Death of a 2-year-old girl in the summer of 2013, as the result of serious, non-accidental injuries. Child X had been in the sole care of mother's partner immediately prior to admission to hospital with head injuries. Police investigation was instigated following the incident; the Crown Prosecution Service (CPS) later concluded there was insufficient evidence on which to mount a prosecution. Child X was diagnosed soon after birth with congenital myotonic dystrophy, a life-limiting condition in which muscles are poorly developed, resulting in profound weakness. Family were well-known to health and social care services as a result of Child X's condition; there had been contact with children's social care prior to Child X's birth in relation to concerns in respect of older sibling. Identifies issues, including: lack of clear planning and management of the case and failure to include the family who were seen as passive recipients of a "package of care"; repeat concerns about cleanliness and disorder in the family home; the extent to which the principal reason for agency involvement being Child X's complex health needs, may have affected assessment of her need to be safeguarded; and the impact of less prescriptive requirements for serious case reviews on the organisation and coordination of the review process. Makes recommendations, covering: arrangements for multi-agency audits of work with children with disabilities including arrangements for appropriate lead professionals; and guidance about identifying and assessing concerns arising from poor home environment.
      
 Title:  Child X: a serious case review. LSCB: Hampshire Safeguarding Children Board Author: Kevin Harrington Date of publication: [2015]  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.                           Page 1 of 30 Kevin        Harrington  Associates      Limited                                             CHILD X  A SERIOUS CASE REVIEW  Kevin Harrington JP, BA, MSc, CQSW                   Page 2 of 30 CONTENTS  CONTENTS.................................................................................................. 2 1. INTRODUCTION ...................................................................................... 3 2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW ....................... 3 3. METHODOLOGY USED TO DRAW UP THIS REPORT ......................... 4 4. KEY EVENTS ........................................................................................... 5 4.1 Background .............................................................................................. 5 4.2 The period under detailed review – October 2012 to June 2013 .......... 6 5. THE FAMILY ............................................................................................ 9 6. THE AGENCIES .................................................................................... 10 6.1 Hampshire Children’s Social Care Services ........................................ 10 6.2 Solent NHS Trust ................................................................................... 13 6.3 Southern Health NHS Foundation Trust .............................................. 16 6.4 Hampshire County Council, Services for Young Children ................. 17 6.5 Naomi House .......................................................................................... 17 6.6 Rainbow Trust Children’s Charity ........................................................ 18 6.7 Home-Start Gosport and Fareham ....................................................... 19 6.8 Portsmouth Hospitals NHS Trust ......................................................... 19 6.9 The General Practitioners ..................................................................... 20 6.10 Housing provider ................................................................................. 20 6.11 Hampshire Constabulary..................................................................... 21 6.12 Hampshire County Council, Adult Services ...................................... 21 6.13 South Central Ambulance Service NHS Trust ................................... 21 6.14 University Hospital Southampton NHS Foundation Trust ................ 21 7. ISSUES ARISING FROM AN OVERVIEW OF THE CASE ................... 22 7.1 Co-ordination and collaboration ........................................................... 22 7.2 The home conditions. ............................................................................ 22 7.3 Children with complex needs ............................................................... 23 7.4 Serious Case Review process .............................................................. 24 8. CONCLUSIONS –  A SUMMARY OF KEY ISSUES AND LESSONS LEARNED .................................................................................................. 26 9. RECOMMENDATIONS FROM THIS SERIOUS CASE REVIEW .......... 27 9.1 Introduction ............................................................................................ 27 9.2 Recommendations to the Hampshire Safeguarding Children Board 27 APPENDIX A: TERMS OF REFERENCE .................................................. 28 APPENDIX B: THE LEAD REVIEWER ..................................................... 29 APPENDIX C: REFERENCES ................................................................... 30 Page 3 of 30   1. INTRODUCTION  1.1 Child X, aged 2, died in the summer of 2013, having suffered a number of serious,apparently inflicted injuries. The child’s mother, Ms A, was elsewhere when the injuries occurred. A police investigation was carried out but the Crown Prosecution Service judged that there was insufficient evidence on which to mount any prosecution.  1.2  Child X had been diagnosed soon after birth with a serious medical condition, and the family was consequently in contact with a wide range of health and social care services. Before Child X was born there had been contact between Ms A and children’s social care services in respect of a sibling, Child Y.  1.3 Taking account of those circumstances the Chair of the Hampshire Local Safeguarding Children Board (HSCB), Ms Maggie Blyth, confirmed that a Serious Case Review (SCR) should be carried out. The purposes of SCRs are set out in the government’s guidance, “Working Together to Safeguard Children1”. They are to be carried out so that “lessons can be learnt and services improved to reduce the risk of future harm  to children”.   1.4 It was clearly appropriate in these circumstances that a SCR be carried out. However it is also right to reflect, at the start of this report, the finding of the review that the death of Child X could not have been anticipated by any of the agencies or professionals concerned. There was never any indication that a concern about inflicted injuries might arise.   2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW  2.1 The Terms of Reference for this review are at Appendix A to this report. They reflect the issues, set out in government guidance, to be considered in all SCRs.  2.2 The HSCB appointed Mr Kevin Harrington, an independent person with substantial experience in this field, to lead the review and draw up this report. Further details are at Appendix B.  2.3 The HSCB determined that the agencies listed below should contribute to the SCR, detailing their involvement during the period under review – from November 2012, when Ms A’s partner, Mr C, joined the household, until the death of Child X.                                             1 Working Together to Safeguard Children (2013) – referred to in this report as “Working Together” – is the government’s statutory guidance on how organisations and individuals should work together to safeguard and promote the welfare of children and young people in accordance with the Children Act 1989 and the Children Act 2004.    Page 4 of 30  Name of agency Nature of involvement Hampshire County Council, Disabled Children’s Services Social care services arising from Child X’s disability Investigation and follow up of child care concerns Hampshire County Council Services for Young Children Various community care services for children with complex needs Solent NHS Trust Specialist community child health services, related to Child X’s medical condition General Practitioners GP services to Ms A and her children Portsmouth Hospitals NHS Trust 1. Maternity services 2. Provision linked to Child X’s complex health needs Southern Health NHS Foundation Trust Universal health visiting services Naomi House A hospice providing support to children with life-limiting or life threatening conditions Hampshire Constabulary Minimal involvement Borough Council Z Housing providers for the family South Central Ambulance Service Conveyed Child X to hospital following the fatal injuries Universisty Hospital Southampton NHS Trust 1. Provision linked to Child X’s complex health needs 2. Emergency response to the fatal injuries Hampshire County Council, Adult Services Minimal involvement as managing agency for the “out of hours” social work service.  2.4 These agencies were asked to submit reports - referred to as Agency Reports (AR) – which addressed the Terms of Reference for the review.   3. METHODOLOGY USED TO DRAW UP THIS REPORT  3.1 This report is based principally on the ARs, background information submitted and subsequent Panel discussions and dialogue with AR authors and other agency staff. Family involvement is discussed at section 5.  3.2 This report consists of  A factual context and brief narrative chronology.  Commentary on the family situation and their input to the SCR.  Analysis of the part played by of each agency, and of their AR.  Closer analysis of key issues arising from the review.  Conclusions and recommendations.  Page 5 of 30 3.3 The conduct of the review has not been determined by any particular theoretical model. However the review has been carried out in keeping with the underlying principles of the statutory guidance, set out in Working Together 2013, detailed below: The review “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 hindsight2;  is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings”.  3.4 The government has introduced arrangements for the publication in full of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would not be appropriate. This report has been written in the anticipation that it will be published and that has been discussed with the family. It will still be appropriate that some confidential information is not disclosed. Consequently the information in the report is limited so as to:  take reasonable precautions not to disclose the identity of the child or family.   protect the right of family members to an appropriate degree of privacy.   avoid any possibility of heightening any risk of harm to other children or adults.  4. KEY EVENTS   This section of the report briefly describes the key events during the period under review and the background to those events. Further detail is then provided at appropriate points throughout the report.  4.1 Background  4.1.1 Child X lived at home with Ms A, Child Y and Mr C. The family had frequent contact with Child X’s father, Mr B.  4.1.2 Child X’s family had been known to statutory services because there had been concerns about Child Y in 2009. By the middle of 2010 those concerns had eased and the local authority’s children’s social care services (CSC) subsequently maintained contact with the family by agreement.   4.1.3 Child X was born prematurely with complex health needs and at an early age was diagnosed with congenital myotonic dystrophy. This is a very serious, life-limiting condition in which muscles are poorly developed and have little tone or power, resulting in profound weakness. Child X remained in hospital for six months. The family then received extensive continuing                                             2 This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. Page 6 of 30 therapeutic and supportive services from a number of health and social care agencies.   4.1.4 Child X was about 18 months old at the start of the period under detailed review when Mr C joined the household. There had been some continuing concerns about cleanliness in the home, particularly in the light of the child’s complex health needs. Otherwise there had been no significant events or developments involving any agency during the previous 12 months. A Core Assessment3 had been completed by the local authority in September 2012, concluding that the family needed “ongoing support” but not identifying any child protection concerns.  4.2 The period under detailed review – October 2012 to June 2013  4.2.1 A large number of professionals and agencies were in touch with this family because of the complex nature of Child X’s condition. This account does not detail  every contact or failed contact. Further details of the various services are given below.   4.2.2 In October 20124 a health visitor (HV1) went routinely to the family home and was concerned about hygiene and cleanliness. This was largely linked to the presence of pets – cats, snakes and a rabbit – and animal faeces were seen on the floors and surfaces. HV1 referred the matter to CSC and liaised with other agencies. The allocated social worker, SW1, visited that day and explained the cause for concern. SW1 visited again early the following day and was satisfied that the family had taken adequate steps to improve the cleanliness in the home.  4.2.3 In early November Child Y’s school notified SW1 that they had learned that Ms A was now in a relationship with Mr C. Mr B continued to be a regular visitor to the home. In fact SW1 was already aware of the new relationship. She was intending to seek permission from Mr C to initiate police checks, to establish whether there was any history which might be significant to the care of the children, but this was never followed up. In fact, had police checks been carried out, they would not have found any cause for concern.  4.2.4 Equally there were no obvious causes for concern in Mr C’s presentation and some professionals judged that he offered a strong, supportive influence in the home. SW1 noted good interaction between him and Child X, and professionals generally were satisfied with Child X’s health and development. The Rainbow Trust was in fortnightly contact with the family, noting some improvement in home conditions. Weekly visits from a Homestart volunteer had been arranged and Child X had been referred to the                                             3 A Core Assessment is an in depth assessment, to be completed over a period of weeks, in line with former statutory guidance in the Framework for Assessment of Children in Need and their Families (2000)). 4 The original Terms of Reference for this review suggested that the period under detailed review should commence from November when the relationship between Ms A and Mr C is thought to have commenced. It then became known that there was a relevant incident in October 2012, so that is described here. Page 7 of 30 Portage service . When seen at outpatients in December Child X was judged to be making steady progress with appropriate weight gain.  4.2.5 In January 2013 the family started to use Naomi House, a hospice / short breaks service for children with very serious and life-limiting conditions. Concerns about home conditions re-emerged that month. A Speech Therapist visited – by appointment but Ms A had forgotten she was coming – and found that the living room contained a large cage in which seven cats – some very young kittens - were sleeping and fouling. The therapist also thought that the size of the cage left little room for the children to play safely. The therapist explained her concerns, which were accepted by Ms A. The therapist did not judge it necessary to make a referral to any other agency.   4.2.6 In early February HV1 went to the home and noted no concerns about the conditions. On the same day an Occupational Therapist contacted CSC reporting concerns about domestic animals in the property and also expressed concerns that Child X was being left sometimes in the care of a neighbour who might not be familiar with her special needs. Two social workers visited the home that day. The visit raised no immediate concerns for Child X who was observed to be clean, well and happy. The reports received were discussed with Ms A and no further action was judged necessary. The following day a Communty Children’s Nurse (CCN1) visited and noted no cause for concern.  A week later a Speech and Language Therapist visited. She noted that Ms A had spoken of finding the care of Child X demanding, but also made no record of concern about home conditions.  4.2.7 After a further visit at the end of February the social worker started planning to reduce and in due course terminate her agency’s involvement because so many other agencies and professionals were in contact with the family. A supervisor confirmed that this was appropriate.  4.2.8 The family were visited by a number of agencies in March. In the middle of that month health professionals met and discussed the family, deciding to seek the involvement of a specialist teacher to promote Child X’s education. No care concerns were raised. However, the following day a neighbour contacted CSC to report concerns about the home conditions and that Child X was left in a cot for long periods. It subsequently emerged that the neighbour had also raised her concerns about the conditions, with specific reference to domestic animals, with the housing provider. (The housing provider had received no other complaints and wrote routinely to Ms A reminding her of tenancy conditions).  4.2.9 SW1 followed up the neighbour’s referral initially by contacting other agencies for information. Child Y’s school had no concerns. CCN1, the most frequent visitor to the home, judged that the conditions were untidy but not dirty. She agreed that Child X spent long periods in the cot but reported that the child had many toys and sources of stimulation, and was “thriving”.  4.2.10 Naomi House reported that there was a good relationship between Ms A and Child X, who appeared knowledgeable about her child’s condition and Page 8 of 30 care needs.  However Naomi House staff did have some concerns about the presentation of the child who was said to be unkempt on occasions, with some immediate care needs not addressed.   4.2.11 A social worker visited the home and felt that the lack of cleanliness was a cause for concern, such that Child X, who was at Naomi House, should stay there for another night while the home was cleaned. The social worker put this request to Naomi House and it was agreed. The situation was routinely discussed with police, as a potential child protection matter, and it was agreed that there was no indication that police involvement was necessary. The following day a social worker made an early unannounced visit to the home and was satisfied that appropriate action had been taken so that the condition of the home was no longer a cause for concern. Child X returned to the care of Ms A.  4.2.12 A further unannounced visit was carried out four days later and the social worker was again satisfied that there was no cause for concern about the children or the home conditions. CCN1 visited the following day and similarly noted that the home conditions were satisfactory. She agreed with the family that she would increase her contact and visit them every week.  4.2.13 There were at least seven visits by professionals during April, from which no concerns emerged. There was also an elective admission to University Hospital Southampton for a sleep study. During April SW1 commenced a period of absence from work and case responsibility was transferred to a colleague, SW2. SW2 already knew the family as she had been involved in some of the responses to  concerns earlier in the year. At the point of transfer a manager reviewed the file and, finding weaknesses in the recording and documentation, and that there was no clear plan for work with the family, requested that these matters be addressed.   4.2.14 A physiotherapist, visiting in early May, noted that Child X was making significant developmental progress. SW2 had been liaising with various agencies to introduce herself as the new social worker and arranged a meeting with the family and key professionals from other agencies. This was referred to as a “Child in Need” meeting although there is no formal documentation of the meeting.   4.2.15 The notes of the meeting kept by CCN1 reflect a very positive discussion. There are references to Child X’s good developmental progress and to the adults having recognised and responded appropriately to the concerns about home conditions. It was agreed that the current level of input from the various agencies would continue and that SW2 would now carry out a renewed Core Assessment. In fact SW2 then had no further direct involvement before the events leading to this SCR. A follow up meeting was scheduled in June but had to be cancelled for reasons which could not have been foreseen.  4.2.16 A number of health professionals saw the family over the following two weeks and no cause for concern was noted. At the end of May Child X was Page 9 of 30 cyanosed5. This required admission to hospital but the child was discharged the following day. CSC were routinely notified of this and the CSC Team Manager contacted Ms A directly to confirm what had happened.  4.2.17 Input from various professionals continued during June – officers from four separate agencies visited during the first two weeks of the month. No concerns about home conditions were noted and CCN1 recorded that the home was clean and tidy. Child X continued to show some signs of developmental progress and no tensions or difficulties in the family were noted.  4.2.18 In the middle of June Child X was admitted to Paediatric Intensive Care at Southampton General Hospital with head injuries. Ms A had been visiting a neighbour and the child had been in the care of Mr C before being brought to hospital by ambulance.   4.2.19 The child was said to have fallen and hit her head on a chair. The Paediatric Consultant considered that there was extensive brain damage.  4.2.20 Child X died a few days after admission to hospital. A lengthy police investigation did not produce evidence to lead to any criminal proceedings.  5. THE FAMILY  5.1 Both Ms A and Mr B came separately to meet the author of this report, shortly before it was completed. Ms A accepted that agencies had needed to respond at times to the issue of conditions in the home. She spoke of the difficulty she had experienced in working with CSC because of changes of personnel, and contrasted this with the continuing support she had received from CCN1.   5.2 Ms A raised issues about the way in which the ambulance service staff had managed the situation when called to the home after Child X had suffered the fatal injuries. She felt that they would have dealt with the situation more urgently if Child X had not been evidently a child with disabilities. The ambulance service is looking into this. Ms A also said that there had been a lack of specialist paediatric MRI services at Southampton Children’s Hospital because it was a weekend. This is being followed up by the hospital as in fact paediatric MRI scans are routinely performed at weekends.  5.3 The same key issues were shared with Mr B. He felt that there had been an issue of concern about the home conditions which should have been tackled more firmly and consistently.   5.4 Mr B reported that he had been disappointed by his experience of working with social workers. He said that they and other agencies had not been mindful of the need to engage him, as the father of Child X, in discussions and                                             5 A bluish discoloration of the skin, fingernails, and mucous membranes caused by a deficiency of oxygen in the blood Page 10 of 30 plans about services to be provided. This is an issue which is reflected in research findings6:  “They also tend to be overlooked by support services, even when the father makes every effort to be involved with his children and is the primary carer or an equal carer with the mother”. Mr B’s comment has been accepted by the SCR Panel and the agencies involved.  5.5 Mr B also raised a concern about the safety of an item of equipment which had been provided and the agency involved is discussing that with him.  5.6 The problems and challenges facing this family were substantial. Day to day they had to manage the complex nursing and health care needs of Child X, living with the knowledge that the child had an incurable illness. Ms A’s own childhood and early adult years had been troubled.   5.7 In those difficult circumstances it is right to recognise that Child X had been making good developmental progress and had often been observed by professionals to present as happy and thriving. No recent concerns had been expressed about Child Y. Ms A engaged well with some professionals and responded positively and quickly when concerns were raised about standards of cleanliness in the home. The key lessons for the agencies lie in their failure to identify and build on those positive factors in promoting a co-ordinated. inclusive approach to working with the family.  6. THE AGENCIES  6.1 Hampshire Children’s Social Care Services  6.1.1 The local authority had been involved with the family in respect of Child Y, and was still involved when Child X was born, although the purpose of that continuing involvement was not clearly defined and agreed with the family. The special needs of Child X and their consequences for the family then affected the nature and extent of the relationship between the family and the local authority, so that the lack of clarity about why they were involved perhaps became even greater.  6.1.2 There were no concerns for Child Y during the period under review –  the school gave very positive positive reports when contacted by CSC in March 2013. However the AR notes that  “By the time the Core Assessment in September 2012 was written, the history (in respect of)  Child Y… did not feature”. There are two concerns arising from this. The fact that there had been a history of involvement was not kept in sight. However, as there were then no continuing concerns, that equally should have been expressly identified by the agency. This characterises the lack of analysis and effective management of the case which continues throughout the period under review.                                              6 SCIE Research briefing 18: Being a father to a child with disabilities: issues and what helps  Page 11 of 30  6.1.3 The greatest part of the agency’s involvement during that period consisted of responses to occasional requests from the family for financial or practical support, or, more often, to expressions of concern from other agencies about the home conditions. There is a separate section in this report on home conditions because this issue, and the way it was managed, became a principal focus of the communications between the agencies.  6.1.4 The AR is forthright in its analysis of the work carried out: “At the start of the period covered by this review, the substantive Team Manager was (not at work). This followed a very poor outcome from a peer inspection of the service and clear expectations being required that improvements be made. In his absence… decision making was carried out by a colleague Child In Need Team Manager, with individual staff having 1:1 supervision with named other managers. It is the view of the authors that this contributed to a lack of management direction in this case, and a lack of clarity as to which manager was driving the decision making”.  6.1.5 The AR identifies a number of managers who “dipped in” to the case, offering guidance that was of varying quality and reliability.  “Management decisions were not recorded often enough and where they were recorded they lacked clarity, both in respect of the grounds upon which they were made and the expectations about actions to be taken”. That weakness in active management sets the scene for the principal concern about the practice of CSC during the period under review, the lack of any structure or purposeful planning in their involvement.   6.1.6 As is often the case with services to disabled children and their families there were good, supportive professional relationships across the network of agencies: “the knowledge and experience of some long standing team members meant that colleagues from other agencies communicated readily…”.   However there was also a tendency in the service to focus on the less challenging dimensions of the overall task: “The service as a whole seemed more at ease when its role was to provide services, or coordinate the delivery of care packages, rather than carrying out social work in the form of assessments or interventions”.  6.1.7 The good relationships across agencies were undermined by the lack of any formal planning process. In fact the good relationships may have served inadvertently to conceal and compensate for the lack of structure in the inter-agency arrangements. After discharge from hospital in 2011 there was no meeting at which all the key agencies came together to plan and review  services until April 2013.   6.1.8 It is also often the case for children with disabilities and complex needs that many agencies can be involved. There is consequently a particular need to ensure that communications are good and services are co-ordinated. Child X was a “child in need” and one would expect to see the social worker, at Page 12 of 30 least in the first instance, drawing agencies together to ensure that there was a child in need plan which was was regularly reviewed. This did not happen.  6.1.9 Throughout the period under review there were occasions, usually linked to concerns about the home conditions, when it would clearly have been appropriate for agencies to meet and co-ordinate their work, but only one meeting was ever convened, in April 2013. It appears that other agencies were waiting to take a lead from CSC, but CSC were not operating with the necessary degree of organisation and focus to give that lead.  6.1.10 Looking at the quality of work by CSC there are weaknesses in the assessments carried out, in following up actions arising from assessments and in compliance with the procedural requirements for assessments. No Core Assessment was carried out during the period under review even though there had been a significant change in circumstances when Mr C joined the family. There had been a Core Assessment just before then but this was unfocussed, proposing a continuing, supportive relationship but without any detail or analysis of aims and objectives. When Mr C was known to have joined the family the need for police checks and checks with other agencies was noted but not followed up. When a social worker responded to the concerns raised by an Occupational Therapist in February, there were no checks with other agencies involved.  6.1.11 The most comprehensive response to a referral was in March 2013 when a neighbour reported concerns. The social worker made a number of agency checks which reflected mixed views as to any cause for concern but did not contact all agencies – the GPs, for example, were not contacted. The social worker visited the family promptly. However there was then a lack of clarity about the statutory basis for what was being done. In some ways it was treated as a child protection referrral (section 47, Children Act, 1989) with all that that entails. At the same time it was not recorded as such and the visiting social worker is said to have told Ms A that she needed to clean the home in order to prevent the initiation of such an investigation.   6.1.12 The intervention also raises concerns around the way Naomi House was inappropriately drawn into the events. They were asked by the social worker to keep Child X, who was with them for a planned short stay, in order for Ms X to clean the house. On the face of it that may seem a sensible, practical step to take but, as discussed below, it was also potentially unlawful, in the absence of clear parental consent, and it placed Naomi House in a difficult position.   6.1.13 The laxity around assessment practice was exacerbated by changes of staffing. As well as a number of managers being involved, the service was unable to provide consistent social work input, because of problems around staff availability. In some ways the service did well to continue to provide swift responses to referrals, in the absence of the allocated social worker. However, as the AR comments Page 13 of 30 “The fact that so many different social workers were involved in visiting the family added to the difficulty of agreeing a plan, and delivering services or interventions to ensure the outcomes of the plan were achieved”. This echoes the point made by Ms A herself.  6.1.14 Finally the AR identifies weaknesses in recording, both by practitioners and their managers. In one instance – the incident in March when a neighbour raised concerns – the review established that there had been a significant disagreement between a manager, who had decided to terminate the investigation, and a social worker who felt that the concerns raised might need to be further investigated. The manager properly asked the social worker to make a file record of her different view but the social worker did not do so, and in fact made no record at all of her visit. The AR emphasises the importance of making accurate records: “Accurate and timely recording is a Departmental requirement and an obligation on all qualified social workers as part of their registration with Health & Care Professions Council whose standards of conduct, performance and ethics require registrants to keep accurate records”.  6.1.15 The needs of Child X do not emerge as the driving force for the agency’s involvement. There is some evidence of staff seeking to describe the child’s behaviour and presentation, and to assess wishes and feelings. However, as the AR notes,  “Child X’s needs do not feature strongly as the central plank  of the work on this case”.  6.1.16 This AR is very direct in identifying and confronting the causes for concern arising from this review. This was a service that had become “set in its ways”, operating as a supportive resource for families, but not complementing that with a structured alertness to the safeguarding aspects of their work. The report details actions taken to address the concerns identified:  An immediate review of current cases to ensure children are safe  Confident management and decision making to be promoted  Staff to follow procedures in respect of assessing, planning and reviewing cases  Case notes and chronologies to be recorded  in line with procedures  Ensuring that children rather than their disability or health needs, or the needs of their carers, are the focus of social care interventions  Increased training and supervision of staff to enhance their skills and knowledge of child protection work  6.2 Solent NHS Trust  6.2.1 This Trust was responsible for providing specialist community health services – Community Children’s Nursing and input from Occupational Therapy, Physiotherapy and Speech and Language Therapy services. A large part of their report, which is thoughtful and analytical, considers issues emerging during the time prior to the period covered in this review, when Child X spent long spells in hospital. The report provides an insight into the pressures facing those caring for Child X: Page 14 of 30  “Child X required a comprehensive care package to manage complex medical needs, some of which required surgery. This would be very demanding for any parent …It is not clear whether they were asked or indeed felt able to say that they found it too much to cope with all her complex medical needs…. (they) gave the appearance/ impression that they were managing Child X’s care, but at times Child X’s mother (was reported) to be struggling and lacking confidence”.  6.2.2 CCN1 was involved with the family during the long period Child X spent in hospital and was then probably the professional who provided most support to them following her discharge. CCN1 was aware of some of the troubled background, although she was not told by CSC that they had previously been involved with the family in respect of Child Y. Ms A was frank with her about the difficulties she had experienced in her life and has said that she found CCN1 supportive and helpful. CCN1 had also been the professional most alert to the practical difficulties the family would experience when Child X completed the initial long stay in hospital, and had requested a meeting of the agencies prior to discharge.   6.2.3 Weaknesses in the sharing of information were aggravated by the absence of any multi-agency planning forum, as noted above. This meant that there was never an identified lead professional7. Planning across the agencies became linked primarily to the practical issues arising from medical and nursing care, rather than also looking at any social or emotional issues facing the family. The AR suggests that other agencies may have assumed the CCN was, either by design or de facto, in the Lead Professional role, because this service had the greatest level of direct contact with the family. CCN1 did not see herself in this role but, in common with all the other professionals involved, she did not raise the issue of the absence of any central co-ordinated planning arrangement .  6.2.4 The AR in fact suggests that the complexity of the child’s medical and nursing needs was such that it would also have been appropriate for there also to be an identified “lead medical professional”, as well as a lead professional whose role included education, development and social care: “consideration should have been given to nominating a lead medical professional to coordinate care requested by all medical professionals involved, and to support the CCN to oversee and review whether Child X’s complex health needs could realistically have been managed within the home environment”.  6.2.5 The final comment illustrates the challenge faced by those caring for Child X – the AR author is suggesting that there would have been real problems for any parent meeting all this child’s needs outside a clinical                                             7 All children and young people who require integrated support from more than one practitioner should experience as seamless a service as possible. This is delivered most effectively when one practitioner – a lead professional – takes a primary role to ensure services are coordinated, coherent and achieving intended outcomes.   Page 15 of 30 setting. The report makes a practical proposal to address one aspect of this issue: “A community drug chart should be used where children are on a complex range of drugs and treatments…to enable parents and professionals to be clear about name of drug, dose and time given by signing on the date and time. Secondary regular checks re drug dosage and administration could be monitored jointly by GP and CCN service”.  6.2.6 It is clear that the CCN enjoyed the confidence of the parents and carers, and there is evidence that they were able to talk to her openly about how challenged they felt by the relentless complexity of Child X’s care needs. In fact the AR wonders whether Ms A may have become over-dependent on the CCN team and consequently “developed a tendency for selective engagement with other professionals involved”. That focus on one professional, perceived to be particularly sympathetic, would not be unusual and again is something that could have been identified and tackled in a team approach.  6.2.7 The AR notes that this was not a case raised by the CCN through safeguarding supervision8 arrangements. There were some organisational problems during the period under review, which may have impeded access to such supervision, but this must be put in context. Before the fatal injuries to this child the only explicit concerns relating to safeguarding were about the home conditions. This was not a child for whom there was any evidence to suggest she might be physically abused or grossly neglected.  6.2.8 The AR tries to keep an open mind on the situation under review: “Child X did make developmental progress…This medical progress and possible acceptance of a ‘good enough’ standard of parenting may have meant professionals were unduly optimistic and missed signs of carers’ stress”. We need to try and see the events as the practitioners would have done at the time. It may be that the CCN, and all the professionals involved, should have been more alert and responsive to the stresses in the family. However that does not mean they could have been expected to anticipate the tragic course of events.                                             8 Safeguarding supervision complements routine clinical supervision. It provides a formal process of professional support to enable the development of a planned response to families where there are or may be particular safeguarding concerns. Page 16 of 30  6.3 Southern Health NHS Foundation Trust  6.3.1 This agency provided the health visiting service to the family. There were only two direct contacts between the HV and the family during the period under review. On the first occasion the HV was concerned about home conditions and properly raised that with CSC. However, in analysing the contact more broadly, there were failures to meet agency requirements.   6.3.2 Firstly no formal assessment of the children and their parents’ and carers’ health needs was carried out or documented by the HV. This is a basic task which aims to make an early identification of any vulnerability factors and to develop a care plan based on any needs identified.   6.3.3 The family was defined as receiving an “enhanced” service because of Child X’s complex care needs. “Child X was on the enhanced health visiting caseload and was required to have a clear assessment of targeted health needs reviewed at least every 3 months and an action plan explaining this decision making recorded in the child’s notes”. This action plan should “include who is present during the visit and any changes in home circumstances including family composition, the presenting concern, the rationale for targeted support, an assessment of the health need and a plan of the intervention / action to be carried out”.  6.3.4 These arrangements were not followed by the HV when she visited the family. Mr C was present during the first visit and the HV did not establish who he was. On the second visit Mr C was again present but the HV did not assess his involvement in the care of Child X. She told this review that she felt this was unnecessary as most of the care of Child X was being undertaken by the child’s mother – which in fact the HV did not know and was not necessarily the case.   6.3.5 It has been established that this HV liaised extensively with other professionals but did not fully record the content of that liaison and any actions arisng:  “There is no evidence in the Health Visitor electronic record and in the written records of the content of these conversations (with the social worker) and of the assessment and action plans made”. When the Health Visitor was unable to attend a multi-agency meeting in May to discuss the family’s situation, no written report was provided, as is required.   6.3.6 The AR provides some context to this.  “During the timeframe of this review the Health Visiting team were working with high caseloads and a number of staff vacancies. This coupled with an increase in the number of children subject to child protection plans meant that  the health visitors were prioritising children and families that required statutory child protection intervention”.      Page 17 of 30 This particular Health Visitor, who was inexperienced, was responsible for 12 children subject to a Child Protection Plan and approximately 25 children where vulnerability factors had been identified.   6.3.7 The service needs to satisfy itself that  staff are responding appropriately to significant changes in circumstances by carrying out re-assessments  newly qualified staff are being given appropriate levels of support and oversight  6.4 Hampshire County Council, Services for Young Children  6.4.1 This part of the local authority managed two services working with the family, the Portage Service and the Early Years Support Service. Hampshire Portage Service is primarily a home visiting service for families with children who have additional needs, from birth to school age. Early Years Support is “a service that aids the coordination of services when there is multi-agency involvement with a family when there is at least one child aged under 5 years old and the child has complex needs”. Both services were directly involved from early 2013 and a number of officers / members of staff visited the home and saw the family. The AR judges that the two services worked well together and complemented each other.  6.4.2 None of the home visits prompted any safeguarding concerns. The fact that the home was sometimes not clean was noted by all who visited but no-one judged that this was at such a level as to represent a child care concern.   6.4.3 The AR questions whether staff should have been more alert to safeguarding concerns but this is really a judgment arising from the hindsight prompted by this review. The report does identify some room for improvement in the quality of case recording but no major issues arise from the involvement of these services.  6.5 Naomi House  6.5.1 Naomi House is a hospice for children and young people with life-limiting or life-threatening conditions. Child X went there for the first time in January 2013, and had four further short stays before her death. Staff at Naomi House had some concerns about unsatisfactory hygiene in Child X’s presentation and spoke to the adults about this. There were no other safeguarding concerns.  6.5.2 Child X was by chance at Naomi House for a short stay in March when concerns arose about the cleanliness of the home. At the social worker’s request Naomi House agreed to keep Child X for an extra 24 hours after the agreed discharge, so that the adults could clean the home. However Naomi House staff were unhappy with this arrangement for a number of good reasons: Page 18 of 30  It was received from a social worker whose employing authority did not have parental responsibility for this child and without any evidence that this was what those who did have parental responsibility wanted.  The request, made in a telephone conversation, was not supported by anything in writing.  The request was made in the late afternoon so that Naomi House was effectively being asked to respond immediately.  Should the adults arrive and seek to take Child X home, Naomi House had no basis to refuse this. They were asked to contact out of hours social workers and police, if necessary – but those agencies would not have had any authority to prevent the removal of the child in the absence of compelling, immediate evidence of harm to the child.  6.5.3 The social worker was attempting to be pragmatic, using the fact that the child was away to enable the adults to clean the home. However this placed Naomi House in a difficult position. It would at least have been more appropriate for the social worker to ask Ms A to speak directly to Naomi House.   6.6 Rainbow Trust Children’s Charity  6.6.1 The Rainbow Trust is a national charity supporting very sick and terminally ill children and their families. Most of their involvement with this family predated the period under review. They report that in late 2012 they were already in the process of withdrawing because so many other agencies were involved.  6.6.2 The report from the Rainbow Trust does not raise any concerns about their contact with the family and the agency is satisfied that there are no matters arising for them from a review of the case. They do comment that the local authority did not make them aware of their previous contact relating to Child Y until they had already been involved with the family for some time, and that they experienced some continuing problems in communications with CSC staff.   6.6.3 Rainbow Trust also report that they were “left out of the loop” when Child X was injured. They were not made aware of this by any agency and learned of the situation only from Ms A herself. Good communications are central to all multi-agency work with children and their families but there is a heightened need to be aware of this in respect of sick and disabled children, if only because of the probability that more agencies and different agencies will be involved. There would have been a clear need to ensure that all relevant agencies were identified and included in discussions and briefings, both when the injuries were identified and after the child’s death. This is a task which should have been identified and followed up by the local authority.  Page 19 of 30  6.7 Home-Start Gosport and Fareham  6.7.1 Home-Start is a national organisation which supports parents with at least one child under 5 who are dealing with a range of problems including disability. The agency website advises that “A carefully selected volunteer who has parenting experience will regularly visit a family in their own home, offering emotional and practical support through difficult times. This parent to parent support is a simple yet effective way of giving hope and enabling families to get back on track”.  6.7.2 The family was referred to Home-Start in September 2012 by the Rainbow Trust. A service of weekly visits by an appropriate volunteer was started in October and continued for seven months until the death of Child X. No concerns were raised by the volunteer. The report judges that “the work in this case was consistent with Home-Start’s policy and procedures for safeguarding and promoting the welfare of children and was in line with wider professional standards”.  6.7.3 However this agency comments on the fact that they were not made aware of the involvement of the local authority’s children’s services. “Home-Start was not made aware that Children X and Y were on the Child in Need Register9 until the team was contacted by Social Services 15 May 2013”. It may be that CSC were not aware of Home-Start’s involvement. However, as a service aiming to provide a weekly visit to the home, it would clearly have been useful to the agencies to get feedback from Home-Start. This was a missed opportunity to promote better communications between agencies and to make the best use of resources. The causes for this are to be found in the weaknesses in overall planning and case management.  6.8 Portsmouth Hospitals NHS Trust  6.8.1 This agency originally knew Ms A through her contact with maternity services. Child X then spent much of the first year of her life in a hospital environment. Consequently this agency was able to provide a good deal of background information. It is clear that Ms A had experienced a number of serious problems in the past and that there were early concerns about how well she would be able to meet her child’s complex care needs. There was a great deal of involvement from a range of agencies and it is encouraging that, when the child was able to return to the family it was “confirmed by (the consultant) that Child X’s parents followed any medical plans of care given and brought Child X to the attention of medical staff (if necessary)… in a timely fashion”.                                                 9 There is no such thing as a “Child in Need Register” but the children were being seen and treated as children in need, in line with the Children Act 1989, section 17 - children who are assessed as requiring additional services in order to reach or keep up a reasonable standard of health or development. Page 20 of 30 6.8.2 This is a very full report which draws out a number of issues relating to how agencies can best work together for families and children who have complex health and social care needs, but it largely refers to events preceding the period under review here.   6.9 The General Practitioners  6.9.1 Because of the complex medical condition, which required close continuing contact with secondary health care services, Child X had relatively little direct contact with the family GPs. In fact the GPs only saw the child twice during the review period for immunisations.   6.9.2 The AR queries whether the GPs might have enquired more closely into the backgrounds of adults of the family but this is a comment made with hindsight. There was nothing in the GPs’ contact with the family to raise any safeguarding concerns. The AR comments that “All GPs records were of good standard and they used read codes10 efficiently and kept contemporaneous notes” and “there was good information and communication between primary and secondary care”.  6.9.3 This report about the GPs was submitted as an AR but contact was so limited that it is effectively a factual report for information, rather than an analysis of involvement.  6.10 Housing provider  6.10.1 The family lived in secure social housing and the report from their landlords confirms that they received a referral from a neighbour, expressing concern about conditions in the home. This led to liaison with social workers but no direct intervention by housing officers was judged necessary.  6.10.2 The report mentions that they were unaware that Mr C had joined the household and that an officer who visited the home did not pick this up. More thorough liaison between agencies in response to the neighbour’s referral should have ensured that they were all more fully informed. However there are no consequences for the issues under review here.                                             10 A standardised system for recording clinical information Page 21 of 30  6.11 Hampshire Constabulary  6.11.1 The only involvement of police during the period under review (or at any time prior to the injuries to Child X) was that they were consulted by CSC when they, CSC, received the referral from a neighbour in March. There was a full discussion and the agencies agreed, properly, that this was not a situation requiring police involvement in the investigation in the first instance. There are therefore no matters arising for police from this SCR.  6.12 Hampshire County Council, Adult Services  6.12.1 This agency was asked to review its records and has submitted a report confirming that they had no significant involvement with the family, other than to receive a safeguarding referral from the ambulance service when Child X was taken to hospital just before death. This was because Adult Services is the department of the local authority responsible for the management of the Out of Hours social work service. This referral is discussed in the next section of this report.  6.13 South Central Ambulance Service NHS Trust  6.13.1 This is again effectively a report for information. The ambulance service only had contact with Child X, during the period under review, when transporting the child to hospital after the fatal  injuries.  6.13.2 On that occasion the ambulance service made a safeguarding referral to the local authority. However, that form states that there are “no obvious concerns”. This begs the question of why a safeguarding referral was being made. It suggests that there was no real understanding of the purpose and potential consequences of making such a referral.  6.13.3 A further concern is that this issue was not identified by the ambulance service itself when considering its contribution to this review. It was only explored in the compilation of this Overview Report.   6.13.4 These matters have been raised with the NHS Fareham and Gosport Clinical Commissioning Group (CCG), the agency which commissions the SCAS. The CCG has recognised these concerns and has advised that they are being addressed. It is recommended that the Board should engage with these agencies in determining and monitoring the improvements planned.  6.14 University Hospital Southampton NHS Foundation Trust  6.14.1  During the period under review Child X attended this hospital for outpatient appointments and planned investigations. In May 2013 she was admitted for 8 days for a respiratory infection. Generally her vulnerabilities were recognised and addressed by appropriate liaison with other agencies. Communications within the hospital were also good. Concerns about home conditions, notified to the hospital by community-based staff, were recognised Page 22 of 30 and raised directly with Ms A and her partner.The only issue leading to a recommendation in the agency’s report is that the hospital did not notify all relevant partner agencies, as they should have done, when an outpatient appointment was missed.  7. ISSUES ARISING FROM AN OVERVIEW OF THE CASE  7.1 Co-ordination and collaboration  7.1.1 The lack of any clear planning and management of the case has already been raised in this report, principally in respect of CSC, the agency with the statutory lead responsibility for safeguarding children. However it is notable that, after the meeting called by CCN1 in September 2011 when the child was being discharged from hospital, no other agency or professional at any time felt the need for a meeting to plan and co-ordinate the work of the many agencies involved.   7.1.2 Even if there had been no other concerns a well co-ordinated approach clearly would have been necessary for a child with such complex needs. This is not just the responsibility of CSC - any of the many agencies involved might have identified this and followed up. This may not be representative of the work of the agencies with disabled children and their families, and there was no indication of discord between the agencies, but the Board will wish to be reassured that it is not a continuing problem.  7.2 The home conditions.  7.2.1 Concerns about cleanliness and disorder in the home were raised explicitly by professionals and a neighbour on four occasions during the period under review. Mr B said this was a concern for him. It is also clear that those issues had been identified previously and raised with Ms A. On each occasion Ms A and Mr C were asked to clean the home and did so, to the satisfaction of officers subsequently carrying out checks.  7.2.2 The extent to which subjective judgments are in play is significant. There are accounts of professionals visiting the home on the same day or within days of each other but responding quite differently to the home conditions. The CCN, perhaps the professional visiting the home most frequently, never felt it necessary to raise concerns about home conditions, although it was she who had flagged it up as an area of potential concern when Child X was being discharged from hospital in 2011. When specifically asked about it by social workers in March, her view was that the home was untidy not dirty. There were occasions when professionals visited, knowing the background of concern, and noted that the home was clean.  7.2.3 This cannot have been an extreme instance of poor cleanliness, given the differing professional views and also the fact that, on every occasion the issue was raised, the family was able quickly to clean and tidy the home to the satisfaction of professionals. Nonetheless the number of occasions when concerns were raised indicates that there was an issue to be tackled here. Page 23 of 30 Child X’s medical condition and treatment of course also increased the need for good hygiene.   7.2.4 It seems that the concerns largely arose from the number of domestic animals in the home and the way in which those pets were looked after. On the face of it that might sound like a relatively trivial consideration for the family, as against the care of their very needy child. But criticism of the way that the animals were looked after could in itself be experienced by the family as distressing and the whole issue probably added to the family feeling that agencies were harassing them. It was an issue to be approached with some sensitivity and, in fairness, there is no indication that the family challenged the agencies’ reasons for raising these concerns, or the way they went about it.  7.2.5 The first evident weakness in the way that this issue was approached is that there is no sense that it was tackled jointly with the family. It largely fell to a social worker, sometimes never seen by the family before, to arrive and tell the family to take action. No family is likely to welcome being told that their home is unclean but the issue would have been easier to tackle in the context of a continuing, supportive relationship.  7.2.6 This was always likely to be a recurring problem – there was strong evidence that it had continued and re-presented over some years. Yet the agencies’ response was always reactive, sparked by concerns raised by a neighbour or professional, rather than something that might be anticipated.  7.2.7 The probability that there would be a continuing problem leads back to one of the key issues identified above, the lack of planning in the management of the case. Many professionals and volunteers were visiting and the issue of home conditions was clearly an area that could be shared, not just left to the social workers to tackle at times of crisis. It may also have been possible to arrange that monitoring and input in a way that was more supportive and less of a threat to the family.  7.2.8 Had there been a planned multi-agency approach that would also have pushed the agencies into being clear about   what their expectations of the family were  whether those expectations were agreed across partner agencies, and   what the family needed to do to ease the concerns of professionals.  7.3 Children with complex needs  7.3.1There is extensive research which underlines the particular vulnerability of disabled children and the barriers, both organisational and attitudinal. A commentator noted 15 years ago that: “Child protection policies and procedures are intended to offer protection to all children, regardless of gender, race or impairment. However, unless  specific attention is paid, by those devising and implementing child protection systems, to the particular experiences and particular needs of disabled Page 24 of 30 children, they will continue to remain invisible within child protection systems”.11  7.3.2 This is a difficult area for staff. Disability services may be grounded in a  commitment to promoting control and choice to such an extent that issues of safeguarding and protection may not receive an adequate priority. Child protection staff may feel out of their depth in respect of the detail of disability issues. Staff may be reluctant to challenge a parent who is responsible for caring on a daily basis, and may be too ready to accept that a carer is “doing their best”. Staff may consequently accept a sub-standard level of care.  There are research findings that “social workers can sometimes feel overwhelmed by the child’s needs and by the sheer hard work which carers face in looking after some disabled children. Feelings such as “I wouldn’t be able to manage” can get in the way of their professional judgement about whether a child is safe”.12  7.3.3 it is appropriate to consider the extent to which the principal reason for the agencies’ involvement, the child’s complex health and developmental needs, may have affected any assessment of her need to be safeguarded. It is right to re-assert the particular safeguarding needs of children with disabilities.  7.3.4 However this report has stressed the need to avoid the bias of hindsight. It is not the case here that the nature and extent of the child’s disability served to deflect any agency from expressing and following up safeguarding concerns, other than those related to the home conditions. There was no evidence that would have suggested that agencies should have been taking formal child protection action at any point.   7.4 Serious Case Review process  7.4.1 This review was initiated very soon after the implementation of new statutory guidance13. That guidance differed from its predecessor in that, in respect of SCRs, the “rules” were relaxed, so that Safeguarding Boards were given greater discretion on when a SCR could be conducted (apart from the clearly defined statutory requirements), and greater leeway as to how reviews would be carried out.   7.4.2 If this review had been initiated prior to the new guidance it would have been led by two independent people – an independent chair and an independent author of this report – now both referred to as “Lead Reviewers”. There would have been a Panel of senior officers from the outset and a more formal, shared process of meetings to ensure the progress of the review.                                              11 Jenny Morris, Disabled children, child protection systems and the Children Act 1989 – Child Abuse Review, Volume 8, Issue 2, March 1999.   12 The child protection system and disabled children (Edwards & Richardson, NSPCC) 13 Working Together 2013 Page 25 of 30 7.4.3 In this review there has only been one Lead Reviewer and initially no dedicated Panel. There have been consequences from that approach for the overall co-ordination of the exercise and the time taken to complete it. Some agencies were not identified as having been significantly involved until relatively late in the process. It would have been helpful to have a more clearly defined, timetabled approach to the review with an identified panel of lead officers across the agencies steering the exercise from the outset.  7.4.4 This has been a relatively straightforward SCR in the sense that it was always clear that the death of Child X was not linked to any continuing, defined safeguarding needs, and could not have been foreseen. However the issues of organisation and co-ordination of the review would have been more challenging in a more complex case. There is accordingly a recommendation to the Safeguarding Board.   Page 26 of 30  8. CONCLUSIONS –  A SUMMARY OF KEY ISSUES AND LESSONS LEARNED  8.1 The death of Child X could not have been anticipated by any of the agencies or professionals concerned. There was no indication of a need to safeguard the child, except in relation to the condition of the home.  8.2 The family was involved with a large number of agencies and professionals because of the complexity of Child X’s care needs. Yet there were no arrangements to oversee, plan and co-ordinate the work of those agencies. There was no sense of a “team approach” and inevitably there were  weaknesses in the sharing of information.   8.3 Any of the agencies could have taken the initiative and tried to bring services together. The requirement to do so sat principally with the local authority’s children’s social care services. The fact that they did not give such a lead may have inhibited other agencies with less clearly defined responsibilities. The local authority has conducted a very thorough review, identifying and addressing a number of factors leading to the weaknesses in their management of this case.   8.4 The lack of planning extended to a failure to include the family – rather, they were seen as passive recipients of a “package of care”. Although Child X continued to have substantial contact with Mr B his involvement was generally overlooked by the agencies.  8.5 A number of agencies found that they had used no clear process of assessment, planning and review. It may be easier for agencies to lose focus in this way when the principal presenting problem lies in a profound and complex disability, with life-limiting consequences. Staff may feel powerless and agencies must ensure that arrangements for case planning and supervision of staff are alert to this potential challenge.  8.6 The only clearly evidenced safeguarding concerns related to the cleanliness of the home, although agencies did not consistently agree about the nature and extent of this problem. There was no attempt to try to understand the causes of the lack of cleanliness, and agencies did not work together to try to prevent it. The family always responded appropriately when challenged about it and agencies were then too ready to set the issue aside until it recurred.  8.7 This Serious Case Review was conducted under the most recent statutory guidance which introduced less prescriptive requirements for the process of reviews. The Board will need to ensure that this greater flexibility does not lead to a lack of rigour in carrying out a review.  8.8 The review has raised concerns about the identification of safeguarding issues by the ambulance service, and then the failure of the service to analyse this effectively in the process of this review. Page 27 of 30  9. RECOMMENDATIONS FROM THIS SERIOUS CASE REVIEW  9.1 Introduction   9.1.1 These recommendations to the HSCB reflect the key lessons to be learned from this review. The review does not make a recommendation for every point of learning that has been identified. The recommendations are complemented by more detailed recommendations, specific to each agency, contained in the reports from those agencies.   9.1.2 Agencies have not awaited the completion of this review in order to tackle issues arising from these events. Some of these recommendations, or aspects of them, have been identified and addressed already.   9.2 Recommendations to the Hampshire Safeguarding Children Board  9.2.1 the Board should make arrangements for multi-agency audits of work being carried out with children with disabilities and their families, to ensure that  Agency involvement is planned, co-ordinated and reviewed  Agencies are appropriately alert to safeguarding issues   Appropriate “lead professional” arrangements are in place  Agencies are alert to the need to involve fathers in their planning and their work  9.2.2 The Board should review and improve as necessary guidance to staff about identifying, assessing and following up concerns arising from poor home conditions.  9.2.3 The Board should ask the South Central Ambulance Service NHS Trust, and the NHS Fareham and Gosport Clinical Commissioning Group to demonstrate improvements made in the ability of the SCAS to identify and respond appropriately to situations which may raise concerns for the safeguarding of children.  9.2.4 The Board should ensure that there are adequate arrangements for the management and co-ordination of any subsequent SCR.         Page 28 of 30 APPENDIX A: TERMS OF REFERENCE  The timescale for the review will be from when Mr C became a member of the household until the death of Child X: November 2012 – June 2013.   The review will consider the family unit as Child X, Child Y, Child X’s parents and Mr C.    The terms of reference are: 1) Identify and analyse key events/opportunities for assessments and decision making. Were any child care or safeguarding concerns recognised and responded to appropriately?  2) Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquires made, in light of the assessments?  3) To what extent were the child/ren’s needs, views and wishes taken into account?  4) Identify and evaluate decisions, assessments and plans made and services offered by agencies in relation to members of the household or other significant adults. To what extent was the need to safeguard and promote the welfare of the child taken into account?  5) Examine and analyse the level and effectiveness of exchange of information and communication between agencies and across areas Identify any gaps which may have impacted upon assessment, service provision or outcomes.   6) Was the work in this case consistent with each agency’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children and with wider professional standards?  7) Were there any organisational difficulties being experienced within or between agencies? Were these due to lack of capacity within the agency?  Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?  8) Highlight ways in which practice can be improved and make recommendations as appropriate?     Page 29 of 30  APPENDIX B: THE LEAD REVIEWER  Kevin Harrington  Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has worked on more than 40 Serious Case Reviews in respect of children and vulnerable adults. He has recently been engaged by the Department for Education to re-draft high profile Serious Case Review reports so that they can be more effectively published. Mr Harrington has been involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council, and has undertaken investigations commissioned by the Local Government Ombudsman. He has served as a magistrate in the criminal courts in East London for 15 years.      Page 30 of 30  APPENDIX C: REFERENCES  Footnotes have been used to indicate specific quotations from or references to research, practice guidance and other documentation. This Overview Report has been generally informed by the following publications   Working Together  to Safeguard Children,(HM Government  2013)  The Victoria Climbie Inquiry (Lord Laming 2003)  The Protection of Children in England: A Progress Report  ( Lord Laming 2009)  Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008   Analysing child deaths and serious injury through abuse and neglect: what can we learn – A biennial analysis of serious case reviews 2003-2005  Understanding Serious Case Reviews and their Impact - a Biennial Analysis of Serious Case Reviews 2005-07 DCSF 2009  London Safeguarding Children Board – SCR Toolkit (2010)  The Munro Review of Child Protection: Final Report (HMSO May 2011)  The Munro Review of Child Protection: Interim Report (HMSO February 2011)  Publication of Serious Case Review Overview Reports: Letter from Parliamentary Under Secretary of State for Children and Families 10th June 2010  “It doesn’t happen to disabled children” - Report of the National Working Group on Child Protection and Disability (NSPCC 2003)  Morris, J. (1999) Disabled children, child protection systems and the Children Act, Child Abuse Review 8, 91–108   ‘Necessary Stuff’: the social care needs of children with complex health care needs. (University of Sussex: SCIE 2007).  Developing an effective response to neglect and emotional harm to children (Gardner 2008)  In the child’s time: professional responses to neglect (Ofsted 2014)  