it to a family. This might mean making a phone call; facilitating an initial meeting or accompanying a service user to an appointment.  Learning Point 5 (para 7.3): Practitioners should be curious regarding how families from different communities might regard services and consider how services might be offered in a more culturally sensitive way.   Learning Point 6 (para 8.3):  Assessments should draw upon information from a range of sources both family and professional, current and historical. The past is an indicator of possible future risk; and the family’s history may indicate the risk of cumulative harm to the child/ren. Practitioners should be mindful of what they don’t yet know.  Learning Point 7 (para 8.1.3): Any family where there is a suspected learning disability is assessed to understand the impact upon parenting. This does not require a specialist assessment but an understanding of the specifics of that parent’s capacity around strengths, needs and risks through an assessment that utilises clear mapping techniques and focus on evidence of good practical parenting skills.  Learning Point 8 (para 8.2.2): There are many risk assessment processes that exist in single- and multi-agency safeguarding practice which must be clearly explained as to the specifics of the possible risk of harm rather than using agency ‘shorthand’ or ‘labels’. The use of a shared risk assessment models or frameworks will support developing a shared understanding of risk.   Learning Point 9 (para 8.2.6): Practitioners may need to reflect on domestic abuse and violence within a broader frame of reference, beyond physical assaults in to considering how a child might experience a parent’s uncontrolled rage or anger or their coercive controlling behaviour.   Learning point 10 (para 8.3): Understanding the specifics of the nature of mental illness and the impact of it upon parenting is vital – practitioners can always ask to check with the GP where the GP is managing the mental health condition of a parent.  Learning point 11 (para 8.4): The assessment and management of the possible risk arising from cannabis use appears as balanced and proportionate. This type of curiosity in inquiry into the specifics Child K –Serious Case Review report v4 30.08.19   22 of possible concerns should be applied across practice. Practitioners were confident in ascertaining how cannabis is used, the frequency of its use and where use takes place in order to understand if there is a risk to children.   Learning Point 12 (para 8.5): Information from an anonymous source can take on more significance when seen in the broader family context or when reviewing past intervention that has taken place in the case. It can add to the understanding of the specifics of our concern in terms of understanding the frequency, intensity, duration and onset of the unwanted behaviour which might cause harm to a child.  Learning Point 13 (para 8.5.2): Effective decision making requires practitioners to weigh up new information, including that from anonymous sources, and to consider it in the light of the family history. These reports add to a picture of cumulative harm. Previous case closure does not always mean that all of the risks have been managed or completely reduced.  Learning point 14 (para 9.2):  Homelessness should be considered as a vulnerability and can be a risk factor for the development of young children. Consideration of how homelessness and housing interact with parental risk factors and the child’s development is central to practice.  Learning point 15 (10.4): At this level of intervention, practitioners should always be curious and respectfully uncertain regarding the ‘lived experience’ of the child. This would include considering the actual details of the child’s daily routine and the impact of parental behaviour upon them.   Learning Point 16 (11.1.5): Focussing on the changes that practitioners hope to support in a family and how they might recognise that they have taken place is central to safeguarding. Practitioners should use supervision and peer support to consider the impact of circumstances and changes in and upon the family as well as asking the family as to how changes might be protective or how they might be complicating and adding vulnerability to the children’s situation.  Learning Point 17 (para 12.4): Practitioners should not assume that information has been shared or received, and so if proportionate and legitimate, practitioners should take the opportunity to share information if it means getting the right support to children and their families, as well as seek advice if they are not sure. This is particularly relevant within the health system for GPs, health visitors and midwives who each offer interventions to new-borns which should as a whole add up to a comprehensive offer to the family. Effective practice can be supported by utilising the procedures on the Area 2 SCB website.   