Ingestion of a potentially fatal amount of methadone by a 20-month-old boy in the autumn of 2018. Both parents were arrested on suspicion of child neglect. Liam is the youngest of three children to the same mother and father. Prior to Liam's birth parents had only been known to universal services and substance misuse services, as both parents were known to have misused heroin. Liam was in the care of the local authority, placed with his mother. Enquiries subsequently revealed that Liam's father had been staying at the family home, without the local authority's agreement, and that, despite suspecting that Liam had consumed methadone, parents had delayed seeking medical help for him. Ethnicity or nationality not stated. Learning includes: ensure that assessments collect and synthesise information from a range of sources; improve the quality of analysis of known risks; the importance of being tenacious about engaging fathers and understanding their role in the family; the challenges of working with families where children are placed with parents as an outcome of care proceedings; improve safeguarding of children living with parents when care proceedings have ended. Recommendations include: revise existing multi-agency safeguarding procedures, protocols and guidance in respect of parents who misuse substances; improve levels of basic awareness of substance misuse, specific safeguarding issues and how to obtain specialist advice; undertake a multi-agency audit of cases where children are living in households where adults are known to misuse drugs or who are now being treated with opioid substitute therapy.
      
 Title:  Serious case review: Liam. LSCB: Wirral Safeguarding Children Partnership Author: Wirral Safeguarding Children Partnership Date of publication: 2020  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.                                  Serious Case Review ______________________________________________  LIAM                           This report will be published in line with statutory guidance.  In order to preserve the anonymity of the children in this family, Wirral Safeguarding Partnership has taken steps to disguise the children’s identities and circumstances.  It has: • represented the children by names chosen at random and which do not necessarily reflect the children’s true gender; • used initials for key family members, indicating their relationship with the child;  • avoided the use of exact dates; and, • removed details about local services which could lead to the recognition of the children and family.  1  Wirral Safeguarding Children Partnership February 2020  1. Background to Review  1.1  Liam was admitted to hospital in the autumn of 2018, having ingested a potentially fatal amount of methadone. Liam was 20 months old and had been in the care of the local authority, placed with his mother (ML).   1.2 Enquiries subsequently revealed that Liam’s father (FL) had been staying at the family home, without the local authority’s agreement. It was also reported that, despite suspecting that Liam had consumed methadone, parents had delayed seeking medical help for him.   Both parents were later arrested on suspicion of child neglect.  1.3 This was the second time that Liam had come to the attention of services following an incident.  While still in the hospital where he was born, Liam was found to have suffered two skull fractures, with no explanation as to how they could have occurred.   Medical evaluation was that such injuries were likely to have been caused by non-birth trauma.  Care proceedings were initiated by the local authority.   During the course of those proceedings, ML revealed that she had dropped Liam.     1.4 Within a month of the second event, Wirral Safeguarding Children Board (WSCB) undertook a rapid review of information readily available to agencies and organisations.  In accordance with the still current requirements of Working Together to Safeguard Children 2015, WSCB concluded that the criteria had been met for a serious case review.  This decision was endorsed by the national Child Safeguarding Practice Review Panel.  1.5 The purpose of the Serious Case Review is to establish what lessons can be learned from the case about the way that organisations worked together to promote Liam’s welfare and to keep him safe, especially given that he was the subject of a care order at the time of incident.  1.6 WSCB decided to take a hybrid systems approach to the review which would ensure that practitioners and first line managers were able to participate.   Current police investigations have precluded parents being offered the opportunity to participate in the review process.   1.7 A Serious Case Review Panel (SCRP) of senior managers from agencies involved with the family was appointed to oversee the conduct of the review. The review was facilitated by an independent reviewer.  1.8 Throughout the course of the review, the SCRP reviewed and revised key lines of enquiry.  The final key lines of enquiry are:  2  Wirral Safeguarding Children Partnership February 2020 i. Prior to the period under review, what relevant knowledge did agencies, organisations or individual professionals have about parents or children in the family? What services were being provided for family members when Liam was born?  ii. How effective was the response of services to original incident?   iii. How effective were care proceedings in terms of promoting the children’s welfare and keeping them safe?  iv. How did the making of care orders with children placed at home affect assessment of risk; care planning; service provision; and, management oversight and review?  v. Given that parental drugs misuse was a key feature of this case, how well did professionals understand the nature of parents’ legal and illegal drugs use and their implications for the care of the children?  How effective were safeguarding measures?  vi. How effective was professional communication and joint working during the period of the review?   vii. How well were the lived experiences of the children known and how did this affect professional practice?  viii. When ML disclosed causing the injuries to Liam; how was the original incident at hospital reviewed and what action was taken?  ix. To what extent did learning from the multi-agency case review Child 8 (2017) affect the work of practitioners, the nature of services offered to this family and/ or management oversight?  1.9 A combined chronology of significant events was completed.  Five key agencies or services were asked to complete learning summaries.   A learning review for practitioners and managers was held in September 2019. Members of the SCRP also attended that event.  This was well attended with good representation from relevant services.   Participants demonstrated ability to reflect on their own service’s contribution to practice and to make respectful enquiries of others.   They were analytical in their approach to learning both as individuals and as a group.   Notes of the meeting were later provided by the Safeguarding Partnership Administrator.   1.10 A complicating feature of this review has been the absence of some key practitioners and managers as a consequence of staff turnover, particularly within the local authority.   The serious case review would have benefitted had learning summaries been requested of all agencies which contributed to the learning event.   3  Wirral Safeguarding Children Partnership February 2020 2. Key Lines of Enquiry  2.1  Prior to the period under review, what relevant knowledge did agencies, organisations or individual professionals have about parents or children in the family? What services were being provided for family members when Liam was born?  2.2 Liam is ML’s third child. The father of all three children is FL.  Prior to Liam’s birth, with the exception of substance misuse services, family members had been mainly known to agencies providing universal services.  During ML’s pregnancy and after Liam was born, professionals understood that ML and FL had ended their relationship.   Agency records suggest that the couple had separated and reunited on more than one occasion during the course of their relationship.     2.3 Both parents were known to have misused heroin.  They had both undergone residential rehabilitation in the past for heroin misuse and both had had opioid substitute therapy.  When Liam was born, ML had been on an opioid substitute programme for a number of years.   ML told midwives that she felt well-supported by the local substance misuse service.  The substance misuse service had adopted a ‘Think Family’ approach to her care.    2.4 FL was said by ML and other family members to have significant health and mobility problems.  His living arrangements were not known to professionals at the point that Liam was born.  The nature and frequency of the children’s contact with their father was unclear.  2.5 Liam’s health visitor had worked with the family since Liam’s older brother, George, was six weeks old.   FL was never seen during this time and ML had said that they were no longer in a relationship.   FL’s details were, therefore, not recorded on the health visitor file.   The relevant agency learning summary indicates that this was normal recording practice at that time.  Since a recent CQC inspection, however, changes are to be made to include information about absent fathers.      2.6 Police and CSC held information about FL’s history of domestic violence in a previous relationship which included an incident in which two of his children were directly harmed.   Within CSC, however, no link had been made between the children of FL’s first family and Liam and his brothers.  Practitioners were, therefore, unaware of this connection.    2.7 Police records also revealed that, as a young person, FL was a suspect in a violent incident which resulted in the death of another individual.   FL later reported to substance misuse services that he suffered post-traumatic stress as a consequence of his involvement in this event.   2.8 ML’s family did not live locally and her mother and stepfather spent most of the year abroad.  While ML was pregnant with her first child, Alexander, she had recently been discharged from residential detoxification and rehabilitation.  Midwives were concerned that she had separated from FL, was low in mood and was socially isolated.  The midwife 4  Wirral Safeguarding Children Partnership February 2020 requested an assessment by CSC.  She noted that FL had relapsed and that ML might also be at high risk of relapse.  The midwife also referred to ML’s ‘ability to be misleading of professionals’.    ML, however, told CSC that she was adequately supported by her worker from her housing project and no assessment was undertaken.  2.9 It is not clear whether ML was having opioid substitute therapy when she was pregnant with Alexander.  Records suggest, however, that therapy was established when George was born twenty months later.   There was no indication that ML’s care of the older children had been negatively affected by methadone therapy or substance misuse.   2.10 The overall professional impression of ML appears to have been of a mother who was somewhat socially isolated but who was generally capable: ‘she presented very well.’  2.11 How effective was the response of services to original incident?   2.12 When he was born, Liam was monitored for symptoms of Neonatal Abstinence Syndrome.   The hospital had previously checked whether there were safeguarding concerns in respect of the infant but there were none.  ML was given methadone in accordance with her prescription.   Hospital staff tried to support ML, both to provide close physical care as advised for babies with withdrawal symptoms while, at the same, helping her to avoid the potential dangers of co-sleeping.      2.13 When Liam was found to have swellings on his head, a CT scan revealed fractures of the skull with underlying bleeding.   Appropriate medical enquiries were undertaken and care provided.   It was noted that no issues had been raised about Liam’s development in the ante-natal period and there was no history of injury to Liam during delivery.  No other bruises or injuries were noted.  No accidental explanation for Liam’s injuries was provided.   ML denied having dropped the baby.  2.14 In those circumstances, the question of non-accidental injury arose and child protection procedures were initiated.   At that point, Liam was in an effective place of safety with the consent of ML.    Arrangements were made to supervise ML’s contact with Liam while he was in hospital.   The other two children were already with paternal grandparents.  Paternal grandparents agreed that ML could live with them and that they would supervise ML’s contact with her children.   It appears that ML was also agreeable to this.      2.15 There is no record of professional discussion with FL during this period.  There is no record either of his having, or seeking, contact with Liam or with the older children.     2.16 Within the hospital, formal enquiries were undertaken in respect of members of staff who had cared for Liam.  2.17 At this point, the local authority considered the children’s living arrangements to have been made by family agreement.  This issue was discussed in depth at the learning event. Practitioners who had been involved at the time emphasised the levels of uncertainty 5  Wirral Safeguarding Children Partnership February 2020 which prevailed and recalled general concern not to wrongly attribute culpability for Liam’s injuries.   Although there was a possibility that Liam had been deliberately harmed by ML or by a member of staff; in reality, practitioners suspected that ML had hurt Liam accidentally but did not want to say so.   At the same time, ML’s ‘very convincing’ denial that she had harmed Liam in any way created further doubt and uncertainty.     2.18 It is acknowledged that this context could have influenced decisions about arrangements for the children.   The local authority was, however, of the view that it would have intervened had ML insisted on the children living at home with her.   In those circumstances, the local authority should have considered looking after the children.   2.19 A second opinion in respect of Liam’s injuries was obtained from a large city children’s hospital.  Medical enquiries were completed within a week reflecting ‘a clinical consensus view of eight other consultant paediatricians from the department, with experience of safeguarding’.   This report concluded that ‘trauma was the most likely cause of these fractures. In the absence of a history of accidental trauma…non-accidental injury cannot be excluded’.   2.20 A week later, before Liam was discharged from hospital, Liam and his brothers were made the subjects of interim care orders.  2.21 Around this time, ML had told her key worker in the substance misuse team (DW1) that she had taken heroin on one occasion since her discharge from hospital: her prescription for methadone had been increased as a result.     2.22 How effective were care proceedings in terms of promoting the children’s welfare and keeping them safe?   2.23 At the point that care proceedings began all parties had agreed that this was a ‘single issue’ case’ focussing on determining the cause of Liam’s injuries; who caused them; and, whether this had been accidental or otherwise.   When it became clear, however, that a hair-strand test was to be ordered to provide a picture of ML’s drugs use over the previous 6 months, ML revealed that she had been using heroin daily while she was pregnant.  At that stage, however; it was acknowledged that concerns about ML’s drugs use, and her lack of honesty about it, would not, of themselves, have given rise to care proceedings.  The court’s focus would continue to be on Liam’s injuries.  2.24 It was noted, from the first hearing, that FL did not intend to take part in the proceedings.   2.25 Shortly afterwards, ML told DW1 she had ‘admitted’ to the court that she had used heroin use in pregnancy.    ML said that she had been able to evade urine testing reviews during that time by attributing opioid positive results to co-codomol.   ML told DW1 that she was in debt as the result of funding her drugs use.  Significantly, ML also said that she had stored surplus methadone while she was pregnant and taken this into hospital to reduce heroin withdrawal symptoms.  Following those disclosures, ML was transferred by the 6  Wirral Safeguarding Children Partnership February 2020 substance misuse team to supervised consumption of methadone.  The substance misuse team reported having informed CSC of the details of this discussion.  2.26 Practitioners at the learning event considered the significance of the likely impact of ML consuming non-prescribed methadone, in addition to the dosage dispensed by staff.   It was suggested that ML would have been drowsier than she would otherwise have been and so, it could have had an impact on her ability to care for Liam.     2.27 This information was not, however, generally known to practitioners and managers prior to the learning event.  Following the initial court hearing, the fact of ML’s heroin use in pregnancy is reflected in a number of records.   ML also provided details in a statement to court.  The SCR, however, has been unable to find evidence that ML’s self-medication on the ward was known to the court.     2.28 The local authority’s assessment does not refer to ML using methadone she had taken on to the ward.    Rather, it refers to later communication with DW1 as recorded by CSC.   That indicates that drugs testing, on the day after Liam was found to have been injured, proved negative for illicit substances.  This was a completely different matter and clearly has a more reassuring quality.    2.29 During the week following the court hearing, Liam was discharged to his paternal uncle and aunt’s care.   ML remained in grandparents’ home along with the older children.    2.30 The notes of hospital discharge meeting refer to paternal grandparents supervising ML’s and FL’s contact with the children.  They describe CSC as being ‘happy’ with arrangements for Liam’s contact with his father, although it is not clear what those were.   All three children were now living within FL’s ‘very large family’.   At the same time, FL continued to avoid both social workers and the Children’s Guardian.    2.31 Neither connected carers’ assessment refers in detail to FL.  Although he is described as having been the most ‘challenging’ of his siblings, as far as their parents were concerned; there is no reference to his history of drugs use or to his living arrangements.  It was agreed in principle that FL’s brother could facilitate contact between Liam and FL.  Paternal grandmother indicated that there was currently no contact between FL and the older two children, due to his chronic ill health.   She also reported having no contact with FL’s other children as their mother ‘had made this difficult’.    There is no evidence of cross-reference between the children’s records at that point.  2.32 At the learning event, the Children’s Guardian described the relationship between ML and paternal grandmother as somewhat tense.  He gained the impression that grandmother favoured FL and tended to blame ML for the family’s problems.   This is not, however, reflected in the assessment undertaken by the local authority which refers to a positive relationship between ML and paternal grandmother.    7  Wirral Safeguarding Children Partnership February 2020 2.33 Twelve weeks into care proceedings, ML told professionals that she had accidentally dropped Liam while they were in hospital.   This should have led to a multi-agency strategy meeting, but none was held.  The police were, therefore, unaware that there was new information about how Liam had come to be injured and so, were unable to review their earlier position in relation to criminal investigation.   A strategy meeting might also have identified that no account had been taken of ML’s earlier disclosure that she had been self-medicating with illicit methadone while in hospital.    2.34 It was also revealed that, earlier that day, ML had told DW1 that she had recently been using heroin.  2.35 The following day, the local authority’s parenting assessment of ML was submitted to the court.  This had been completed before ML said that she had accidentally dropped Liam.  A short statement about ML’s disclosure was appended.  The CSC learning summary acknowledges that, an extension for submission of the parenting should have been sought in the light of this new information as it ‘fundamentally changed the assessment of mother’s capacity to parent’.      2.36 At a court hearing the following month, parties discussed ML having dropped Liam and having recently taken heroin.    It was agreed that care proceedings would continue due to ‘ML’s failure to seek immediate medical attention for Liam, the concealment of the accident, coupled with a longstanding history of substance misuse’.   No evidence has been provided that there was any discussion as to whether there were avoidable factors on ML’s part which could have contributed Liam’s fall.  2.37 It appears that CSC and the Children’s Guardian accepted that Liam’s injuries were the result of an accident for which no blame could be ascribed.    The court commissioned medical opinion did not contradict ML’s account of the time that the injury occurred or that the event as she had described had the potential to cause Liam’s skull fractures.   Without analysing other risk factors, the paediatric report concluded that the injuries were accidental.    Supervision arrangements were lifted and it was agreed that the children could return to ML’s care prior to the final hearing.     2.38 No evidence has been provided of consultation with the Independent Reviewing Officer or with partner agencies in respect of the decision to return the children to their mother’s care, although these are required by Wirral Children’s Specialist Services Procedures Manual when reunification of looked after children with their parents is being considered.     2.39 The CSC learning summary indicates that there is little information on file in respect of the analysis and decision to return the children to their mother’s care.   It notes that the reunification was ‘not informed by, or supported by’, the NSPCC framework for reunification .  As a consequence, the approach taken was ‘overly optimistic’ and the reunification was ‘not based on sound assessment and analysis.’    8  Wirral Safeguarding Children Partnership February 2020 2.40 It is significant, however, that, according to the CSC learning summary, there is no record of formal supervision being provided to the allocated social worker from the start of care proceedings until after the children had returned home.   Absence of supervision and management oversight would clearly be serious impediments to good risk analysis and case planning.  2.41 A week after assuming the care of all three children, ML told DW1 that she had taken ‘2 bags of heroin’.  Her treatment was adjusted and CSC were informed.   There is no evidence that this disclosure had any significant impact on care planning.    2.42 Two weeks later, FL attended the substance misuse service for an initial assessment, as he had relapsed on heroin.  He said that he lived with his mother and had no contact with his children.  He made no reference to ML.  Although FL had previously been known to the substance misuse service; he had not been an active service user at the point when the current service was commissioned.     This meant that his historical records were not taken forward when service provision transferred.   As a result, the service was unaware of the link to ML and the children.  FL was offered opioid substitute therapy, under a supervised consumption regime.     2.43 Four days later, at the final court hearing, it was acknowledged that ML had relapsed but that she was seeking appropriate support.  Care orders were made by agreement: the children’s placement with their mother continued.   2.44 As he had previously declared; FL had been wholly absent from care proceedings.  He had stated at an early stage that, if the children could not remain with their mother; he did not want to be considered as an alternative carer.  As a consequence, he was not the subject of a parenting assessment.   Despite being the father of ML’s three children, there was little consideration of the role that he played in ML’s life.   The matter of his current and envisaged contact with the children did not form part of the final analysis of risk.  Details of FL’s previous family and criminal convictions appear to have been unknown to practitioners working with ML and her children.  This suggests that standard agency checks, including with police records, were not undertaken.      2.45 During the course of care proceedings, there were two looked after child reviews.   A learning summary has been provided by the local authority Safeguarding Unit.    This summary describes the recommendations of the first review as ‘very passive’ and ‘limited in value’.  The full report of the looked after review was not found due to a technical issue about workflow within the local authority electronic record.  2.46 Between the first and the second review, there was a change of IRO.  At the second review meeting, ML talked about having dropped the baby while they were in hospital.   Although this disclosure created a watershed in case planning; the Safeguarding Unit learning summary describes the notes of the meeting as being of poor quality; brief; and lacking reflection or challenge.  Only two recommendations ‘of little value’ were made.     9  Wirral Safeguarding Children Partnership February 2020 2.47 Shortly before the children returned home, the social worker spoke to the IRO about events in court and confirmed what was to happen.  The IRO record, however, provides ‘no commentary or analysis in respect of the care plan or discussion with the social worker’.  At that point, the allocated IRO changed for the third time.    2.48 There is little evidence of effective multi-agency working during care proceedings. This matter is considered in more detail later in this report.  2.49 How did the making of care orders with children placed at home affect assessment of risk; care planning; service provision; and, management oversight and review?  2.50 When care orders were granted, Liam was less than 6 months old and there were two other young children in the household.    It was known that Liam had suffered a serious injury and that his mother had delayed seeking treatment for him, exposing him to further risk of harm as well as to the possibility of unnecessary additional medical investigations.    ML’s explanation was that she had been afraid to say what had happened, ‘due to her drugs use’.   ML was now understood to have relapsed on heroin for which she was seeking support.     2.51 Uncertainty about FL’s role in the children’s lives continued.   While not recognised during care proceedings, practitioners working with the children appear to have been generally aware that they were having contact with FL, although the nature and frequency of that contact was not clear.  There is more than one reference to the contact taking place at paternal grandparents’ home, where FL had told the substance misuse service he was living.  There was a general belief that there was no current relationship between ML and FL.     2.52 It might have been anticipated that care plans would have focused on continuing to assess the impact of ML’s drugs use on her capacity to care safely for the children; multi-agency arrangements to increase the opportunities to scrutinise compliance with expectations; and, efforts to establish and assess the implications of FL’s involvement in the children’s lives.      2.53 In the event, however, rather than being seen as the beginning of new phase of work with the family; the granting of care orders appears to have been considered as an end in itself.  The care plans presented to court describe the new situation as ‘permanence plans until such a time as the court discharges the care order or until the children reach the age of 18’.  The local authority did not recognise the change of legal status as offering an opportunity to review previous history and to set a clear, targeted plan for the future.   Instead, the local authority anticipated that the benefits of shared parental responsibility would be to ensure ‘a high level of monitoring’ and the capacity ‘to take protective action if the children were deemed at risk’.   During care proceedings, the local authority had specifically ruled out any further assessments ‘as not being within the children’s timescales’.    10  Wirral Safeguarding Children Partnership February 2020 2.54 As a result of this somewhat passive approach, therefore, significant gaps which had already developed were not identified and managed.   Instead, the local authority acknowledges that care planning became ‘somewhat chaotic’, ‘directionless’ and ‘inadequate’.  In particular, care plans ‘did not provide a road map for all agencies to understand what they were doing and what the objectives they were working towards’1.  2.55 No evidence has been provided that professionals working with the family had been party to developing a shared care plan or that a placement plan was completed.   As a result, there was no clear articulation and shared undertanding of what was expected of ML; of the local authority; of partner agencies; and, of other family members.   Proposals within the court care plan to have 4-weekly care planning meetings were not realised.     2.56 Within a week of care orders being made, FL attended substance misuse services.  Blood tests were positive for illicit methadone and opiates.  FL said that he had been using heroin regularly for the previous four years.   His drugs use was ‘funded by benefits and friends’.  FL reported also having depression, which he said was being treated by his GP.    2.57 The following day, the pharmacy contacted the substance misuse service to say that ML had not been consuming all of the methadone that had been prescribed.   The service had not yet made the connection between FL and ML.  2.58 Less than a week later, CSC received an anonymous referral reporting concerns about ‘children out late and unsupervised at night; mum and dad’s drug use; and, drug users calling at the property’.   CSC concluded that there was no evidence to support allegations: it was suspected that the allegations were malicious.    There was no apparent enquiry about the significance of the reference to ‘dad’s drug use’.  2.59 A month after the care orders were granted, ML told the health visitor that she was to be evicted.   ML said that this was due to damage to the property but she denied that she was responsible for it.  ML said that she was receiving support from the relevant services.     2.60 Within CSC, a family support worker services were allocated for ‘direct work’ but it is not clear what this entailed.  No summary has been provided to the review.  The local authority did not identify a family support worker or manager to attend the practitioner learning event.    2.61 When Liam was seven months old, ML attended the first two sessions of the parenting course provided by the substance misuse service.   She was still using heroin and drugs use was having an impact on her lung function.  ML told DW1 that she only used heroin when she did not have the children with her.    ML said that she had only had a small amount of contact with CSC and that her social worker was absent due to illness.    1 Safeguarding Unit learning summary 11  Wirral Safeguarding Children Partnership February 2020 2.62 Throughout this time, FL was receiving methadone on prescription but he was not initially compliant with collection arrangements and did not attend planned sessions with his recovery co-ordinator.   When he began to attend as required, he tested positive for methadone and opioids.   2.63 During the autumn, ML secured a new tenancy.    2.64 Within CSC, casework responsibility was reallocated to a newly qualified social worker in her Assessed and Supported Year in Employment (ASYE).    The CSC chronology provided for the review, suggests that, because of its complexity, this case was not appropriate for an ASYE to hold.  In the learning event, however, it was acknowledged that with a third of children’s social workers being ASYE; ideal allocation was not always possible.  In recognition of their lack of experience and expertise, however, ASYEs are expected to have fortnightly reflective casework supervision.    In this case, no record was found of social work supervision for almost 12 months after the care orders were granted, including eight months after casework responsibility transferred an ASYE.     2.65 Throughout this time, the absence of regular case management meetings meant that agencies were working separately, rather than collaboratively, with ML and the children.  This increased the likelihood that the significance of information known to agencies would be overlooked.  For example, on three separate occasions in three months; Liam was seen to have either a fading bruise or a cut to his head which, each time, ML explained as having resulted from a fall against a glass TV cabinet.  It is acknowledged that children learning to walk are prone to falling.  In the circumstances of the case, however, the detail and significance of these incidents should have been more fully explored.  Consideration should have been given as to whether a child protection medical was required.   2.66 At the beginning of the New Year, when Liam was coming up to his first birthday; ML was continuing to struggle to abstain and she indicated that she would like to attend residential detoxification and rehabilitation.  The substance misuse team could only provide funding for the adult component of a placement.  DW1, therefore, negotiated with CSC to provide funding for a specialist family rehabilitation placement.     2.67 The following month, ML and the children moved out of area to the rehabilitation facility for 12 weeks.    The health visitor, however, was not informed that ML had left the area with the children.     2.68 At the end of the 12 week period, ML was drug-free.   She was keen to return home as soon as possible: an abstinence based aftercare plan was designed to support her.  This would be a new phase of recovery and would include access to peer-to-peer support.   CSC agreed to support the necessary child care arrangements.  CSC records state that if ‘all continued to go well until the end of the year’; discharge of care orders would be considered.  12  Wirral Safeguarding Children Partnership February 2020 2.69 On the family’s return home, Liam started nursery.   Alexander and George re-enrolled at the school they had previously attended.  The school found that they adapted to this change back without difficulty.   2.70 From the New Year until this point, FL’s engagement with the substance misuse service had been poor: he had not attended planned medicals.   Around this time, ML told her recovery worker that FL was also a service user and that he wanted residential rehabilitation.  ML said that she had also told her social worker this.   It appears that it was at the point that the connection between parents had been made as, around this time, DW1 was allocated as FL’s key worker.   2.71 Shortly afterwards, ML said that she had decided to work with a different abstinence-based provider to support her recovery.     2.72 During the summer, FL reported to the drugs service that he had not used illicit drugs for six weeks.  A mouth swab test showed positive for methadone only.  The drugs service record indicates that FL was now having regular contact with the children and that the relationship between parents was said to be positive.     2.73 In the same month, ML and FL planned to go on holiday with the children, visiting ML’s mother and stepfather.     ML initially spoke to CSC about the planned holiday, but it is not clear what was understood about the travel plans and where the children would be staying.   No record of agreement to travel arrangements has been provided by CSC to the SCR.      2.74 ML later telephoned DW1.  She confirmed that she and FL would be on holiday together.  ML and the children would, however, be staying with maternal grandmother while FL would be staying in another hotel with relatives.  Arrangements were made for FL’s medication.  These took into account that children would be in the travel party although FL would not have direct responsibility for them.     2.75 These events suggest that there was a material change in family circumstances which warranted further evaluation.  2.76 Around the start of the next school term, a looked after child review was held.   This was the 5th review which had taken place since care orders had been granted.     The Safeguarding Unit learning review notes that IRO activity had increased over the previous ten months.  There had been a further change of IRO.    2.77 At the point of the latest review, the children’s placement was noted to be ‘going well’.  Recommendations were generally designed to support progress, although gaps in health information were identified as continuing a problem.  It is not clear what these gaps were but it is suggested that they had endured for some time without resolution.   FL’s absence from the review process was noted, although it was recorded that he was now having ‘unrestricted contact’ with the children.   No plan to engage him was identified, however, 13  Wirral Safeguarding Children Partnership February 2020 and no actions were recommended to assess the suitability of this contact or to formalise arrangements.  It was proposed that the care plan would be discharged if ML could demonstrate sustained change over the following 12 months.  2.78 In considering the effectiveness of the IRO role in this case, the local authority Safeguarding Unit concludes that there was an over-reliance on ML’s perceived openness while ‘the fact that she had denied dropping the baby and later admitted to it, would seem to have diminished in importance’.    The learning summary refers to a ‘silo mentality as opposed to true partnership working’.  At the learning review, partner agencies were surprised to learn that 4-weekly planning meetings had been agreed in court and it was acknowledged by the local authority that regular planning meetings for looked after children were not common practice.      2.79 The Safeguarding Unit learning summary also notes that, throughout case planning, insufficient attention was given to building ML’s resilience.   As with the practitioners in the case, the IRO service was ‘overly optimistic’ about the family’s progress and about their ‘levels of cooperation and truthfulness’.   2.80 A week after this looked after child review; Liam was taken by ambulance to hospital following a 999 call from house.  Ambulance staff found him to be unresponsive, grey and not breathing on his own.  On admission to hospital, Liam was very close to death.  2.81 Child protection procedures were put into effect.  Alexander and George were taken from school to a place of safety.   The police began an investigation and both parents were arrested.   At the time of writing, the police investigation remains live and so, no details of parents’ accounts are provided.   2.82 Given that parental drugs misuse was a key feature of this case, how well did professionals understand the nature of parents’ legal and illegal drugs use and their implications for the care of the children?  How effective were safeguarding measures?  2.83 Elements of this line of enquiry have been addressed in earlier sections of this report.   2.84 As is already evident, the substance misuse team was very active during the period of the review. The relevant learning summary indicates that the recovery plan that was developed with ML would ordinarily be viewed as an example of good practice in addressing opiate addiction.     2.85 There is evidence that ML’s methadone prescription was reviewed in accordance both with her assessed need and in the context of any disclosed illicit drugs use.  CSC was provided with up-to-date information.  When ML made clear that she was committed to becoming drugs-free; the service was instrumental in helping to secure funding in CSC for a rehabilitation placement that would allow the children go with ML.   In-patient detoxification and residential rehabilitation is regarded as an intensive intervention that maximises the chances of successful recovery.    14  Wirral Safeguarding Children Partnership February 2020  2.86 At the end of the 12 week period, ML was drug-free.  From the perspective of the substance misuse service, therefore, ‘the objectives of the structured drug treatment appeared to have been reached’.  The service also advocated on behalf of ML and sought child care support from CSC.    2.87 From a child protection perspective, however, there should have been a much more effective multi-agency approach to recognising and responding to the risks of parental drugs misuse.    2.88 For the greater part of this review period, parents were understood to be estranged.  ML was known to be the children’s primary carer.  During this time, the pattern of ML’s known drugs use varied, but no comprehensive assessment was ever completed of its impact on her care of the children.  2.89 At the same time, it was generally understood by professionals that the children were having some contact with their father although this had never been formally assessed or agreed.   FL’s inconsistent engagement with the substance misuse service, however, meant that there was only a partial understanding of his drugs use.  2.90 Finally, there was no clear understanding of the parents’ relationship.  Despite their going on holiday together with the children, no evidence has been provided of significant enquiry as to whether they had reunited.    As a consequence, no assessment was proposed of the couple as a parenting partnership.   There was no formal evaluation of the impact that of each individual’s drugs’ use on the drugs’ use of the other or of implications of that interaction for the children.   2.91 As the substance misuse learning summary indicates: ‘It is reasonable to believe that FL spent more time at ML’s house than the service or children’s social care were aware of at the time.  Because the service wasn’t aware of FL’s methadone being in the children’s home environment, the risk could not be adequately or safety managed’.   In addition, it had been understood that due to the combined work by the service and by CSC, ‘the case wasn’t viewed as high risk’.  ML was considered to be ‘a protective factor’ after leaving rehabilitation.  As the learning summary acknowledges, however; ‘this assumption was incorrect’.  2.92 Beyond discussion about this particular family, the practitioner learning event revealed that most practitioners had significant gaps in their knowledge about both the potential effects of opioid use on parents’ capacity to provide care for their children and how their impact would be measured in any individual case.    2.93 There were also clear misunderstandings of the purpose and effectiveness of routine drugs testing as an indicator of illicit drugs use.   This was significant as non-specialist practitioners were overly reassured by negative results.    15  Wirral Safeguarding Children Partnership February 2020 2.94 How effective was professional communication and joint working during the period of the review?   2.95 Throughout the review period, there are examples individual practitioners working well with family members and in accordance with the expectations of their agencies and organisations.   A number were discussed at the learning event and are acknowledged in agency learning summaries.   There are also examples of good communication, particularly between health disciplines.  Where barriers were encountered, there are also examples of tenacity and escalation.  The contribution of DW1 both in terms of professional practice and input to review’s learning event is particularly acknowledged.   2.96 Immediately following Liam’s initial injuries, communication between professionals was good.    Communication between the hospital, the local authority out-of-hours service and the police was timely and safety plans were implemented.  At the earliest opportunity, the allocated social worker and DW1 made a joint visit.  The health visitor spoke to ward staff for an update in respect of Liam.   A strategy meeting was held in hospital which facilitated the attendance of staff involved with Liam’s care.  CSC attended with a local authority solicitor to expedite care proceedings if required.    2.97 When care proceedings were current, however, there were few formal opportunities for information-sharing and case planning.  Participants at the learning review described this as unsatisfactory but reported that it was consistent with their experience and preconceptions.   There was an assumption that, in proceedings, the local authority and lawyers effectively ‘own the case’ and, as a result, there is little expectation of a multi-agency approach.     2.98 Concerns were expressed that this had potential disadvantages in day-to-day casework with families.   In addition, questions arose as to whether, in the absence of jointly approved notes of meetings and discussions, there was an increased possibility of professionals’ views being misrepresented or inaccurately interpreted. Two examples of such instances were identified in this case.   The implications of not holding a multi-agency strategy meeting when ML said that she had dropped Liam have already been outlined.   2.99 Then, when the children returned to ML’s care, practitioners were unclear both about the local authority’s rationale for their return and about what it signified in terms of risks and safeguards.   There was no clear understanding of the implications of ‘shared parental responsibility’ and what this might look like in practice.   As already noted, this was exacerbated by the lack of a care plan and placement plan for which they had shared responsibility.     2.100 Throughout the time that the children were subjects of care orders, both 0-19 service and the substance misuse service experienced considerable delays in calls being returned by CSC and information was rarely shared with them in a timely manner.    The quality of looked after child reviews, while improving over the period of the SCR, was generally poor.    16  Wirral Safeguarding Children Partnership February 2020 2.101 Although the children’s school was represented at the learning event, only minimal information was provided for the joint chronology and they were not asked to provide a learning summary.   There are few references to the school in the documents which have been provided to the SCR and no evidence has been provided that the children had personal education plans.  This represents a gap in the SCR process but also suggests shortcomings in a multi-agency approach.  2.102 The initial incident considered by this review was characterised by ML’s concealing both her illicit drugs use and the circumstances in which Liam was injured.  During the review period, however, ML came to be seen as ‘open and honest with regards to her drugs use’2.  Professionals did not recognise that, in reality; ML, FL and, to a lesser extent, members of FL’s extended family had all concealed, or failed to divulge, information that was significant to the children’s wellbeing and safety.     While better formal arrangements for information-sharing, planning and joint working, therefore, would not necessarily have led to a better outcome; it would have made good safeguarding practice more likely.  2.103 How well were the lived experiences of the children known and how did this affect professional practice?  2.104 The information which has been provided to the review suggests that professionals did not have a very clear understanding of the lived experiences of the children.    Participants at the learning event talked about how well ML presented at all times.  She has been described as ‘middle class’.  There is no reference to any professional concerns about home conditions, despite ML being evicted at one stage du, by her own report, to damage to the property.   The family moved twice during the review period, not including the temporary move out of area.    There was a single referral to CSC during the review period which referred to illegal drugs use and to poor supervision of the children: this was understood to be malicious.  2.105 The children appear to have had generally good health, although Liam had eczema which required medical management.   He appears to have made a good recovery from head injuries.  Liam and one of his brothers had planned minor surgery.   The relationship between ML and the children was good and, according to the IRO, the children appeared to be happy around her.   The health visitor described ‘excellent attachment’ between Liam and ML: she was warm and responsive towards him.      2.106 Around 12 months old, Liam was not yet achieving some personal/ social developmental milestones.   Liam and George were, at different times, referred to Speech and Language Therapy.   2.107 While the children were with ML outside of area, no significant concerns were identified about ML’s care although it was noted by the health visitor that ‘supervision of the children  2 CSC learning summary 17  Wirral Safeguarding Children Partnership February 2020 has occasionally been an issue as it a busy place … where they are staying’.  It was reported that there had been ‘a serious incident’ at school when Alexander described an assault by a fellow pupil.  No further details are provided but CSC record indicates that practice was as expected and that a safety plan was put in place.  2.108 At the learning event, practitioners referred to ML struggling to manage the children’s behaviours.   A family support worker was involved but, as noted earlier, it is not entirely clear what her role was: no record of her observations has been provided to the review.   2.109 The CSC learning summary notes that there is little evidence of direct work with the children and visits did not explore their lived experience.  Information which was relied on came from other agencies rather than directly from the children.   Significantly, Alexander’s ‘comments regarding his father being in the home were not picked up on and actively explored by the social worker and family support worker’.  2.110 When ML disclosed causing the injuries to Liam; how was the original incident at hospital reviewed and what action was taken?  2.111 Following the original incident, the hospital undertook a root cause analysis (RCA).   This allowed the hospital to identify any critical problems or issues.   According to the hospital learning summary, key safety and practice issues were noted.  It concluded that ‘while they may not have contributed to the actual incident’, others could learn from the findings.      2.112 The changes which have taken place include employing a specialist drugs and alcohol midwife who will develop detailed plans for mothers using drugs, whether or not there are safeguarding concerns.   It is anticipated that this approach will help develop a trusting relationship with mothers and will contribute to a better response around any potential incidents.   This has also been supported by learning for ward staff and increased vigilance in respect of co-sleeping.  2.113 At the time the RCA was conducted, however, it was not known that ML had dropped the baby although the hospital had been informed of ML’s reported heroin use in pregnancy.  As already indicated, it is not clear whether ML’s information about ML’s illicit methadone use on the ward had also been provided.   In terms of the hospital’s learning, mother’s concealed drugs use is significant particularly in the context of her later admission that she had dropped the baby.    2.114 To what extent did learning from the multi-agency case review Child 8 (2017) affect the work of practitioners, the nature of services offered to this family and/ or management oversight?  2.115 There is no indication from the record that this was influential on practitioners’ work with Liam and family members.    The CSC learning summary notes that there was ‘again evidence of disguised compliance and a lack of assessing parental capacity to change.  No evidence based risk assessment tools appear to have been used.’  The 0-19 learning 18  Wirral Safeguarding Children Partnership February 2020 summary indicates that the review had been shared with staff across the workplace.   The report states that staff have ‘a clear understanding of disguised compliance’ which is emphasised in agency and LSCB safeguarding training.    19  Wirral Safeguarding Children Partnership February 2020 3. Lessons learned  3.1 The principal lessons and recommendations will be focused on two specific practice issues which arise from this case.  They are: • safeguarding children where parental drugs use is a feature of family life, particularly where individuals are receiving opioid substitute therapy; and, • the particular challenges of working with families where children are placed with parents as an outcome of care proceedings.   3.2 At the same time, there are a number of issues raised by basic safeguarding practice in this case which have more general application.   These include: ensuring that assessments collect and synthesise information from a range of sources; improving the quality of analysis of known risks; and, helping practitioners identify the most appropriate means of measuring how these risks are being managed in the children’s everyday lives.   Most significantly, this case illustrates the importance of being tenacious about engaging fathers and understanding their role in the family.     3.3 It is acknowledged that, when Liam was born, the local authority children’s services and the Local Safeguarding Children Board had been recently judged as inadequate by Ofsted.  As in this review, inspectors found that good practice standards were not being communicated to practitioners through managerial oversight or supervision and that IRO challenge was ineffective and did not lead to positive change for children.  Inspectors concluded that, as a result, a culture of over-optimism often went unchallenged.     3.4 The Ofsted report also made reference to the impact that poor case recording; insufficiently focused assessment and plans; case complexity; and, high staff turnover had on practice and on outcomes for children.   These were also features of local authority work with this family.      3.5 Over the course of the following 18 months, Ofsted made eight further visits during which progress in making improvements was evaluated across discrete elements of social work and service provision.   Improvements were noted in purposeful visiting and direct engagement with children.  Similarly, improvements were noted in management oversight; elements of assessment; the quality of support plans; and, in effective record keeping.   Additional resource had been added to the IRO service which was found to be more challenging.  3.6 In 2019, a second full inspection by Ofsted found that leaders were making a good impact on social work with children and families and that there had been improvement in areas previously identified as inadequate.   Not all areas of practice were found to have improved at the same pace but it was acknowledged that the local authority had plans in place to address outstanding as part of ongoing service improvement.  20  Wirral Safeguarding Children Partnership February 2020 3.7 The Safeguarding Partnership will, however, want to be assured that safeguarding improvements identified by Ofsted in children’s social care have been consolidated since the inspection and that they are reflected in improved multi-agency practice.   In terms of recommendations, however, it is anticipated that, where possible, necessary actions will be incorporated into existing or proposed practice improvement plans and learning schedules, both single- and multi-agency.    3.8 Safeguarding children where problematic parental drugs use is a feature of family life, particularly where opioid substitute therapy is prescribed  3.9 The NSPCC provides a summary of risk factors and learning for improved practice around parents with substance misuse problems.   The learning in respect of Child 8 undertaken by Wirral LSCB in 2017 is consistent with this summary report.  This review does not propose to repeat that learning, although there are common features in both.    In particular, there were findings in respect of ‘disguised compliance’ and the need to ensure holistic assessments addressing parents’ capacity to change.  These findings are highly relevant to this case.   3.10 Where parents are being treated with opioid substitute therapy  3.11 In 2014, Adfam published Medication in Drug Treatment: Tackling the risks to children.  This report acknowledged that since the publication of Hidden Harm in 2003, the needs of the children of problem drug users have received much greater attention in policy and practice, including a greater emphasis on child protection in clinical guidelines.  Opioid substitute therapy is considered to be an effective treatment which reduces harm across a number of measures.    3.12 Opioid substitute therapy can be a protective factor for children as it can allow parents to improve their finances; to stabilise relationships; and, to be more available for their children.  Opioid substitute therapy is described as having ‘a rightful place of medication in a recovery-orientate treatment system’.  At the same time, accidental ingestion of methadone is a specific risk for children living in the household.  3.13 Readily available data  3.14 In Medication in Drug Treatment, One Year On, Adfam expanded upon the findings and recommendations of its previous report.   New data revealed that, between 2003 and 2013, at least 110 persons aged 0-18 died from opioid substitute drugs in the UK.   In England and Wales, of the 72 methadone related deaths involving children and young people, 18 years old and under.  Only 6 of those deaths resulted in a SCR.    During that same period, hospital admissions statistics in England indicated that at least 310 children under 18 were admitted to hospital with methadone poisoning: a further 18 were admitted in 2013-14.  Given identified gaps in the data, however, this was believed to be an underestimation of the true figure.   21  Wirral Safeguarding Children Partnership February 2020 3.15 New data also suggests that the majority of children ingesting opioid substitute drugs are adolescents; not very young children as had been previously reported.  Although the details of how these young people were able to access the medication and the circumstances in which they ingested was not known, the data from Scotland might suggest that some of those adolescents were drug users or had taken the drug as a suicide attempt.  Those hypotheses could not be confirmed against the data available.    3.16 The SCRP discussed the potential implications for safeguarding practice where substance misuse, particularly drugs use, is a feature of family life.   Panel members, from their experience of attending the learning event, raised a number of questions about local professional culture and practice.  Members questioned whether there might be some reluctance on the part of practitioners to ask potentially intrusive questions of drugs users especially when that use was thought to be ‘managed’ and there were no obvious signs of child neglect.   In addition, they gained the impression that, when the substance misuse team became involved with a family; there was tendency for others to see the team as holding both the requirement to understand the details of risk and the responsibility to challenge it.   Taken together, these factors would produce a fundamentally flawed safeguarding environment.    3.17 The SCRP is keen, therefore, to ensure that professionals from all agencies are sighted on the inherent safety and safeguarding risks to children in households where parents are misusing drugs; particularly, but not exclusively, when parents are receiving opioid substitute therapy or treatment.   3.18 In September 2018, Adfam published Opioid Substitute Treatment (OST) and risks to children: Good Practice Guide.  Adfam acknowledges that their guide is aspirational.  While they propose this as the standard to which all those involved should be aiming for, the organisation recognises that agencies are under pressure and may not have the resources needed to comply fully.   It is recommended for the purposes of this SCR, however, that this guide should inform any proposed changes to local guidance.     3.19 In December 2018, HM Government published a guide for local authorities; ‘Safeguarding and promoting the welfare of children affected by parental alcohol and drugs use’.  That guide suggests what alcohol and drug treatment services can do to help prevent harmful consequences for both parents and children.  In addition, it recommends that there should be a local joint protocol between substance misuse and children and family services in order to safeguard affected children; to promote effective communication between adult-focused and child-focused services; and, to set out good working practice for the services involved.   3.20 The substance misuse service learning summary acknowledges that recommendation and indicates its intention to support such an initiative whose consolidation, it states, ‘would form part of the CQC improvement plan following its local inspection of health services for children looked after and safeguarding (2019)’.      22  Wirral Safeguarding Children Partnership February 2020   3.21 The particular challenges of working with families where children are placed with parents as an outcome of care proceedings.   3.22 There are two separate but related central issues.  The first issue is professional practice when children are placed with parents following care proceedings.   The lessons in respect of this first issue can be implemented locally in the expectation of positive change.  The second issue is more complex and includes questions about the extent to which decisions to place children with parents at the end of proceedings are necessarily a response to the child’s need or whether they are disproportionately affected by cultural assumptions and practice.    3.23 Improving safeguarding of children living with parents when care proceedings have ended  3.24 The main lesson from this case review is that where the intention is for a child to live with a parent at the end of care proceedings, the child must be able to benefit from co-ordinated multi-agency support and protection.   To that end, there needs to be an increased awareness across the Partnership that, when children remain with parents at the end of care proceedings; this is not necessarily an endorsement of the quality of care that parents are providing.  There are highly likely to be continuing child protection concerns.     3.25 This means that, while there are statutory requirements in respect of children who are looked after; such arrangements may be insufficient for children where there are continuing child protection risks.  This finding has implications not just for CSC social work teams but also for IROs and local authority partner agencies who are expected to contribute to keeping children safe.  3.26 Clarifying the purpose and aims of placement with parents following care proceedings  3.27 For children who are placed with parents, it is particularly important to question whether such placements are, in themselves, permanence plans as they were described in this case.  The Children Act 1989 guidance and regulations (2015) states that for many children, permanence will be achieved through a successful return to their birth family, ‘where it has been possible to address the factors in family life which led to the child becoming looked-after’.   For children placed with parents following care proceedings, these issues are, almost by definition, unlikely to have been resolved.   The question is, therefore, whether such placements might be more usefully regarded as a stepping stone to living permanently with parents without a legal relationship with the local authority.  3.28 This approach would require a more focused approach to care planning in the immediate post-order period, clarifying what changes need to be made and sustained.   Timescales could be set for appropriate discharge of the care order and identifying a suitable contingency if this cannot be achieved safely.   The expectations for children who are placed with parents cannot be less than for children who are placed away from their 23  Wirral Safeguarding Children Partnership February 2020 parents or who have never been the subjects of care orders.    The contingency plan for children placed with parents might be for the children to live elsewhere rather than, as might happen by default, to live indefinitely under the auspices of a care order with no prospect of adequate change.   3.29 Reviewing and implementing revised placement with parents procedures  3.30 Wirral Children's Specialist Services Procedures Manual contains comprehensive procedures in respect of placing children with parents.   These appear to be consistent with statutory guidance.   No evidence has been provided, however, that the procedures were implemented in this case or, indeed, that there was a clear expectation that they would be.  At the same time, it is not wholly evident that the procedures as they stand address the particular vulnerabilities illustrated by, but not restricted to, this case.     3.31 Without adequate guidance for practitioners and managers and scrutiny of its implementation, the shortcomings identified in this case are likely to be replicated in future.   3.32 To what extent are the issues in respect of placement with parents from court common to other local authorities?  3.33 The data indicates that there are regional disparities in applications for care orders and their outcomes3.   Among those disparities; it has been recognised that, in the NW of England, children are more likely to be made the subjects of care orders when proceedings end and that placements with parents are disproportionately represented as a care option when compared to all other regions of the country.     3.34 At the end of March 20184, of children who were recorded as being the subjects of care orders (CO) or interim care orders (ICO);  in England overall, 8.5% lived with parents while, in the NW, 15.6% were placed with parents.  In Wirral, on the same date, 11% of children subjects of CO or ICO were placed with parents.   3.35 It was in recognition of the regional discrepancy in respect of placements with parents that the North West Association of the Directors of Children’s Services worked with CAFCASS and Sefton Council to coordinate an audit of commissioned, in 2017, an audit of 62 cases, across 18 authorities in NW England, where children had been placed with parents.  Copies of the report were made available to all LSCBs in the region5.   Authors identified that, following care orders, the children’s circumstances had improved in 60% of cases, but in a substantial minority of cases;  the situation was said as ‘tentative with evidence of recent  3 See: Care Demand and Regional Variability in England: 2010/11 and 2016/17, a report by the Centre for Child and Family Research and Lancaster University (2018).   4 https://www.gov.uk/government/collections/statistics-looked-after-children 5 Hodgson, Hayes and Bunker (2017): Placement at home with parents – North West Audit Summary Report.  Sefton MBC, CAFCASS and ADCS 24  Wirral Safeguarding Children Partnership February 2020 slippage’.  In three cases, children had already been removed.   Although only a small scale survey, the audit tends to confirm that placement at home does not, of itself, lead to children living stable lives with their families.  3.36 The SCRP understands that there is generally an increased awareness across the region that the NW is an outlier when compared with other authorities.   It has also been reported there is a present willingness on the part of local authorities, CAFCASS and the judiciary to consider how the local culture has developed and to examine its merits.   In October 2018, the then Chair of Wirral Safeguarding Children Board wrote to the President of the Family Division of the High Court highlighting the issue from Wirral’s perspective.       3.37 It is suggested, therefore, that there could be significant benefit in conducting a systematic analysis of decision making by professionals and outcomes for children across the wider area.   This could certainly not be achieved, however, using the resources of a single local authority or Safeguarding Partnership.   This has implications for any related recommendations.          25  Wirral Safeguarding Children Partnership February 2020 4. Recommendations  4.1 Safeguarding children where problematic parental drugs use is a feature of family life  4.2 The learning event for practitioners and managers revealed the low levels of knowledge among non-specialist practitioners about drugs misuse and its impact on parents’ capacity to keep their children safe.   At the same time, concerns were expressed that substance misuse practitioners were not sufficiently included in multi-agency assessment, planning and working.   There was no evidence either that practice was influenced by learning from the previous case review conducted in similar circumstances.  These factors contributed to ineffective risk assessment and risk management in this case.     4.3 Wirral Safeguarding Children Partnership has recently updated its website to provide guidance to professionals about substance misuse and the potential safeguarding risks that children can be exposed to due to their parents’ addiction.  The information is up-to-date and includes links to the local substance misuse service.  Improvements have also been made to enable young people, parents and carers to more easily find relevant information.  Links have also been made to the Safeguarding Partnership multi-agency training programme.   The Partnership intends to work with the local service provider to improve available information about methadone treatment in the community.  4.4 The SCRP, however, recognised that multi-agency information and training is not a substitute for the responsibility that each agency has to ensure that practitioners and managers have appropriate levels of knowledge about the impact of substance misuse on children and, as importantly, know how to seek information from experts where there are gaps.    4.5 The first 3 recommendations relate to safeguarding children whose parents misuse substances.  It is anticipated that they will be enacted sequentially, as they should, in turn, improve the availability of basic information; encourage better joint working; and, measure the extent to which learning has been embedded in practice.   4.6 Recommendation 1:  The revision of existing multi-agency safeguarding procedures, protocols and guidance in respect of parents who misuse substances.  4.7  It is recommended that the Partnership: i. oversees the development of a joint working protocol between substance misuse and children’s services; ii. works cooperatively to develop with substance misuse services to complete its revision of practice guidance in respect of children whose parents misuse substances, ensuring that this specifically addresses safeguarding children in households where an adult is being treated with opioid substitute therapy; and, iii. ensures that, as existing generic safeguarding procedures are reviewed, there is an assessment of the impact of changes on children whose parents misuse substances. 26  Wirral Safeguarding Children Partnership February 2020  4.8 Recommendation 2:  Improving levels of basic awareness of substance misuse, specific safeguarding issues and how to obtain specialist advice   4.9 The Safeguarding Children Partnership should require agencies to provide evidence that relevant practitioners and managers : i. have sufficient levels of knowledge about the potential negative impact on children of parental substance misuse, proportionate to their role;  ii. know how to access specialist knowledge; and,  iii. are able to respond appropriately to concerns about a child’s welfare.     4.10 Where agencies are not able to provide this assurance; they should provide details of the steps that they intend taking to improve awareness and practice knowledge.   4.11 Recommendation 3:  Measuring the impact of change on practice  4.12 It is recommended that, within 12 months of roll out of updated guidance, the Partnership undertake a multi-agency audit of cases where children are living in households where adults are known to misuse drugs or who are now being treated with opioid substitute therapy.  4.13 The particular challenges of working with families where children are placed with parents as an outcome of care proceedings  4.14 In December 2018, on its final monitoring visit, Ofsted found that, in the previous 12 months, the local authority had successfully discharged the care orders of more than 30 children who had been placed with parents, with the potential for a similar number to follow.    During that visit, inspectors also ‘saw examples of strong, clear placement, with parents’ agreements and good support work to ensure that children were safe, and that their needs were met’.    This suggests that there has been a significant effort within the local authority to combat drift for children placed with parents resulting in successful resolution for a good number of families.     4.15 The key issues raised by this review remain, however, in respect of the specific safeguarding /child protection needs of children immediately after being placed with parents.    The following two recommendations address these matters.  As before, it is anticipated that these will be implemented consecutively.   4.16 Recommendation 4:  Revising procedures and practice guidance in respect of children placed with parents.    4.17 The Safeguarding Children Partnership should ask the local authority to revise its Placement with Parents protocol to take account of the learning from this review.  The local authority should also outline for the Safeguarding Children Partnership, a strategy for engaging with partners in respect of any proposed changes to multi-agency working and how they will be 27  Wirral Safeguarding Children Partnership February 2020 implemented.   The local authority should highlight any anticipated implications for multi-agency training.   4.18 This review has identified the particular vulnerability of children placed from care proceedings with parents as they may be less likely to be seen as being in need of protection than other children who are at risk of, or who have suffered, significant harm.   The SCRP recognises the challenges in changing professional assumptions and expectations of multi-agency practice with children in those circumstances.   It has suggested, therefore, that there should be an imaginative approach to disseminating and promoting learning for practitioners and managers.  4.19 Recommendation 5:  Increasing the likelihood that practice will improve    4.20 The Safeguarding Children Partnership should ask relevant partners, following the revision of procedures as proposed;  to develop a plan of learning sessions, workshops and/or other means to support practitioners and managers to understand ‘what good looks like’ in this area and how it can be best achieved.   4.21 Recommendation 6:  Engaging with others to analyse and evaluate the use, in the NW of England, of placement with parents following care proceedings.   4.22 The Safeguarding Children Partnership should seek opportunities to initiate, collaborate or build on local research in the NW of England to understand the extent of placements with parents following care proceedings and review the reasons for the NW being an outlier.  4.23 Issues raised in this case about basic safeguarding practice  4.24 Key agencies provided learning summaries for this review.   These identified lessons learned and made recommendations for change.  It was not always clear, however, how these recommendations would be translated into action.  At the same time, the learning event and the analysis contained in this report have identified additional potential learning for those agencies as well as for organisations from which summaries were not requested.   4.25 Recommendation 7:  Translating single-agency  learning into action  4.26 The Safeguarding Children Partnership should require all agencies and organisations which contributed to the SCR to review and, where appropriate, to revise their learning and recommendations for change.  In particular, all agencies and organisations should consider their response to ‘hidden males’.  Agencies and organisations should provide evidence that they have clear plans identifying the actions that they intend to take.         28  Wirral Safeguarding Children Partnership February 2020 4.27 Recommendation 8: Confirming single-agency learning  4.28 The Safeguarding Children Partnership should reserve the option of requesting evidence that single agency action plans have been effectively completed. The Partnership should determine the mechanism by which this can be most constructively achieved.    IC/25.10.19   