Circumstances around Child N becoming a looked after child at the age of 7. Child N was the fourth child within a sibling group of six children born to the mother (MN) and father (FN). Aged 3 Child N was removed from nursery in an intimidating and threatening manner by FN when he felt that the Early Years Lead was interfering with his family. Health visitors felt that FN was aggressive on a visit to the family home and left under threat. Three years later MN contacted the police when FN physically assaulted an older sibling of Child N. Following this all children were placed in foster care and disclosed physical, sexual, emotional and psychological abuse. FN and MN are both under public law investigations for the abuse against the children. The family was known to Trafford Council, Pennine Care and Greater Manchester Police. Identifies learning lessons in relation to multi agency working maintaining the child as the focus. Recommendations included: focused outcomes and plans for children, the value of multi-agency working, undertaking a thematic audit on working with violence and aggression and developing a strategy to hear the voice of a child for children subject to multi agency procedures.
      
 Title:  Serious case review report: Child N. LSCB: Trafford Safeguarding Children Board Author: Trafford Safeguarding Children Board Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           TLSCB SCR ‘N’   (MAY 2016)  1       Serious Case Review Report  Child N    This report will be published in line with statutory guidance. In order to preserve the anonymity for the children in this family, the author has: • used initials to represent people • made no reference to the gender of children • avoided the use of exact dates • not used any details about local services which could lead to  recognition of the children and family  TLSCB SCR ‘N’   (MAY 2016)  2   Contents   1.  The circumstances which led to a Serious Case Review   2. Methodology, Scope and Terms of Reference 3. Parallel Proceedings  4. Overview of what was known to Agencies  5. The Family Perspective 6. Context in which professionals were working 7. Analysis 8. Learning Outcomes  9. Recommendations    TLSCB SCR ‘N’   (MAY 2016)  3  1 Introduction  1.1 This Serious Case Review (SCR) concerns Child N who became Looked After by the Local Authority at the age of 7 years.  Child N was the fourth child within a sibling group of six children born to the mother (MN) and father (FN) over a period of nine years.  1.2 Aged 3 years, Child N commenced a nursery school which was part of a primary school attended by Child N’s older siblings. Child N was considered to be a timid and somewhat withdrawn child and the Early Years Lead staff member quickly identified Child N as vulnerable. In order to support Child N, and, noting that MN was pregnant with a sixth child, the nursery offered a full time place rather than the more usual part time hours. By the end of the first term, the Early Years Lead had concerns about Child N’s development and had observed a lack of warmth towards Child N by MN. Shortly into the second term, Child N was removed from the nursery by FN in an act that was intimidating and threatening to those present because he considered that the Early Years Lead was interfering within his family.  1.3 Shortly after this incident, a visit to the family home was made by a Health Visitor and Nursery Nurse from the Health Visiting service. This visit was made outside of the core heath visiting programme in order to follow up on the primary visit for Child N’s youngest sibling and                to discuss Child N’s needs. During this visit, and with children present, the Health Visitor and Nursery Nurse experienced FN as extremely angry and aggressive when Child N was discussed and the professionals had to leave the house under threat. The incident was reported to the Police and to Children’s Social Care.  1.4 A Strategy Meeting was convened and following an Initial Assessment, it was agreed that a period of social work intervention was required as the children were identified as Children in Need. Over the following six months, a Core Assessment was completed and four social work visits were made before the case was closed to Children’s Social Care. The Trust providing Health Visiting services communicated to FN and MN that no further health care professional would be visiting the family home and that MN could attend clinics for child health services whilst FN was not permitted to attend any Trust premises.  1.5 A three year period elapsed with the children accessing universal education and health services. Child N was 7 years old when MN contacted the Police and stated that FN had TLSCB SCR ‘N’   (MAY 2016)  4  physically assaulted an older child of the family. When Police attended the property, MN further disclosed that she had also been subject of a sexual assault by FN and he was taken into police custody. The Police Officer attending the property noted that all the children were up late at night and that the house was unkempt and untidy. The Officer applied a vulnerability coding to the recording of the visit so that the Public Protection Investigation Unit (PPIU) would be made aware of the circumstances.  1.6 Initially, the children remained in the care of MN, but over the course of the following week, evidence emerged through a range of sources that MN also had culpability for the harm that the Child N and the siblings had suffered. All of the children were removed from her care and public law proceedings were initiated.  1.7 Once placed in foster care, Child N and siblings made many disclosures about their life with MN and FN, and it became evident that they experienced physical, sexual, emotional and psychological abuse throughout their childhoods. The extent and forms of abuse are shocking and the children lived through highly damaging experiences in a family where fear and control was used to isolate the children from opportunities to connect with, or confide in people outside of the family unit.   1.8 The case was referred to Trafford Local Safeguarding Children Board (TLSCB) for consideration as to whether a SCR or a Learning Review should be undertaken. From information known at that time, it was considered that Child N had been seriously harmed by an adult and there was cause for concern about the way in which local professionals and services had worked to together to safeguard and promote the child’s welfare.   The crux of the determination was the fact that a period of multi-agency working had occurred following an incident from which the family home was considered to be too unsafe for health professionals, but had been determined as safe for the children.  1.9 There was no dissent to the decision to recommend to the TSCB Chair that a serious case review was appropriate.    TLSCB SCR ‘N’   (MAY 2016)  5  2   Methodology  2.1      Working Together 2013 requires that Serious Case Reviews are conducted in a manner which:   • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what, and the underlying reasons that led individuals and organisations to act as they did;  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way that data is collected and analysed; and  • makes use of relevant research and case evidence to inform the findings.  2.2 The TLSCB appointed an Independent Reviewer to facilitate the Review, and a Review Panel of senior officers representing the agencies that had been involved with the family was established. This included: • Director, Safeguarding and Professional Development, Trafford Council  • Head of Service, Pennine Care  • Safeguarding Development Manager, TSCB • Designated  Nurse Safeguarding for Children and Children in Care • Designated Doctor Safeguarding for Children and Children in Care • Detective Sergeant SCR Team, Greater Manchester Police  • Early Years Foundation Stage Consultant, Trafford Council • Senior Tutor, Trafford College 2.3 The Review Panel did not set rigid Terms of Reference from the outset, instead, the Review identified the key issues as they unfolded through scrutiny of professional practice. Each agency submitted a timeline of interventions at the start of the Review and this was chronoIated to illustrate the multi-agency activity, who knew what and when. In addition, each agency completed a brief agency report which addressed the key issues emerging from the single agency timeline of interventions. The general timeline for the Review covered from 2011 to 2015, the period of time from Child N commencing nursery to becoming Looked After TLSCB SCR ‘N’   (MAY 2016)  6  in the care of the Local Authority. Agencies were asked to provide any pertinent information in relation to Child N and the siblings prior to this period.  2.4 In line with statutory guidance, the Review Panel wanted to adopt an approach that involved practitioners directly and at the heart of the Review,  to understand this case and the general practice issues that emerged from the practitioners perspective, but also to maximise the opportunities for reflection and learning. A multi-agency practitioner’s event was planned to review this case, however, shortly before the planned date, new information emerged through the police investigation that meant bringing practitioners together could have been detrimental to a new line of criminal enquiry. For this reason, practitioners were seen individually to talk through their recollections and reflections of the case.  This information was considered by the Review Panel and from this, the following lines of enquiry remerged:  1. To what extent was the significance of family history identified and appreciated; 2. To what extent was the approach to Child In Need robust and complaint with expected standards of practice;  3. To what extent was Child N and siblings  the focus of multi-agency work;  4. To what extent was multi-agency working characterised by trust and/or challenge;  5. What contributed to the circumstances by which MN and FN could disguise a degree of compliance that satisfied agencies that the children were safe in their care?  2.5 Given that this Review was examining practice that took place some four years ago, the Review Panel considered it important to build in the opportunity to establish across agencies the extent to which the findings in relation to practice and the systems that supported it were reflective of current experience. To this end, the Independent Reviewer held two seminars to discuss the issues that emerged from this case, one with a multi-agency group of practitioners and one with a multi-agency group of senior managers. This proved to a very useful exercise in contextualising what can be learnt from this SCR in order to enhance current practice.    TLSCB SCR ‘N’   (MAY 2016)  7  3.   Parallel Proceedings  3.1 The Review was mindful throughout of two concomitant processes. Firstly, Child N and siblings were subject to pubic law proceedings within which the children’s ongoing therapeutic needs were identified in line with plans for permanence. The Review Panel understood this to be an anxious time for the children, and therefore considered any plans to consult the children as part of the Review would need to take place once they felt secure about their future.   3.2 Secondly, a complex police investigation was ongoing. Whilst FN was charged with serious offences against Child N and sibling children early into the process, during the Review significant new information emerged about MN which led to her becoming a suspect of investigation, with the possibility of co-charges with FN. This created additional complexity in the timing of criminal proceedings which are incomplete at the time of this report.   4. Overview of what was known to Agencies 4.1      In 2010, aged 3 years, Child N began attending a Nursery School which was integrated with the Primary School attended by Child N’s three older siblings. The Early Years Lead was keen that Child N accessed maximum support as Child N was identified as needing additional support to aid social development and speech and language. For this reason, and knowing MH to be pregnant with a sixth child the Early Years Lead extended the core offer of a part time place to a full time place. Through observations during the first term, the Early Years Lead developed a concern that the relationship between MN and Child N lacked warmth and noted an occasion at the end of the first term when MN was asked to collect Child N because of illness, MN was angry and stated there was nothing wrong with the child.  4.2 Child N was removed from Nursery shortly into the second term. The Early Years Lead had invited a representative from the local Sure Start programme into Nursery to talk about what support was available locally. On this day, because MN was in hospital with the recently born sixth child, it was FN that attended the Nursery with Child N. FN was described as having dragged Child N away from the Nursery setting once he was made aware that a Sure Start representative was present to speak with parents.  FN stated that he would not have people TLSCB SCR ‘N’   (MAY 2016)  8  interfering with his family and would not allow Child N to attend the Nursery again. The Early Years Lead was alarmed and somewhat surprised by FN’s reaction, and informed both the Primary School Head teacher (also the Designated Safeguarding Lead) and the Health Visitor of what had occurred. The Early Years Lead was particularly concerned that Child N needed the support of Nursery and although Child N never returned to Nursery, the Early Years Lead recalled occasions when she would see MN in the school playground and try to encourage Child N’s return.  4.3 S5, the sixth sibling was born with a blockage to the bowel that required surgery at a regional children’s hospital. This necessitated a lengthy period in hospital whereby MN remained at the hospital leaving FN to care for the five children at home.  4.4 After receiving the information from the Early Years Lead, the Health Visitor made a home visit accompanied by a Health Care Assistant. This was a primary visit following the birth of S5, but the Health Visitor also wished to discuss the health and development of Child N. During the visit, Child N was said to be asleep upstairs and therefore was not seen and FN remained upstairs throughout the visit. MN told the Health Visitor that Child N had attended a speech and language walk-in clinic as well as a hearing and eye appointment with no concerns. It was noted that the health needs of S5 placed additional pressure on the family. 4.5 The Health Visitor returned to the family home approximately three weeks later accompanied by a Nursery Nurse to give advice about S5 and to discuss Child N further.  The Health Visitor had checked records between visits and found that Child N had attended audiology, attended an initial appointment with an orthoptist but did not attend the follow up appointment, but no record could be found of Child N attending a speech and language assessment.  This visit was unannounced and initially only MN was in the home with the children; FN returned to the home part way through the visit. When the Health Visitor said she needed to discuss Child N, FN suddenly became verbally aggressive, shouting and swearing and was extremely upset that the Health Visitor was suggesting there was anything wrong with Child N.  FN said he was sick of the Early Years Lead contacting the Health Visitor about Child N’s development and there was nothing wrong.   The Health Visitor attempted to speak to both parents; however, FN continued to shout, initially with the baby in his arms before passing it over to MN.  FN’s manner became quite erratic, darting in and out of the room and behaving in an intimidating TLSCB SCR ‘N’   (MAY 2016)  9  manner.  The Health Visitor tried to talk to FN and asked him not to shout, reassuring him that her interest was the children’s health. FN responded by saying that the Health Visitor was there to see the baby and not Child N.  When FN walked out of the room, the Health Visitor took the opportunity to ask MN if she wanted any further appointments for Child N which MN declined. FN said that they had finished with everyone and would not be taking the children to further appointments.  At this point, the Health Visitor and Nursery Nurse considered it safest for all concerned if they left the premises. As they were leaving the Nursery Nurse heard FN say if you come back here I will ‘blade’ you.  4.6 The Health Visitor and Nursery Nurse returned to the office shaken by the incident and were concerned that in trying to end the incident safely the children remained in the house.  They had noticed that although Child N and two younger siblings were present, none of the children flinched at the incident and appeared to react as though this was a common occurrence. With support from a Line Manager, a referral was made to the Police and to Children’s Social Care first response MARAT Team. As decision was taken to initiate an investigation under Section 47 Children Act 1989. 4.7 The Police took statements from the Health Visitor and Nursery Nurse and established that FN had a criminal record which included dishonesty, offences against the person and public order. The Police spoke with FN who stated that the Health professionals had misheard him and denied that he had made any threats; FN said that he had said that if they returned be would ‘blame’ them. The Police established that no physical violence was used and there was no charge from this incident as Public Order offences are only relevant if committed outside of the house, therefore FN had not committed any offence and was not liable for arrest. FN was warned about his behaviour. The attending Police Officer recorded the incident and applied a vulnerability coding to his written report. The Officer noted concern that children had been present during this incident, that FN had five children already in care and that from his observations all of the children appeared under nourished and sad. The vulnerability coding meant that the incident was picked up the PPIU, the Sergeant of which was co-located in the MARAT team with Children’s Social Care.  TLSCB SCR ‘N’   (MAY 2016)  10  4.8  A home visit was undertaken by two social workers from the MARAT Team three days after the referral was made. FN, MN and the children were at the family home. FN repeated that the health professionals had misheard what he said but agreed that he did shout but not swear because he believed the Health Visitor was too intrusive. FN stated that he had also removed Child N from Nursery School because he was unhappy that Sure Start were becoming involved. FN told the Social Worker that he had five older children from two separate relationships, that one child was adopted and one child in a residential home from his first relationship and two children adopted from the second relationship. The Social Worker looked around the house including the children’s bedrooms and spoke with the children in the presence of FN and MN. FN was advised to follow up health appointments for Child N and locate alternative Nursery provision if he was not agreeable to a return to the current Nursery.   4.9 Within ten days a Strategy Meeting was held. Fulsome minutes of this meeting indicate that: • FN had previously had an aggressive outburst in the Nursery in front of all the children. For this reason two health professionals visited the home together • FN had said that he had already had children taken away from him and it wasn't going to happen again. FN was described as shaking and shouting  • During the incident in the home, the children were present but very quiet even when FN became very angry and loud they did not flinch, move, or look at him. Although S4 was woken up by FN shouting the child did not react • A similar referral was investigated four years earlier of FN shouting and making threats to the children • Police records indicate one previous referral of domestic abuse and also that FN was convicted on an assault to a neighbour’s child seven years previous • That FN had agreed he was angry during the incident but denied swearing or making threats • FN agreed with the Social Worker that Child N could return to the same Nursery.   The Description of Child N by the Early Years Lead raised concerns about health and development. Although Child N attended Nursery School for one term, the child did not speak TLSCB SCR ‘N’   (MAY 2016)  11  at all for the first half term and speech and language was described as very limited. Child N was described as very subdued and withdrawn spending most time alone. The Early Years Lead recalled the incident in school when as soon as she mentioned Sure Start, FN started to swear and shout and became very intimidating pacing in and out of the room and into the personal space of staff. The Early Years Lead said that the speed with which FN switched from being a reasonable adult to being a threatening and aggressive individual without any apparent trigger was shocking. It was noted that all of the children in Primary School had good school attendance and were well presented, they were described as polite and engaged in conversations.  From a health perspective the following issues were noted:  • S5 had been re-admitted to hospital which placed additional pressure on the family. There are concerns about slow weight gain • S4 was referred to the GP but was not taken because growth and weight were below 0.4 – 2nd centile at the 32 week check. The Health Visitor made a further assessment with minor improvement noted but S4 was not taken to child health clinics for monitoring and assessment as was advised and was overdue immunisations • Child N was referred to the paediatrician at the 32 week check for a small head circumference. Child N saw a Paediatrician at hospital but did not attend 2 appointments for a Griffiths development assessment with the community paediatrician. A 2 year assessment was completed with height and weight stable on 0.4 and 2nd centile. The health Visitor identified concerns at a 3 year speech and language assessment and referred for speech therapy, orthoptist and audiology. There                was no evidence of attending speech therapy or follow up to an initial orthoptist appointment.  • S3 failed an orthoptist test in 2010, and when the orthoptist rang the family home, MN shouted at the orthoptist and refused to re-attend the clinic. S3 did attend a later appointment for spectacles • S2 height and weight on 25th centile. No outstanding health issues • S1 height and weight below 2nd centile. No outstanding health issues  TLSCB SCR ‘N’   (MAY 2016)  12  4.10 The Strategy Meeting concluded that FN’s anger issues appeared to have increased since the birth of S5, and that MN presented as low and depressed. It was agreed that MN and FN would be encouraged to work with a multi-agency plan at Child In Need however, if the parents refused to do this, than an Initial Child Protection Conference would be convened.   4.11 Within Children’s Social Care, the case then transferred from MARAT to a locality based Area Team. There was a significant gap from transfer to allocation and several failed attempts to visit the family which meant it was ten weeks before a further social work visit was made to the family home. The case was allocated to Social Worker 2 (SW2) who wrote to FN and MN to make introductions. FN contacted the office irate and a third social worker (SW3) made the first home visit on the day of receiving the telephone call. In the intervening period, S5 had been discharged and re-admitted to hospital with dehydration, and FN had been sent a letter by Pennine Care NHS Foundation Trust advising that he was not permitted to enter any Primary Care Trust premises and that the Health Visiting service would continue to be offered at a clinic base or children’s centre with the children accompanied by MN alone. S4 did not attend for a scheduled 2 year developmental assessment.   4.12 The first of four social work contacts at the family home was made by SW3 who responded to the phone call by FN.  During the visit it was established that S5 was in hospital with MN and that FN was finding it difficult to cope with the five children at home. FN said he had been offered support from neighbours and an after school club but did not want to be seen as not coping for fear of losing the children. FN told SW3 that he had lost two sets of children and was fearful the same thing would happen again. SW3 discussed the incident with the Health Visitor and FN repeated that he had not sworn or threatened anyone but did not like what the Health Visitor was saying. FN said that MN would be really angry that he had met with SW3 and initially asked that SW3 did not tell MN. SW3 advised that this was not appropriate and both spoke with MN by telephone. The children were seen playing around the house and garden, they were recorded as chatty and interactive with SW3 and well presented. The meeting concluded with SW3 encouraging FN to accept the available offers of support and to contact SW3 if he wished for further discussions about help. S5 was discharged approximately two weeks later with support from the Community Nursing Team.  TLSCB SCR ‘N’   (MAY 2016)  13  4.13 A Core Assessment is recorded as completed by SW2 three weeks after the first home visit.  The Core Assessment is mainly generic in respect of all six children, but does state that MN and FN will take Child N to speech therapy even though they do not agree it is necessary and will ‘in all likelihood’ permit Child N to return to the Nursery School. The Core Assessment places a lot of emphasis on the impact of S5 being hospitalised,  and also on the limited observations of Child N from one visit presenting as happy and growing in confidence. This somewhat dismissed the concerns of the Early Years Lead gathered over the course of a term. The assessment outlines that FN has parented five previous children some of whom have been adopted, all of the information on this matter was self-reported by FN. The assessment concluded that MN and FN were meeting the needs of all of their children but would benefit from ongoing support through Child in Need procedures.  4.14 A second, unannounced visit was made to the family home by SW2 and SW3 five weeks later however the social workers were not permitted access to the family home.  FN was in bed and shouted at the social workers through the window to go away.  FN said that he was going to move to the family to Wales to get away from them. 4.15 The first Child in Need Meeting was held three weeks later, five months after the precipitating incident. This meeting was attended by SW2, Health Visitor, Primary School Head Teacher and the Community Nursing Team. In the intervening period, S5 had been discharged from hospital with a nasogastric tube for additional feeding but missed a subsequent appointment with the Paediatrician.  Child N did not recommence Nursery or access speech therapy and S4 had not had a 3 year developmental assessment. FN and MN were invited but did not attend the meeting.  The minutes of this meeting record the following issues: • That the older children were attending school and were well presented • There is little co-operation from FN despite stated intentions  • That MN was disputing the frequency that S5 required weighing according to the hospital discharge plan  • That Child N is due to start reception class after the summer break • That whilst in hospital with S5, MN had made allegations to ward staff of domestic abuse by FN TLSCB SCR ‘N’   (MAY 2016)  14  • The Health Visitor expressed a view that the children were like ‘frightened rabbits’, the Head Teacher disagreed with this, describing the children as quiet but not withdrawn.  The meeting concluded that FN would be asked to meet with SW2 and the Team Manager to outline the necessity of working together.   4.16 The next record made by Children’s Social Care is of supervision between SW2 and the Team Manager. Contrary to the minutes of the Child in Need meeting only three days earlier, the record indicates that FN was engaging and agreeable to fortnightly visits for three months and that the children are presenting well.  4.17 A third planned home visit was made by SW2 one week later. During this visit, FN agreed that his aggression gets him into trouble and stated that he had previously attended an anger management course. It was agreed that FN would provide the Social Worker with names of professionals that he had been involved with in relation to his previous children. The children were seen during this visit playing about the house and MN and FN were described as attentive to their needs. The Social Worker discussed the possibility of entering into a restorative justice process with the health professionals, FN said although this would be difficult he was prepared to try. The Social Worker advised that further visits would take place over the following two months. Three weeks later, and with no additional inputs the case was discussed in supervision between SW2 and the Team Manager and it was recorded that a further Child in Need Meeting should take place to plan the closure of the case. 4.18 The second and final Child in Need Meeting was held two weeks later, seven weeks after the first. In the intervening period, as well as the second social work visit to the home, S5 had the nasogastric tube removed but was not taken to the one year developmental assessment. The second meeting was attended by SW3, Head Teacher Primary School and MN. The minutes of the meeting stated that Children’s Social Care had offered the family a schedule of fortnightly visits to monitor and support and that during these home visits concerns were discussed with both parents and all of the children were seen. It was documented that MN and FN had engaged with services, were meeting the needs of the children and that the children were thriving. On this basis it was agreed that the case would be closed to Children’s Social Care after two further visits.  TLSCB SCR ‘N’   (MAY 2016)  15  4.19 Four days after this meeting, a fourth home visit was made by SW3. FN advised SW3 that he had been given medication by his GP to help him relax which would be reviewed after one month. The GP had no knowledge that the children were identified as Children in Need. FN was advised that the Primary School Head Teacher was happy to make himself available to FN when he needed to talk. S4 and S5 were both at home and seen by SW3 whilst the other children were in school. SW3 advised one further visit would be made before the case was closed. A date was scheduled for this visit but it did not happen. Two weeks later, the Health Visitor was advised during a telephone discussion with a Social Worker that the case was being closed, the Health Visitor reminded the Social Worker about the outstanding developmental assessments and immunisations which the Social worker agreed would be communicated to FN and MN in writing. Two weeks later a letter of closure was sent to FN and MN by Children’s Social Care.  4.20 The Health Visitor subsequently left a telephone message reminding the parents of S4’s developmental check. MN returned the call and stated that they would not be attending for the developmental check for S4 and that S5 was being followed up by the hospital so they would not be attending appointments for S5 either. MN was described as rude on the telephone, hanging up when the Health Visitor tried to explain why the checks were important. Following this, the School Nurse tried to engage the parents in follow up audiology appointments for Child N but they were non co-operative.  4.21 Five months after the case was closed to Children’s Social Care the School Nurse discussed concerns about Child N with the Primary School Head Teacher. The School Nurse believed that a Paediatric overview of Child N was necessary and the Head Teacher agreed to speak with FN alone, concerned that he would not react well to this suggestion from a health professional or within a meeting. FN stated that he was told by a Paediatrician that there was nothing wrong with Child N, and that the child would catch up over time because of being born prematurely.  4.22 Over the following years, children’s health service made continued attempts to engage MN and FN in a preschool health programme without success. S4 did not attend Nursery but went straight into reception class.  The children did continue to attend the Primary School and the Head Techer worked carefully with MN and FN to ensure the children were able to access the TLSCB SCR ‘N’   (MAY 2016)  16  opportunities and extra-curricular activities. On one occasion S5 was taken to accident and emergency with an arm injury, the parental explanation was that a fall from a chair onto a carpet had taken place. One another occasion the School contacted MN and requested that the children be treated for persistent head lice. When arriving at school, MN banged on the office door and upon seeing S4 poured the lotion over the child’s head stating ‘there it’s done now’. 4.23 No further episodes of multi-agency interventions or significant single agency interventions occurred until MN contacted the police when Child N was 7 years old.  4.24 Through subsequent disclosures it is now believed that Child N was exposed to sexual abuse during the period that the multi-agency professionals were working with the family.    5 The Family Perspective   5.1 The Review Panel was keen to involve family members in the Review, firstly to explore the day the day lives of Child N and siblings, but secondly to seek information from FN and MN about how they experienced working with agencies and individual professionals. Their perspective is seen as particularly important to understanding the circumstances within which the professionals around the children accepted the family was functioning well when the opposite is now known to be true.  5.2 Due to the continuation of the criminal investigation, the Police, following consultation with the Crown Prosecution Service advised that speaking with FN, MN or any of the children should be scheduled only after a criminal trial had taken place. The Review Panel intends to seek consultation with FN and MN once the criminal trial is completed.  5.3 The Review Panel gave careful consideration to the possibility of involving Child N or siblings in the Review either directly or by consultation through professionals working closely with the children. The Panel was however mindful that that children are experiencing a period of change and adjustment and refocussing on past events was not considered to be in their best interests at this moment in time. Once the criminal trial is completed, consultation will take TLSCB SCR ‘N’   (MAY 2016)  17  place with professionals and carers around the children to consider how best to advise them of the Review.  5.4 To the best knowledge of this Review, there are no other family members who were involved with the children during the period of Review.  6. Context within which Professionals were working  6.1 The social work service was structured in such a way as that referrals were made to a front door service MARAT (multi-agency risk assessment team). This team undertook Initial Assessments and cases would be passed onto area social work teams if a threshold was met for continued intervention. This meant that the plan for intervention would be determined within the MARAT team prior to allocation within the area social work team. The area social work team that received this case was a fully staffed patch based team that held cases under both Child Protection and Child in Need categories. The social workers generally held a mixed caseload of both thresholds. Child N was allocated to a newly appointed Social Worker, a Social Worker with substantial post qualification experience but with a differing client group of young people. The Social Worker had never previously undertaken a Core Assessment and working with younger children and assessing risk within a familial setting was a new area of work. The team had a culture of co-working, and this case was co-worked between the allocated Social Worker and the Team Senior Social Work practitioner although this is not reflected in records. 6.2 In 2011, the Health Visiting and School Nursing teams were located within Bridgewater Community Healthcare NHS Foundation Trust in co-located teams. The practitioners worked within the policies and procedures of that Trust, this included Lone Working, Violence and Aggression and Health and Safety. From April 2013 the functions moved to Pennine Care NHS Foundation Trust. 6.3 A Serious Case Review was completed by Trafford in 2012 (Child MLK). This Review considered the approach to working with Children in Need during the same period of time at this current review and made the following recommendation: Trafford Safeguarding Children’s Board must take immediate steps [1] to implement its Children in Need policy fully and [2] consider what continuing organisational support is necessary to ensure that implementation is and remains TLSCB SCR ‘N’   (MAY 2016)  18  effective.  This Review has drawn some similar conclusions about the effectiveness of Child in Need arrangements and drew together current practitioners and managers to establish the extent to which changes as a result of the precious SCR have been effective and maintained.  6.4 The school attended by Child N and siblings has a catchment area that incorporates a relatively high level of need.  The school takes a highly nurturing approach to the children and regularly works with a range of children’s agencies as part of multi-agency plans around children.  7. Analysis  The examination of single and multi-agency working leading up to the precipitating incident of this Serious Case Review has identified several aspects of single and multi-agency learning alongside some significant reflections about how judgements were applied at key points of interventions. The analysis is structured around the key lines of enquiry and endeavours to use the findings about practice of four years previous as a mechanism to review aspects of current single and multi-agency practice.  7.1 To what extent was the significance of family history identified and appreciated  7.1.1 Good quality assessment is the underpinning foundations of successful interventions with families and children in need. Effective targeting of interventions can only be achieved by understanding the complexity of current family functioning which is acutely influenced by past family experiences. Shortcomings deriving from the absence of key information, and the impact this has on the reliability of the analysis of strengths and risk in families can lead to compromised decision making for children and leave children exposed to risk and danger.   7.1.2 When Child N commenced Nursery school, the family was known to the school as the older siblings attended primary education at the same site. The Early Years Lead quickly identified that Child N was a vulnerable child, the observations being that Child N was somewhat isolated from peers, was shy to the extent of being withdrawn and tended to play alone. The Nursery was keen to support Child N, and as an expression of this offered a full time Nursery placement to support Child N’s development.  The Nursery Head was therefore taking a measured and methodical approach to getting to know the family in order to best support the child. This TLSCB SCR ‘N’   (MAY 2016)  19  approach was thwarted when FN refused to let Child N return to Nursery when he concluded that the Nursery were ‘prying’ into his family life. At this time the Early Years Lead was suspicious about the reasons for FN’s behaviour and contacted the Health Visitor as the only other professional with access into Child N’s life at that time. The Health Visitor diligently followed up the work of the Nursery with FN and MN and this led to the aggressive exchange which ultimately led to the referral to Children’s Social Care.  7.1.3 From the first Strategy meeting it was documented that FN had children from two previous relationships that he had no contact with, some of whom had been adopted. In terms of assessment and family functioning this was highly significant information, firstly because adoption is the highest form of intervention in family life and in general occurs only when birth parents are assessed as unable to safely parent, and secondly because it meant that FN had a substantial history of working with professionals which led to the loss of his older children. Records indicate that FN was open about his history with professionals and cited this as a reason why he reacted aggressively for fear of losing his third family of children.   7.1.4 A DFE Research Brief in 2011 Social Work Assessments of Children in Need: Messages from Research,  identified five areas that were found to be repeatedly problematic at that time; differential thresholds, failure to engage the child, inadequacies in information gathering, short comings in critical analysis and shortcomings in inter-professional working. This Review illustrates how all of these factors were a feature of the work around this family.   7.1.5 All professionals from Children’s Social Care, Health, Education and Police were aware that FN had children previously adopted, and this Review has found it quite remarkable that despite this, the facts were never established with the Local Authorities who initiated the interventions and therefore any information that was known was accepted at face value when self-reported by FN.  This issue was discussed with all professionals as part of this Review. The Chair of the Strategy Meeting and SW2 both readily acknowledged the significance of this information and reflected that a firm line of enquiry should have been to follow up this information with the Local Authorities concerned.  SW2 considered that the reason this did not happen may have been because of her inexperience in child care matters at that time and a lack of understanding TLSCB SCR ‘N’   (MAY 2016)  20  of the significance of adoption in the life of a father as much as a mother. The Chair of the Strategy meeting is an experienced manager who agreed that this information became lost.  The passage of almost five years between the meeting and the Review means that any real memory of the meeting is limited, but the Review Panel, taking into account the reflections of practitioners, considered that a number of factors may have influenced the decisions of the Strategy Meetings to conclude the enquiries without establishing all relevant history. These included the fact that relatively speaking FN did not have an extensive criminal history (although he did have an offence against a neighbours child), that FN’s older children were significantly older and would have been adults, that that Primary School gave positive reports of the older children in school and potentially a belief that a Health Visitor is less seasoned and able to cope with an aggressive incident than a Social Worker would be.   7.1.6 The Head Teacher and School Nurse both recalled that there was a gap in establishing the family history because the social workers had not made contact with the Local Authorities who were previously involved with FN, and the Police Officer agreed this should have raised questions that required concrete answers.  It is apparent that the absence of this information is perceived as an oversight by Children’s Social Care, but this also raises the fundamental principle that every agency must take responsibility for safeguarding and offer constructive challenge to key agencies were there is discontent or dissent.   7.1.7 In contrast to the reflections of other professionals, SW3 told the Review that it would not be expected that historical information was pursued with another Local Authority in a case that had a Child in Need status. The view of this social worker suggested that children were receiving a two tier service, and that a case with a Child in Need status would not have the same safeguarding standards applied as a case that had met the threshold for a Child Protection Plan. Whilst the practitioners meeting spoke about the constant pressure of time to dedicate to individual cases, they were also clear that cases that fell within the Child in Need category could potentially have greater risk than those managed under a Child Protection Plan because the risks may well be less exposed and articulated.  In general terms, the practitioners were extremely clear that safeguarding standards applied to all cases consistently and that it TLSCB SCR ‘N’   (MAY 2016)  21  was a function of their role with a family to access all available sources of information to triangulate the evidence in analysis.   7.1.8 The views of SW3 are particularly significant as SW2, a then inexperienced worker, was looking to SW3 to provide mentorship and guidance. The Core Assessment was completed after the first home visit to FN and before any work had taken place with the family. The Core Assessment followed the Assessment Framework but was superficial and generalised. In the case of Child N, the assessment was not informed by a clear articulation of child development or by the information available from an experienced Early Years practitioner. To this end the assessment concluded that Child N’s needs were being met when the child’s developmental and socialisation needs had been severely compromised by being removed from an Early Years education setting with no alternatives considered.  The management oversight of this case did not identify the deficiencies of the Core Assessment or that SW2 needed additional support to complete such an assessment for the first time. There is a sense that the assessment was little more than a document that needed to be completed rather than the key to working with a family in need.   7.1.9 The Review has been keen to establish what practitioners understood of the reason why this case met the threshold for a Child in Need allocation. SW2 recalled that the brief was to achieve FN’s ability to work with other agencies and this would account for the reason the home visits seemed to focus on establishing and seeking to understand FN’s vulnerabilities rather than those of the children.  An Ofsted thematic inspection, In the Child’s Time: Professional Responses to Neglect (2014) found that nearly half of the assessments in the cases considered did not take sufficient account of the family history and did not adequately convey or consider the impact of neglect on the child. Some assessments were found to focus almost exclusively on the parent’s needs rather than analysing the impact of parental behaviour on children. In this instance, the lack of clarity about the reason for intervention was compounded by an acceptance of self-reported information by FN and MN. This approach paved the way for the parents to maintain a position of non-compliance, they received no challenge about the missed health appointments or the impact of Child N not attending Nursery school.   TLSCB SCR ‘N’   (MAY 2016)  22  7.1.10 The Review would go as far as to say that FN manipulated the professionals around the family, he directed professionals away from his family through a range of behaviours: - by being aggressive, by being charming, by being avoidant and by paying lip service to what he knew professionals wanted to hear.  It was apparent that during the period of intervention led by SW3 several professionals empathised with FN as a man with a wife and poorly baby in hospital struggling to look after the five remaining children in the family alone.  It may be in this context that another piece of significant information was missed by professionals, that being that MN had disclosed to nursing staff that she experienced domestic abuse perpetrated by FN. Despite this being reported in the first Core Group meeting, the issue of domestic abuse was never discussed with either FN or MN, meaning that any potential impact on the children was never assessed.  During the conversations with practitioners, several described MN as having limited intellectual capacity, it was also known that the relationship formed when MN was an older teenager and FN was twenty years her senior.   7.1.11 Examination of the issues in the case show several aspects of family history that required   deeper exploration within a Core Assessment. These included: • A history of substandard parenting by FN when he reported that his children were placed for adoption against his wishes •  A history of poor engagement with child health services  • FN’s history of aggressive behaviour evidenced by a conviction for the assault of a child. Behaviour towards two sets of professionals in different settings, and a police attendance at an incident of domestic abuse • MN disclosing the presence of domestic abuse within the relationship  Specifically historical and current issues that gave rise to safeguarding concerns were identified within the multi-agency working processes, but there was a significant deficit in the appreciation why the issues were so significant in understanding the family functioning and the impact this had upon the individual children of the family.  These issues were not subject to rigorous assessment because there was an absence of clarity about why the case met the threshold of Child in Need and this impacted greatly upon a lack or purpose or desired outcomes to be achieved.   TLSCB SCR ‘N’   (MAY 2016)  23  7.1.12 The practitioners meeting advised that since the period covered by this Review, two key changes have occurred; the introduction of a single assessment which replaced the Initial and Core Assessment, and the introduction of a transfer meeting between the key professionals in the case when it moves from MARAT to an area team. This professional’s only meeting allows dedicated time to think and reflect on the issues of the case so that the reasons and focus of intervention are clearly articulated. Currently, it is a requirement that a single assessment is completed prior to transfer of a case from MARAT although it was recognised that this could become problematic if the receiving team did not revisit and update the assessment during the longer term interventions. The MARAT is a busy intake team with a need to process work in an efficient manner in order to respond to the incoming referrals.  This means that in reality, the completed assessments are more likely to address the issues of crisis rather than provide the depth of exploration one would expect in longer term work with a family. The locality social work teams are also under pressure of competing demands for time, so it is important that the social workers and managers ensure that assessment is not simply seen as one off activity completed prior to transfer, but as part of a dynamic process of engaging and working with a child and family.    7.2 To what extent was the approach to Child In Need robust   7.2.1 Trafford LSCB had a comprehensive Child in Need policy and procedure which is underpinned by a commitment to placing the child at the heart of a multi-agency plan around the child. This has been strengthened and developed since the multi-agency practice examined within this Review. Without doubt, the approach to managing this case as Child in Need was weak and compromised by the lack of clarity about the purpose of intervention as well as poor adherence to multi agency processes and a lack of challenge between agencies.   7.2.2 It is expected that every child subject to a Child in Need process would have a Plan that is bespoke to their needs. Within this family of six children, the Child In Need Plans were not appropriately individualised, and this was significant as to how the particular needs of Child N became overlooked.  Child N was the fourth child of the sibling group, and whilst reports of TLSCB SCR ‘N’   (MAY 2016)  24  school attendance, presentation and attainment were generally positive for the older three children, the same was not true for Child N. Child N was described by the Nursery teacher as timid and withdrawn and observations suggested a lack of warmth from MN. The Core Assessment and Child in Need Plans addressed the needs of the children collectively and this approach resulted in the specific needs of Child N being overlooked because the older children were reported as having no difficulties in the primary school setting.   7.2.3 During the period of multi-agency planning, two Child In Need Meetings were held. As this case was not formally co-worked by SW2 and SW3, their respective roles in the case were not clarified. The two meetings were chaired by different social workers and overall it is difficult to get a sense of continuity. The first meeting was attended by representatives from health, school and SW2 with no parent present and the second was attended by the school, SW3 and MN. The first meeting identified significant concerns about the level of parental engagement in the plan and the impact of this on the children, yet only seven weeks later with only one visit to the family in between, the second meeting recommended that the case was near ready for closure to Children’s Social Care. This was on the assertion that following a schedule of fortnightly visits to the family home, MN and FN had engaged with services, were meeting the needs of the children and that the children were thriving. In reality, four visits had been made to the family home over a seven month period, one of which FN refused entry to the social workers, attendance at medical appointments remained an issue of concern and Child N had missed six months of early years education.                                                                                                     7.2.4 The limitations of the Core Assessment and Child in Need Plans impacted upon the purposefulness of the Child in Need meetings, there are minutes of both meetings which indicate a lack of focus on the plans for the children and what the professionals were seeking to achieve for Child N. This contributed to the two meetings drawing very different conclusions without any additional progress other than Child N starting statutory education.   7.2.5 The meeting with practitioners discussed in some detail the current approach to multi-agency meetings for Children in Need. It was agreed that the convention of multi-agency meetings around the child are a common occurrence, however, it was also suggested that the purpose TLSCB SCR ‘N’   (MAY 2016)  25  of the meetings and desired outcomes were clearer for children subject to a Child Protection Plan. The sharing of Child in Need Plans as a common approach to working towards change with families was described as inconsistent and this may be because there is a perception that child in need is predicated on voluntary engagement whereas Child Protection is referred to as the  statutory element of the work.  The Children Act 1989 placed a statutory responsibility on Local Authorities to provide services to children in need, with the need for protection being a part of that continuum. In recent years, diminishing resources and pressures on workloads has resulted in a tendency to raise thresholds for intervention as a means of rationing resources and this means that it is children and families with substantial problems that become known to Children’s Social Care. The difference between Child Protection Plans and Child in Need Plans is often as simplistic as the parent’s willingness to engage in the plan and work towards change and the presence of additional resilience factors for children. What may be perceived differently by professionals is the level of independent scrutiny and oversight through the Independent Conference and Reviewing service that is more commonly associated with Child Protection Plans.  In 2013,  following the SCR of Child MLK, Trafford Children’s Social Care introduced an Independent Reviewing Officer for Child In Need Plans. In the reflective session held with senior managers, they identified that this post had led to improvements in the quality of planning and review for the cases that attracted this level of accountability, however, it was recognised that the impact is limited because there is only one post which restricts the scope of what can be achieved by this quality assurance role. Senior managers agreed there was a need to tackle any culture which suggested that Child in Need work was less significant than work completed under Child Protection procedures.  7.2.6 The strength of the progress that can be made within Child in Need processes will be highly influenced by the parental response to the identified need for a multi-agency plan around their children. SW3 commented during the Review that consent is necessary progress a Child in Need Plan, and whilst this is true, it must be recognised that it also the role of professionals to assess whether consent and co-operation is genuinely present or whether a parent is paying lip service to appease professionals and detract them from identifying serious dysfunction in families that presents risk to children. For children subject to multi-agency plans because of concerns about their welfare, there will be a need for change in parental TLSCB SCR ‘N’   (MAY 2016)  26  behaviour at some level and assessing parental capacity for such change, alongside determining the impact of continued substandard parenting upon children, is the core business of multi-agency working in safeguarding. In common with a culture that places Child in Need as lower priority, there is a danger that if co-operation is not achieved without appropriate escalation, then a fatalistic sense of hopelessness follows. It is for this reason that robust assessments and clearly articulated plans subject to stringent review are crucial to achieving positive outcomes for children. It is already stated that FN manipulated professionals, systematically removing them from his family life through various strategies. The Review Panel considered whether this case demonstrated typical features of disguised compliance, but ultimately considered there was non-compliance in part because no particular expectations were placed on the parents to attend all medical appointments or address Child N’s needs for early education and support. Brandon et al (2008) in the biennial analysis of Serious Case Reviews noted that disguised or partial compliance can often wrong foot professionals, and lead to prevention or delayed understanding of the severity of harm to the child. A common pitfall when working with openly hostile parents, is the ease at which professionals can be lulled into a false sense of security when parents appear to be welcoming to certain professionals only. Taking this at face value paves the way to professional manipulation and parental control of the perception of compliance.   7.2.7 The Core Assessment was not an assessment completed with the parents, indeed there is no evidence that the need for, or presence of, a written assessment was discussed with FN or MN. Neither parent was asked to take part in the assessment, their own history of being parented, their attitudes to parenting and their responses to the individuality of each of their children was not discussed with them. In essence, the assessment did not have enough information to inform any measured analysis of strengths and vulnerabilities and was not used as a tool to engage with the parents or children.  Given FN’s propensity to aggression, it is surprising that no contact was made with the GP either at the point of the Core Assessment or when FN reported that he had been prescribed medication for his mood. GP’s are important safeguarding partners, yet infrequently are they advised a Child in Need Plan or asked to contribute to assessments. GP’s often hold the most readily accessible records as to TLSCB SCR ‘N’   (MAY 2016)  27  where a person has lived and if previous safeguarding concerns have been apparent as GP records travel with the patient throughout their lives.   7.2.8 The Child in Need arrangements achieved little for Child N but the limitations on expectations and challenge of the parents would have served to develop FN’s feeling of omnipotence and distorted thinking about how he could control his family. Ultimately, the unlocking of the key to understanding the depth of abuse suffered by Child N and the siblings came from within the family itself, from the contact by MN to alert to the risk of physical harm and then once feeling in a safe place, from the children telling their experiences of sustained physical, emotional, psychological and sexual abuse.   7.3 To what extent was Child N and siblings  the focus of multi-agency work  7.3.1 The referral to Children’s Social Care from Health Visiting services stressed that three of the children were present in the family home when FN became aggressive. The Heath Visitor spoke of the need to think quickly on her feet about how to best diffuse the situation, in particular as the children were present. The Health Visitor said she felt very concerned about leaving the children in the house, but as she was the focus of MN’s anger, made a judgement that he would be calmer if she left and she could get help without inflaming him further. Despite feeling the ‘most threatened I have every felt’, the Health Visitor did remain focussed on the children and was particularly concerned to note that the children did not register or flinch at their fathers irrational behaviour and aggressive shouting. The Early Years Lead at the first Strategy Meeting gave an account of having witnessed FN behave irrationally and aggressively with Child N present and also shared that over the period of a term she had observed Child N and was worried the child’s demeanour and development.   7.3.2 From the first Strategy meeting a picture was emerging of specific concerns about Child N that were not present in the older children.  The Early Years Lead spoke of feeling frustrated by being told that the Social Worker had seen Child N yet had no concerns when she had gotten to know the child over a four month period and became increasingly concerned. The Early Years Lead said she was anxious to extend a welcome so that Child N could return to Nursery TLSCB SCR ‘N’   (MAY 2016)  28  and was disappointed that this never happened. The Children Act 2004 places a duty on Local Authorities to ascertain the child’s wishes and feelings and take them into consideration when making decisions that affect them, as far as is reasonable, practicable and consistent with child’s welfare. The contacts and observations of the children made by SW2 and SW3 were limited to short visits to the home and none of the children were purposefully engaged in any direct work to ascertain how they experienced day to day life or to establish whether they wished to discuss any worries or concerns.  The comments on the strength of attachment between the children and their parents were similarly superficial but carried weight in the decision to close the case.   7.3.3 Each child had an individual Child In Need Plan but they did not address the issues of concern and this had a particular impact for Child N. A great deal of emphasis was placed on the view of the school who identified no issues of concern for the older children, they were reported to be well presented, engaged in school life and appropriately social with adults. None of the children were ever however specifically asked about their life. The Munro Report (2011) consulted with young people who had experience of the child protection systems and they stressed the importance of children being heard separately from their parents and being listened to. A report by Action for Children, Child Neglect: The Scandal that Never Breaks (2014) includes some poignant comments by young people who have experienced neglect: • ‘I think it’s the adults that need to approach children if they think something is not right, it’s not up to the children to approach them. It can be a big burden for a child to ask for help’  • ‘some kids don’t know they are being neglected until they go to school because it has just been their life, so teachers need to ask’ • ‘If you see an unhappy kid, you should ask them what is wrong’.  Simple and straight forward messages from children reminding professionals not to be afraid of talking to children, asking questions, and enabling children to confide their worries. The approach and the method of consulting and communicating with children needs to be a feature of every child’s plan.   TLSCB SCR ‘N’   (MAY 2016)  29  7.3.4 The Review Panel has discussed in depth the decision made by Pennine Care NHS Foundation Trust to cease all home visiting by staff and prevent FN from attending any Trust premises. Taken at its simplest level, one has to question if a parent is not seen as safe for professionals  to be in contact with, what this means for any child in the home. The decision to cease working with FN was taken by the Trust as a protective measure as an employer, however, this also had implications for the welfare of children and wider aspects of multi-agency working. It could be argued that the decision gave FN what he set out to achieve, to be rid of health care professionals asking questions about his children and having a presence in his family home. Successive enquiry reports have highlighted the dangers to children when professionals do not engage with abusive men and that by taking this approach, professional are colluding with men who wish to avoid services and refuse to face up to problems that stem from their behaviour. It is somewhat ironic that the very reason to be concerned about the children’s welfare also became the reason not to work with the source of that threat. Whilst appreciating that organisations need to put in place risk assessments and control measures for staff facing aggression and violence, there also needs to be an appreciation that working with aggression and violent men needs to be a core function of safeguarding agencies and multi-agency working. In a multi-agency partnership, the operational decisions of one agency will have an impact upon another agency and it is necessary therefore to think beyond the immediacy of the response to an incident to reflect of the bigger picture from the perspective of staff and vulnerable service users.   7.3.5 The focus of the multi-agency work in this case was not structured around the needs of Child N and the sibling children. The focus was on FN, and achieving a degree of compliance that would satisfy agencies into accepting that there was no need for further intervention.   7.4 To what extent was multi-agency working characterised by trust and/or challenge  7.5.1 The early interventions and communications between the Nursery and Health visitor demonstrated a trusting and co-operative working style. The Nursery was able to share the concerns about Child N which the Health Visitor endeavoured to follow up when the Nursery was no longer in a position to do so.  TLSCB SCR ‘N’   (MAY 2016)  30   7.5.2 The Review Panel were keen to explore the perception of cultures across agencies, and one practitioner was brave enough to admit that the seriousness of how FN behaved towards the Heath Visitor may well have been diminished by a prevailing view that Health Visitors and teachers do the nice, safe parts of multi-agency working and wouldn’t cope with the more gritty issues commonly experienced by social workers and police. The reality is somewhat different from the rhetoric, and this is particularly evidenced in this case where it the teacher and Health Visitor that are challenging of aspects of FN and MN’s parenting yet when the social workers were allocated there is little evidence of challenge to the parents, and in turn FN took up a position of seeming co-operation.   7.5.3 A particular feature of this case that undoubtedly had an impact on the continuity of approach and the strength of multi-agency working was the co-working arrangements between the two social worker that lacked clarity about who was acting as Lead Professional, why a co-working arrangement was in place and how the family and other professionals understood this. Although SW2 was the nominated case holder and completed the Core Assessment, in reality it was SW3 who made the majority of visits to the home and implemented the decision about case closure. SW2 was reliant on SW3 to provide mentorship through this period of intervention, and in the conversations with the Reviewer it was clear that SW2 was a reflective practitioner who showed considerable distress about the limitations in practice whereas SW3 was not so reflective and could ostensibly fall into the same pitfalls of practice.   7.5.4 A particular feature of the case was the absence of challenge from all agencies despite the obvious limitations in approach to developing and reviewing the Child in Need Plan. The school have been stunned and shaken by what is now known about the children’s experiences and questioned hard whether and how they could have identified anything that would indicate the abuse they experienced. The school reflected that there was a risk of being falsely reassured about children’s welfare by overly focusing on issues such as physical presentation and how they needed to ensure they remained equally attuned to children’s emotional presentation. The school prides itself in having a culture of high control alongside high TLSCB SCR ‘N’   (MAY 2016)  31  warmth, and of creating an environment that supports and takes ownership of the pupil’s welfare. The Review was however advised that one member of staff had made an anonymous referral to Children’s Social Care, and that this was not shared with the Head Teacher as designated lead for safeguarding. It must be stated that no such referral has been identified as received by Children’s Social Care however, the information does beg questions as to why a professional would resort to making an anonymous referral. The motivation to undertake such a course of action can only be speculative as the identity of the person is unknown to the Review despite efforts to establish this but it does suggest a mistrust of using professional processes to raise concerns about a child.   7.5.5  The conversations with practitioners suggested a passivity of approach to the Child in Need process, and the absence of any challenge about process, suitability and accessibility of a Child in Need Plan is suggestive of a culture that overly defers to Children’s Social Care. This issue was discussed in the Practitioners meeting, and Practitioners demonstrated a general feeling of confidence in multi-agency working but recognised some of the limitations from this case in current practice, specifically the limited development of the Child in Need Plan as a tool to action and review progress and a tendency to passively accept that it is the sole responsibility of Children’s Social Care to convene and facilitate multi-agency meetings.   7.5.6 Perhaps the most significant issue in respect of trust was the poor appreciation of what the Nursery and Health Visitor observed in respect of Child N. The Early Years Lead was clear and gave precise information from a basis of early year’s knowledge and experience of the concerns she had about Child N’s demeanour and development. The Health Visitor has clearly articulated concern about Child N’s lack of emotional response to the witnessing the father’s erratic, loud and intimidating behaviour. Through my work with multi-agency professionals in case reviews I see a pattern of responses that I describe as an ‘invisible filter’ that diminishes concern, to describe the process of what happens very often when one agency expresses concern about a safeguarding matter to another in contrast to how a professional may react if the same piece of information was shared by a direct colleague.  This is suggestive of an inbuilt level of professional mistrust and a need to test out the issue for oneself.  So when FN allowed the social workers into the house without challenge or troublesome behaviour this TLSCB SCR ‘N’   (MAY 2016)  32  almost negated the testimony of Nursery and health professionals and similarly when Child N responded socially to the social worker this overshadowed the testimony of the Nursery.   7.5.7 The practitioners group indicated a reasonable level of confidence in multi-agency working, they also acknowledged the need to sharpen aspects of practice for cases within Child in Need arranges and replicate the more developed planning and review processes embedded into multi-agency child protection work.   7.6 What contributed to the circumstances by which MN and FN could disguise a degree of compliance that satisfied agencies that the children were safe in their care  7.6.1 Disguised compliance has become commonly understood term in multi-agency working to describe what happens when a parent doesn’t admit to their lack of commitment to a process and subversively works to undermine it. Professionals are continually encouraged to maintain a ‘healthy scepticism’ and triangulate additional sources of evidence to support analysis in assessment.  In this case much of the information relied upon was self- reported by the parents or based on relatively superficial observations of the children in the home environment.   7.6.2 The multi-agency process lacked any real sense of engagement with either parent or the children themselves. The assessment and Child in need plans appeared as documents to be completed as a bureaucratic exercise as opposed to a tool to working with the family to address the issues of concern.  SW2 stated that the assessment was rushed in order to meet timescales, in particular because there had been a gap in allocation since the Initial Assessment was completed. This occurred at the same month as the publication of the Munro Review of Child Protection which concluded that ‘complying with prescription and keeping records to demonstrate compliance has become too dominant. The centrality of forming relationships with children and families to understand and help them has become too obscure’   TLSCB SCR ‘N’   (MAY 2016)  33  7.6.3 The approach of the locality social workers was to seek satisfaction that FN’s behaviour was not a cause for concern in a parenting context, and I would suggest that from the first contacts a mind-set was adopted that meant that the social workers sought out information to support this and too readily dismissed the factors that challenged this. The multi-agency working reflected this position, the school appeared comfortable because they did not have concerns about the older children and were anxious not to become alienated from the parents in order to get their support in pursuing a Statement of Educational Needs for Child N, health professionals were however much less comfortable and through strategic decisions and case work practice they effectively came adrift from multi-agency working. The decision to close the cases to Children’s Social Care was made in the second multi-agency meeting with just Children’s Social Care and School represented.   7.6.4 The tendency to dismiss information that does not support a working hypothesis is emphasised by the way in which FN’s behaviour was too readily dismissed when both social workers attended the home unannounced (see para 4.14), they were refused and entry and FN threatened to move the children away from the vision of services. Although the multi-agency meeting following this incident discussed this visit as a matter of concern, this did not appear to translate into challenge of FN and it would appear that no further unannounced visits were attempted. As already stated, FN used a variety of methods to keep professional at bay or see them only on his terms.   7.6.5 There were a number of indicators that FN was a controlling man who could quickly rise to aggression.  The hospital reported in the first multi-agency meeting that MN had disclosed domestic abuse but no opportunity was created to speak with MN alone and FN was never held to account with regard to this allegation.  This was a poor response to the information about domestic abuse, especially as MN was perceived to be vulnerable herself. During the period of work with the family, the following significant factors were known but not addressed: • that FN had a long history of involvement with child welfare agencies and had been unable to parent five older children • that FN had a conviction for a physical  assault to a child in the neighbourhood TLSCB SCR ‘N’   (MAY 2016)  34  • that FN had shown aggression to all professionals around the children, health visitor,  school, Nursery and social workers  • that Child N was removed from much needed early years support  • that there was a history of patchy co-operation with health appointments for the children • that MN was perceived as vulnerable and had disclosed domestic abuse whilst staying away from the family home in the hospital all of these factors if analysed rigorously should have led to a more questioning approach to how FN’s behaviour impacted upon family life.   Child N experienced multiple forms of abuse, including sexual abuse during this period. A recent report published by the Children’s Commissioner, Protecting Children from Harm: A Critical Assessment of Child Sexual Abuse in the Family Network in England and Priorities for Action (November 2015) notes that there is an over-reliance on children disclosing abuse to statutory services and that a refocus is needed so that professionals are attuned to changes in behaviour of children, their emotional responses and to enable them to talk about their experiences. In 2015, the national average of the percentage children subject to Child Protection Plans under category of sexual abuse is 4.5% and in Trafford this is 3.4%. This Review is a an important reminder to professionals to think beyond what is obvious and be particularly alert to the many forms by which power is abused within a family setting and that professionals should always make the connection between the difficulties they experience when trying to see or work with a child and the likelihood that the child is experiencing stressful and abusive behaviour.   8   Learning Outcomes  8.1      Optimum and safer outcomes in multi-agency working with children will be achieved through systems which maintain the child as the focus which are underpinned by comprehensive assessment and understanding of family functioning, considered planning to meet children’s needs with robust and objective review systems in place.    There was a fundamental weakness in how this case was approached which stemmed from the limitations of the assessment and adherence to Child in Need procedures which resulted TLSCB SCR ‘N’   (MAY 2016)  35  in sub-standard Children’s Plan.  This limited implementation of formal Child in Need processes was identified by the previous SCR which considered multi-agency practice in 2011. There is confidence amongst practitioners and managers that positive developments in relation to Child in Need have taken place since then partly as a consequence of actions taken following the Child MLK SCR which strengthened structures and raised the safeguarding profile of Children in Need. The introduction of oversight and scrutiny from a designated IRO was identified as a particularly important mechanism to provide feedback and support to multi-agency systems around children. Extending this role across Child In Need cases open to Children’s Social Care was identified by practitioners and managers as a favoured position but also recognised as   something a utopian desire within a climate of rationalisation. There is however a recognition of a need to further develop and standardise multi-agency practice for Children in Need incorporating the principles of improvement as Plan, Act, Review and Adjust. In taking a lean approach to strengthening this area of work, maximum impact can be achieved through targeting the Plan and Review stages and the following recommendations are made to support this.    Recommendation:  1. That the activity of the Board promotes the pathway to, and practice of, achieving personalised, SMART and outcomes focussed Plan for children across all spectrums of need. Children’s PLANS – what training/development have staff received 2. That the within the existing Child in Need processes, consideration is given as to how to strengthen the independence and objectivity that needs to be available when reviewing Plans  8.2 The most effective multi-agency working will be achieved through dismantling the barriers and myths that exist between agencies and to continually build up  trust and respect for the specific knowledge , skills and experience that multi-agency partners bring to case assessment, planning and review.  TLSCB SCR ‘N’   (MAY 2016)  36   Achieving and maintaining a multi-agency culture of ownership and challenge must be a constant objective delivered through LSCB training, development and reflective practice opportunities.    The establishment of effective multi-agency working relationships depends on four key areas: clarification of roles and responsibilities in a manner which values diversity and ensures parity, securing commitment at all levels, engendering trust and mutual respect and fostering understanding between agencies through joint training and sharing of expertise. This case is illustrative of commonly found issues across multi-agency partnerships, that being that when Children’s Social Care become involved, all too often other agencies relax their approach in the belief that the ‘experts’ are taking responsibility. This tendency, coupled with Children’s Social Care at times also seeing themselves as the real professionals in safeguarding mitigates against the key area outlined above. Multi-agency working can be time consuming, it can lead to conflict, and for this reason it can be tempting to take a silo approach. However, irrespective of individual professional perceptions of value, procedures and policies, guidance and legislation is driven by extensive research on what it is that best protects and support the welfare of children. Real cases such as this demonstrate locally to professionals the pitfalls of agencies working to poorly defined common goals, and remind of the need to continually nurture and develop strong multi-agency partnerships.    Recommendation: 3. That the Board promote the value of multi-agency partnerships though all of its activity, taking opportunities to bring multi-agency professionals together to think, reflect and learn through a practitioner led approach to audits or reviews.  4. That Board partners review their internal policies and procedures with regard to Violence and Aggression to reflect that critical decisions that impact on responsibilities to children are taken in consultation with multi-agency partners and place the safety of children as the paramount consideration.    TLSCB SCR ‘N’   (MAY 2016)  37  8.3 Working with male figures in family life, especially when their behaviour is the source of concern is critical to exposing and addressing abusive behaviours and utilising this knowledge to robustly assess risk to children  The tendency to either consciously or unconsciously avoid focus on men, particularly men with problematic behaviours needs to be ever present in the minds of practitioners, managers and quality assurance officers. Whilst not wishing to move from the specific to the general on the strength of one case, the contacts with professional would indicate a need to give further consideration to this issue to develop current practice. To this end, it would be useful to undertake a thematic audit on working with known violence and aggression to learn from practice to what extent multi-agency partner’s work together to achieve a non-collusive approach whilst protecting the needs of all vulnerable clients.   Recommendation: 5. The Board to undertake a thematic audit on working with violence and aggression with the purpose of sharing good practice and identifying problematic practice that makes poorer outcomes more likely    8.4 Working directly with children of all ages when undertaking assessments of risk and plans to enhance their welfare and safety should be a feature of every multi-agency plan around a child.   Successive Case Reviews, research and academic studies have shown that both children and professionals believe that better decisions will be made for children if they are actively involved in assessment and decision making processes. The LSCB needs to be assured that practitioners have the skills, resources and commitment to achieve this. To this end, every child’s plan should include when, how and who will work with the child as an integral part of intervention, and how any resistance to achieving this would be addressed.  Recommendation: 6. For the LSCB to undertake a consultation with multi-agency partners to establish what is needed to support practitioners to develop skills, confidence and resources to work with TLSCB SCR ‘N’   (MAY 2016)  38  children. This information to support a strategy to develop the voice of the child for children subject to multi-agency procedures,   8.5    The national statistics for children subject to Plans for sexual abuse support the view that practitioners may be less attuned to the risk of familial sexual abuse than perhaps was the case in previous decades. The statistics in Trafford are lower than the national average and this would suggest a need to develop an understanding of why this is so.  Recommendation: 7. For the Board to dedicate time to debate the issue of sexual abuse, using recent studies and performance data to consider the position in Trafford and whether further Board directed work is indicated.       SCR Child N  Trafford Safeguarding Children Board SCR Child N Action Plan September 2017  It should be noted that since the SCR Report was written in May 2016, there have been a number of significant organisational changes in Trafford.  A Section 75 agreement was signed between Trafford Council and Pennine Care NHS Foundation Trust in April 2016 – a strategic partnership agreement for the delivery of integrated all age community health and social care services.  The last 18 months have seen the establishment and continued development of Trafford’s integrated health and social care neighbourhood model.  Trafford is also in the process of securing transformation funding from GM which includes ambitious plans to reshape our children and families services.  This project aims to promote more appropriate, cost-effective and family & community based services that promote family resilience.   This work will be underpinned by a new theory of practice and operating model, based on restorative principles, to stem the increase of demand on social care and to ensure families & young people receive the support they need at the correct level of intervention.  Regardless of funding, we have already begun to make changes which directly impact on a number of the recommendations made below.    Recommendation Action to be taken Lead Timescale Outcome/Evidence/RAG 1. That the activity of the Board promotes the pathway to, and practice of, achieving personalised, SMART and outcomes focussed Plan for children across all spectrums of need.     Upgrade LCS system so that format of plans is smarter and more outcomes-focussed CA  July 2015 Format of CIN/CP plans and EH plans has been amended Audit of CP & CIN plans to be completed CRe July 2015 71% of plans found to be Good or better Appoint Review and Improvement Team to identify multi agency model of practice to enhance assessment and planning CRo  September 2017  Team appointed  Promote role of IROs in making formal and informal challenges to care plans CRe  March 2016 IRO Annual Report 2015/16 demonstrates significant increase in challenges Review all CP cases of children subject to a plan over 18 CRe/GW Feb 2017 Completed February 2017 SCR Child N  months Introduce recording structure to ensure health visiting and school nursing records are outcome focused and provide a plan of care.   LW Oct 2015 Completed Currently in the process of being further updated. 2. That within the existing Child in Need processes, consideration is given as to how to strengthen the independence and objectivity that needs to be available when reviewing Plans   Continue to develop the role of the Child In Need Independent Reviewing Officer CRe  April 2017  Refocus of CIN IRO role agreed April 2017  Management review of CIN cases open over 2 years KM July 2015 Completed TSCB Child in Need policy and guidance to be updated  CF Nov 2015 Completed  3. That the Board promote the value of multi-agency partnerships though all of its activity, taking opportunities to bring multi-agency professionals together to think, reflect and learn Multi agency neglect audit completed CF  Feb 2016  Completed – presented to TSCB June 2016  Further multi agency neglect audit to be completed CRe/SW  Oct 2017 Audit completed – report to be finalised. Multi agency neglect conference/learning event held CF/JA  Feb 2016 Completed   SCR Child N  through a practitioner led approach to audits or reviews.   Enhance our Early Help training offer JP Mar 2017 TSCB now offer 6 Early Help training courses per year, increased from 2 per year TSCB Learning & Improvement Committee “Framework in Practice” presentation to multi agency staff CF/JA Oct 2016  Completed  Thematic review of cases referred to the LIC undertaken, and findings to be shared with the workforce and will inform the development of improvement strategies SW Dec 17    To be included in learning events on 5th and 6th December Learning and Improvement committee receive referrals from frontline practitioners for review of cases that they believe could have been managed more appropriately.  Cases are reviewed by partners, and improvement strategies are developed to address practice issues SW      Ongoing  Completed      SCR Child N  Professional thinking time (PTT) has been embedded into practice so that complex and difficult cases can be discussed so that core groups are clear about thresholds and plans.  Use of PTT Will be reiterated in Child N Learning event SW Ongoing Completed SCR learning event to be held following publication JP/SW/CRe December 2017 Learning events booked for 5th and 6th December 2017 4. That Board partners review their internal policies and procedures with regard to Violence and Aggression to reflect that critical decisions that impact on responsibilities to children are taken in consultation with multi-agency partners and place the safety of children as the paramount consideration.    Health visitors/school nurses to change criteria for supervision to include compulsory discussion about any parents that have displayed aggression to staff  SW    Aug 16    Completed  Chair of Safeguarding Children’s Board to seek assurance from partners that they have appropriate policies and procedures that staff are familiar with MN October 2017 Chair to write to partner agencies to seek assurance. 5. The Board to undertake a thematic audit on working with Establish a Complex Safeguarding Group reporting to the Safeguarding Board Executive Group December 2017 We do not feel that an audit is necessary but the establishment of the complex safeguarding group will include work on SCR Child N  violence and aggression with the purpose of sharing good practice and identifying problematic practice that makes poorer outcomes more likely  which will develop a work programme relating to improving  practice in working with violence and aggression violence and aggression and an action will be included from this SCR. Trafford already has an established multi agency Domestic Abuse Strategic Forum. 6. For the LSCB to undertake a consultation with multi-agency partners to establish what is needed to support practitioners to develop skills, confidence and resources to work with children. This information to support a strategy to develop the voice of the child for children subject to multi-agency procedures  Practitioners to continue to be supported through training, professional supervision and support to ensure that the voice of the child is embedded into practice All Board partners Ongoing      Develop a Neglect toolkit which indicates level of assessment required within each threshold of need CF/JA   April 2016  Completed   Use of the neglect toolkit will be reiterated at the planned SCR learning event Update child protection consultation booklets for young people CL  Feb 2017 Completed  Commit to funding annual subscription to Research in Practice CRo  March 2017  Completed SCR Child N  7. For the Board to dedicate time to debate the issue of sexual abuse, using recent studies and performance data to consider the position in Trafford and whether further Board directed work is indicated  TSCB partners to write a self-assessment in preparation for a potential JTAI inspection which would include a themed inspection around intra-familial sexual abuse.    CRo Dec 2017  This Self-Assessment will allow us to benchmark existing practice, identify areas for improvement and create an action plan to implement changes required.    Leads  CA Cathy Atherton CRe Chris Reilly CRo Cathy Rooney KM Katherine Mackay CF Catherine Fleming SW Steph Whitelaw JA Julie Adesanya JP Jed Pidd MN Maureen Noble LW Lauren Whyte 