Concerns about the risk of sexual abuse of two half-siblings aged 10 and nearly 6 years old, and about the drift and delay in planning for their future. Involvement from Children's social care services from the time of the birth of Patrick, the older sibling, because father and grandfather both had separate convictions of sex offences against adolescent girls. Mother has learning difficulties and her first two children had been removed from her care. Multi-agency assessments on at least nine occasions during a 9-year period, followed by care proceedings being issued. Siblings subject to child protection plans three times. Delay of six months from the decision to seek interim care orders to when an application was made. Learning includes: there is a difference between the risk of reoffending and the risk of harm that a convicted sex offender might pose to a child in their family; the need for social workers to understand other agencies' risk assessments; the importance of keeping historic 'risk' alive; the importance of pre-birth assessments and child protection conferences; the effectiveness of step-down and escalation. Recommendations to the LSCB include: amend Child Protection procedures to state that when a child is subject to a child protection plan and a parent or carer is on the sex offender register, their sex offender manager should be a part of the core group; when children's names are on a Child Protection plan and there are concerns about possible sexual abuse, risk of sexual abuse is the most appropriate category.
      
    Serious Case Review No:  2019/C7638  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.           Serious Case Review concerning  Patrick & Patricia                    2  Independent Author: Felicity Schofield Contents 1. Introduction ........................................................................................................................................ 3 2. The Terms of Reference ..................................................................................................................... 3 3. The Process ......................................................................................................................................... 4 4. Involvement of the Family & Children ............................................................................................... 4 5. Background to the scoped period ...................................................................................................... 5 6.    Patrick’s birth leading up to the birth of Patricia ........................................................................... 6 7. Case opened and closed to CSC, Patrick on a Child Protection Plan ................................................ 7 8. Case reopens to CSC; children subject to a Child Protection Plan .................................................... 9 9. Both children remained on Child Protection Plans, care proceedings were planned but not commenced ........................................................................................................................................... 10 10. Duration of the care proceedings .................................................................................................. 12 11. The Children’s Lived experience .................................................................................................... 14 12. Themes Emerging from the Review ............................................................................................... 15 Understanding the risks posed by adult sex offenders................................................................... 15 The ease with which case records summarise historical risk ......................................................... 16 The category of the Child Protection Plan ....................................................................................... 16 The use of written agreements ........................................................................................................ 17 The role and function of Core Groups ............................................................................................. 17 Escalation .......................................................................................................................................... 18 The effect of organisational change & the role of the LSCB ........................................................... 18 13. Action that has already been taken ............................................................................................... 18 14. Recommendations ......................................................................................................................... 20    3  1. Introduction 1.1 The subjects of this Serious Case Review (SCR) are half-siblings (Patrick) and his sister (Patricia), aged 10 years and nearly 6 years respectively when this review was commissioned. 1.2 This case is about the risk of sexual abuse and how that risk was assessed at various points in time from Patrick’s birth until the conclusion of care proceedings. The case is also about the drift and delay in planning for these two children’s future. 1.3  There has never been a disclosure of sexual abuse. 1.4  There was involvement from Children’s Social Care (CSC) services from Patrick’s birth onwards because both his father and the man who he knew as his grandfather had separately been convicted of sex offences against adolescent girls. In addition, Patricia’s mother was a vulnerable woman with learning difficulties whose first two children had been removed from her care. 1.5  There were multi-agency assessments on at least nine occasions during the nine year period under review which ends when care proceedings were issued. In addition, the children were subject to child protection plans during three periods. There was a delay of six months from the decision that interim care orders were to be sought to when an application was made. 1.6  During the period under review the Local Authority Children’s Services Department embarked on organisational changes which resulted in a significant deterioration in its safeguarding services. The effects of those organisational changes are evident in this Serious Case Review and the experiences of the two children. 1.7   During the Care proceedings there was criticism regarding failing to undertake a robust risk assessment of the children’s grandfather and for the lack of urgency in putting the case before the family court.  2. The Terms of Reference 2.1  The detailed terms of reference were agreed and kept under review throughout the process by the Review Panel. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described within these. Eight agencies contributed reports to this review. 2.2  It was agreed that the scope of this review would consider eight specific points in time between Patrick’s birth and the final court hearing. These were critical points where there was, or should have been, multi-agency involvement to inform decision-making and to improve and safeguard the children’s welfare. A ninth point in time was added during the course of the review. 2.3 Given the passage of time and the organisational and legislative changes that have taken place over the last decade, attempts have not been made to understand why certain actions and decisions were taken during the first few years of the scoping period. However, it will be seen that decisions made in this earlier period had a significant effect on subsequent decision making. 4  3. The Process 3.1  Children’s Social Care Services referred the case to the LSCB and it was considered by their SCR subgroup the following month.  A recommendation was made to the Chair of the LSCB that the case met the criteria for an SCR.   3.2  The Chair also agreed that this case met the criteria for a SCR and that one should be commissioned. The reasons for reaching this decision were that, despite there being no disclosure of sexual abuse, there were concerns both about multi-agency working and the long term management of risk. 3.3  The report author met with the Chair of the SCR sub-group to draft the Terms of Reference in and single agency reports were commissioned. The Overview Report writer is independent of all professional agencies in the local area, has had no previous direct involvement with or knowledge of the family who were subject to the review and has had no previous involvement in a professional capacity with safeguarding practice in the local area.  She is a social worker by profession. 3.4 Working Together to Safeguard Children 2015 states that serious case reviews should: • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;  • be written in plain English and in a way that can be easily understood by professionals and the public alike; and  • be suitable for publication without needing to be amended or redacted.  This serious case review has been undertaken in a way that ensures these principles have been followed.  3.5  Two practitioner events were held. The first event was for those practitioners who had worked with the family. Its aim was to seek their views on the emerging themes from the review. The second practitioner event did not require attendees to have any prior knowledge of the case. Its purpose was to discuss with practitioners the learning from the review in order to establish whether, given the passage of time, areas of concern which had been identified by the review were still prevalent in 2017. The practitioners’ contributions have informed the recommendations. 4. Involvement of the Family & Children 4.1  The lead reviewer met with the younger sibling’s current carers, who are members of her extended family, and with the paternal grandparents. Their views were included in the consideration of the case. 4.2  The contribution of these relatives is greatly appreciated, and it was clear that they all cared a great deal about the two children. Meeting with them served as a timely reminder about how difficult it is for families of limited means to cope with care proceedings, especially when they are not in agreement with the Local Authority.  5  4.3  The children were not interviewed as part of this review. In the opinion of the lead reviewer the younger sibling was too young. With regard to Patrick throughout the care proceedings, which lasted for a period of ten months, Patrick was aware that he might have to leave his carers with whom he had lived for over two years and this caused him a great deal of distress.  4.4  Patrick has moved more recently to live with his birth mother. It seemed inappropriate therefore to reawaken Patrick’s earlier distress by interviewing him for this review. 4.5 All family members were invited to meet with the Independent Chair in order to hear the learning from this review and this opportunity was taken up by the father and grandparents. 5. Background to the scoped period 5.1  This family had been known to Children’s Social Care services (CSC) for many years (a genogram was provided to the Review Panel to assist the review process). Prior to the birth of Patrick, the grandfather had been convicted of sexually abusing an adolescent girl, serving five years of an eight year prison sentence. During the investigation into this offence, the adolescent victim stated that she had also had sex with another family member who was living in the family home at the time.  5.2  The grandmother did not believe the allegations about her husband, even though he had admitted to them. The adolescent victim subsequently came into care and never returned home. 5.3  On the grandfather’s release from prison an initial child protection case conference was held in respect of his son (Patrick’s father) and Patrick’s father was placed on the child protection register (CPR) under the category risk of sexual abuse.  5.4  A risk assessment on the grandfather was carried out by a psychologist who concluded that the risk to Patrick’s father from his own father was low, although the risk would be greater to a female child in his care.  5.5  Patrick’s father was convicted of having sexual intercourse with a girl of fourteen years when he was aged nineteen. He was placed on the sex offenders’ register for five years. Around the same time, he developed health needs which were not well controlled. 5.6  Prior to beginning her relationship with the father of Patricia, the mother had given birth to two children.   The mother struggled to meet these children’s needs and they had both come into care when they were under a year old. Both children were placed permanently with alternative carers.  Analysis  The importance of family history 5.8  Both parents had grown up in families with skewed sexual boundaries. In addition, Patrick’s father had been convicted of a sexual offence and Patrick’s step-mother had a history of sexualised behaviour following her own sexual abuse. It would have been reasonable to assume therefore that the parents’ childhood and adolescent experiences might potentially affect their ability to protect their children from sexual abuse.  6  5.9  The approach taken by CSC on the grandfather’s release from prison was appropriate and sought to understand the risk posed by the grandfather to his own son, Patrick’s father. CSC’s actions were informed by a forensic psychological risk assessment which specifically addressed the question of the risk posed to the father, rather than the risk of reoffending.  5.10  It is of concern that this risk assessment was neither reviewed nor updated for a further 19 years, despite the grandfather both taking over the full-time care of Patrick and playing an active role in the care of Patricia. 5.11  One of the significant messages from this review is that there is currently no agreed pathway for the updating of the risks posed by adult sex offenders. 6. Patrick’s birth leading up to the birth of Patricia 6.1  When Patrick was born the maternity hospital contacted CSC to ascertain whether it was safe for the father to have contact with Patrick given his sex offender status. After a brief delay, CSC undertook an initial assessment. The assessing social worker sought advice from both the probation service and the police regarding the potential risk posed by the father. The two organisations offered conflicting opinions, with the police sex offender unit assessing the father as posing a high risk of reoffending and probation assessing him as posing a low to medium risk of reoffending. Analysis The need for social workers to question and understand other agencies’ risk assessments 6.2  It was good practice for the maternity hospital and the police to consult with CSC when they became aware that a sex offender was caring for a baby. Similarly, partnership working continued to be effective when the health visitor alerted CSC to a significant change in the family’s circumstances. 6.3  The significant issue arising from this early period is that the discrepancy between the two risk assessments, whilst noted, was not pursued with regard to reaching an understanding of the implications for Patrick, either at that time or in the future. Not only was there a discrepancy between two agency’s risk assessments, but the social worker chose to record the risk posed by Patrick’s father as ‘low’ which did not reflect accurately the outcome of the probation risk assessment, let alone the police assessment. Unlike the risk assessment undertaken on leaving jail, these later assessments related to the risk of reoffending rather than to the specific risk that the father might pose to Patrick or subsequent children. For the next nine years this conclusion was relied upon whenever a family assessment was undertaken. 6.4  It is not suggested that a more in-depth analysis of the risks posed by the father and grandfather would have led to CSC allocating the case or putting Patrick on a child protection plan at that time. The immediate risk to Patrick from his father probably was low. However, there needed to be a better understanding of how that risk might change over time, especially given the background of intergenerational sexual abuse and Patrick’s relationship with his grandfather. 6.5  As part of this SCR, it has been established that it was quite common 10 years ago for the police and probation to reach different conclusions about the risk of reoffending. They used different 7  assessment tools. Had they been consulted, both organisations could have explained the likely reasons for their differing conclusions and would have advised a reassessment whenever the person’s circumstances changed significantly. Despite being assessed as posing a ‘low to medium’ risk, Patrick’s father was managed by probation as a ‘medium risk’ throughout his time on the sex offenders’ register. 6.6 Today, police and probation share the same risk assessment tool – Active Risk Management System (ARMS) – so some of the issues identified above would not occur. It remains of vital importance however for workers within Children’s Services to understand what such assessments mean in relation to the specific family they are working with. 7. Case opened and closed to CSC, Patrick on a Child Protection Plan 7.1  From the birth of Patricia onwards there is evidence in the children’s medical records that their medical practice were in receipt of the full facts of the safeguarding risks surrounding Patrick and his sister. 7.2  The case was reopened by CSC in April 2010 following a referral from the maternity services. The mother was pregnant, and the family were temporarily living with the grandfather and his partner. An initial child protection conference was held with Patrick becoming the subject to a Child Protection Plan (CPP). The conference recommended that a pre-birth conference would be required shortly before Patricia’s birth.  Analysis The importance of keeping historic risk ‘alive’. 7.3  The majority of times that the children were seen by a GP a red ‘Safeguarding concern flag’ was in place. There were also extensive easily visible references to social work involvement including many entries from the health visitor.  These items should have acted as an alert to GPs and GP Locums to understand that the children were living in an environment where safeguarding risks were being managed by the multi- agency teams lead by CSC. However, the GPs who saw the children did not appear to consider or be aware of the seriousness of the risks surrounding both children which might have led to either a differential diagnosis and/or sharing information with the Social Worker. 7.4  During the latter part of the year neither the review conferences nor the core groups nor managers took action to ensure that some of the important and outstanding actions identified at the ICPC in May had been completed. In the absence of the information which would have been available from these actions, subsequent conference decisions were based on the ‘here and now’ rather than on an analysis of the many concerning risk factors in this family’s background and the implications of these factors for these two children.  The importance of pre-birth assessments and child protection conferences 7.5  In the opinion of both the author and practitioners who were consulted as part of this SCR it was an omission not to place Patricia on a Child Protection Plan at birth and quite exceptional given that her mother had had her first two children permanently removed as young babies. There is scant 8  information in the records regarding the reasons for the removal of the mother’s other children’s and no analysis regarding the risk of a repeat scenario for Patricia. 7.6  With regard to the ante-natal period and Patricia’s birth, the hospital trust procedures require a referral to their internal safeguarding team when a parent attends hospital and concerns about their presentation have been raised. It is too long ago to establish why this did not happen when the mother was admitted towards the end of her pregnancy. However, there is now a more sophisticated electronic recording system, which includes more safeguarding prompts and alerts. Midwifery staff now also have access to a shared drive which contains copies of any safeguarding plans. 7.7  Multi-Agency decisions were not made regarding the risks to Patricia both before and immediately after her birth because two child protection conferences were not attended by a sufficient number of agencies to enable decisions to be made. Given the mother’s history it would have been appropriate for the chair of the conference to take a more proactive approach in order to ensure effective, coordinated safeguarding action from Patricia’s birth onwards. The lead reviewer has been informed that attendance at child protection conferences is not a concern today and therefore no recommendation has been made in this regard. The use of written agreements 7.8  In the final few months before the case was closed to CSC seven months after Patricia’s birth, there were incidents of domestic violence between the father and his ex-partner, who was temporarily living in the family home. CSC’s response was to put in place a written agreement. However, there is no record of this agreement being monitored or of any checks that the mother in particular had the literacy skills to understand such an agreement. The use of written agreements has been highlighted in other SCRs and is one of the learning points from this review. 7.9  During this period the potential risk posed, particularly by the grandfather, gradually drifted out of consideration. For example, Patricia was seen by a health visitor at her grandparents’ home, with no concerns raised. Similarly, the social worker recorded the grandfather taking Patricia into another room to feed her, again no concerns were identified. The father’s strongly stated conviction not to let the grandfather have unsupervised access to his children had been ‘forgotten’ by family and professionals alike and both the father and grandfather had become protective factors against the mother’s vulnerability and her own ‘risky’ extended family. The effectiveness of Step-Down and Escalation 7.10  Coordinated multi-agency working below the threshold of CSC was not well embedded at the time. However, since that time, there have been some fundamental changes to the Early Help processes and the Step-Down process is now believed to be more effective. Nevertheless, at the meeting in 2017 practitioners were still expressing both confusion about the process and frustration about what they perceived as the high thresholds into CSC. 7.11  Formal escalation to more senior managers when there was a disagreement about the decision-making of a particular agency was rarely used at the time. Following learning from other SCRs, the 9  LSCB has actively promoted its Escalation Policy. However, there were still practitioners who attended the events for this review who were not familiar with it. 8. Case reopens to CSC; children subject to a Child Protection Plan 8.1  Three years after Patricia’s birth the police attended the family home following an incident of domestic violence. This incident was referred to CSC who allocated a social worker and undertook an initial assessment. The father was described as hostile and intimidating when the social worker visited him at home. Patrick was said to be living at his grandfather’s home. 8.2  Over the next few weeks, the original risks posed by the father and grandfather were recognised by the new social worker, and the team manager advised the social worker to undertake a core assessment. However, whilst this assessment was completed, it did not address the risks posed by the two men to the two children and it did not result in a plan.  Analysis The understanding, investigation and response to possible sexual abuse 8.3  During this time period the potential risk of sexual abuse from paternal relatives re-emerged and was correctly identified by the chair of the case conference, the social worker and her team manager, together with other risks relating to neglect and domestic violence.  8.4  However, the category of abuse did not change which may explain why, for example, the various GPs who saw Patricia were not concerned enough to inform CSC when her parents brought her to the medical centre in January, March and April with symptoms that could be possible indicators of sexual abuse or neglect. Despite being on Child Protection Plans throughout this period, with reports being provided to case conferences in February, April and August, the GPs did not consider that these visits could have been a cause for concern. 8.5  Prior to this the social worker talked to Patrick about ‘good and bad touches’ and asked Patrick if anyone had touched him. Patrick’s negative response reassured the social worker who concluded that he had not been abused. Patrick was only seven years old with some developmental delay. His understanding of what was ‘good’ and ‘bad’ could easily have been skewed by his experiences. Social workers need to be aware of the potential distress such brief interventions might cause to a child and be very careful about drawing inaccurate conclusions. 8.6  If the child protection plan had been worked proactively and rigorously for the three months it could have provided the detailed risk assessment and clarity about the various concerns that were required by a Legal Planning Meeting (LPM). However, what actually happened was that the case was transferred to a long-term team for the required work to be done, which resulted in drift and delay. 8.7 Given Patricia’s developmental delay, it may have been unrealistic to have expected her to have provided much more information; however, there is no evidence that the social worker spent any time speaking to Patricia, as had been agreed at the three strategy discussions with the police. Given the amount of time Patricia was spending with her grandfather, a convicted sex offender who 10  had been assessed as posing a greater risk to girls rather than boys, this was a significant error of judgement. 8.8  The strategy discussions following the three referrals between March and May should have included a health representative, which would be the case today.  8.9  The attendees at the meeting in April agreed that Patricia was not being protected by the child protection plan. A Legal Planning Meeting was unlikely to have led to the immediate removal of the children, therefore there should have been a discussion about what other action could have been taken to protect the children in the short-term; for example, restricting Patricia’s contact with the grandfather and/or implementing and monitoring a written agreement.  The importance of confident front line practitioners who can challenge decisions 8.10  While senior managers must be the gatekeepers of expensive resources, they should not just refuse funding without understanding the detail of the case, the consequences of their decision and offering advice about alternatives. CSC could and should have challenged this decision, supported by their colleagues in legal services and possibly the case conference chair. Instead, the decision led to further drift and delay with no agreed way forward. This impasse, does not, however explain the delay in entering pre-proceedings given that the LPM had stated that the assessments could be undertaken during that stage. 8.11  There appears to have been a culture of ‘top-down’ management within CSC during the period of restructure which had the effect of stifling professional judgement at practitioner and first line manager levels. Even service managers appeared to be ‘told’ what approach to take about cases. This culture was contrary to the recommendations of Professor Eileen Munro’s review of child protection in England, the final report of which had been published in May 2011. Her review called for a move from a compliance to a learning culture, where practitioners had the freedom to use professional expertise in assessing need and providing help. 9. Both children remained on Child Protection Plans, care proceedings were planned but not commenced 9.1  Nearly a year after Patricia’s birth the children’s situation remained seriously concerning, although there were no further reports of the previous concerns and symptoms, following the LPM and the removal of the dog from the family home.  There were fewer concerns about Patrick. 9.2  Core group meetings took place on a regular basis. However, on interview, head teachers stated that whilst social workers sought information from them, they did not think that their opinions were valued or influenced decision making. They also expressed sympathy for the social workers’ situation which involved a major reorganisation, a new information system and new phone system, which was seen as a barrier to telephone and voicemail communication.   9.3  A month later the father was admitted to hospital and the grandfather arrived at the family home and removed Patricia ‘kicking and screaming’ from her mother’s care. The police were involved and considered Patricia to be safe and well at her grandparents’ house.  11  9.4  A referral was made by the hospital ward sister to the Out-of-Hours service to ascertain whether it was safe for the grandfather to have care of Patricia. The Out of Hours worker looked at CSC records and consulted her manager; the decision was reached that Patricia could stay where she was for one night on the basis that her brother was there already, assessments were (supposedly) on-going, and the police had observed her to be safe and well. The following day, the team manager agreed that Patricia could remain with the grandparents until the review case conference, due to be held a few days later.  9.5  In interview, the social worker stated that she was on leave at the time Patricia went to stay with her grandparents and was horrified to return to work to find Patricia established in their home. 9.6  The health visitor undertook a developmental review of Patricia. She was found to be functioning approximately twelve months below her chronological age. Organisational Context 9.7  During the period covered by the section above, a restructuring of Children’s Services took place. This process led to considerable instability with many workers and managers leaving the service. As a result, there were periods during which this case was managed by agency workers and managers, some of whom remained involved for only a few weeks. The staff turbulence had a serious impact on the care planning and contributed to drift, delay and a lack of clear direction at a crucial point in the case.  9.8  A new electronic recording system which had been introduced at the same time as the restructuring also contributed to social workers’ difficulties in accessing, and thus taking account of, historical information and earlier assessments. As well as exacerbating staff frustration this led to a period during which there was duplication of records and multiple ‘legacy’ documents, while records created previous to this period could only be accessed in the form of scanned casefiles which were difficult to identify and time-consuming to trawl through. 9.9  A third problem was caused by the installation of a new phone system which resulted in it being very difficult to leave messages for social work staff.  9.10  Schools reported considerable sympathy for the beleaguered social workers, often trying to find other ways of compensating for the poor service being offered from CSC. This sympathy may explain why they did not formally escalate their concerns. 9.11  The medical centre also suffered from staff shortages resulting from ill-health and as a result there were a large number of locums during this period. Analysis The relationship between the child protection processes and care proceedings 9.12  Given the close relationships between the extended family members and the Grandparents, there should have been an assessment of their ability to protect Patricia immediately after she was placed with them at the age of nearly four. As a result of that assessment the extended family members caring for Patricia could then have been given the advice they needed to keep Patricia safe. Their 12  ability to understand and follow that advice could then have contributed to the care proceedings and the recommendation for the final care plan. 9.13  In fact, over two years later, when interviewed for this review they had still not had an assessment of their ability to protect Patricia or any detailed professional guidance about how to keep her safe in the long-term. Given the carer’s own learning difficulties, one must assume that particular efforts would have had to have been made to ensure that she understood what was being expected of her.   9.14  Care proceedings were planned from the mid-year point but were not actually commenced until the following March. Throughout this time there were core group meetings and review child protection conferences. Whilst various parties expressed concern for the children’s circumstances, nothing actually changed. This delay was unacceptable and was caused, in the main, by the problems within CSC referred to above. 9.15  This was a complex case without a clear way forward. Working out the best possible approach to take for these children was simply unachievable with changes in both social workers and team managers every few weeks.  9.16  This family were predicted to contest any proposed removal of the children into foster care and therefore the Court needed to have a clear narrative regarding the risks the children were subject to. Neither the social workers nor their managers were able to articulate this in a way which satisfied firstly their own legal advisers and secondly the Court. 9.17  Changing the category of the child protection plan for Patricia to ‘risk of sexual abuse’ when she moved to live with extended family following the concerns earlier in the year might have raised awareness across the partners and might, for example, have prompted the GP to contact CSC when Patricia was brought to the medical centre with symptoms that could have indicated signs of sexual abuse. 9.18  The information at that same conference that Patricia was taking ‘naps’ with her grandfather was rightly responded to by the conference chair and resulted in Patricia being moved. However, the overall independent scrutiny and challenge which should have been provided by the conference chairs was ineffective in that agreed actions did not take place, and nothing was done to expedite this lack of progress.  9.19  It is significant that the conference the following year was chaired by a new chair as the previous chair, who knew the case well, had left. Neither of these chairs used the existing escalation process. There was no systematic handover process when independent chairs changed, and no tracking system to ensure that concerns raised by independent chairs with social workers were escalated if they were not resolved. These issues have now been addressed. 10. Duration of the care proceedings 10.1  A Children’s Guardian was appointed at the commencement of the care proceedings. Once the care proceedings began Patrick was significantly affected by the uncertainty and the prospect of having to leave his grandparents’ home.  13  10.2  At the final hearing for Patrick a care order was granted, and he was removed from the care of the grandfather and placed in foster care. By that time, Patrick had lived with his grandfather for 18 months and was desperate to remain living with him. He had repeatedly asked for, but not received, an explanation from his social worker as to why it was not safe for him to stay with his grandad. Analysis The management of care proceedings 10.3  The guidelines for the length of time to be taken by care proceedings is 26 weeks. One of the reasons for this relatively short timeframe is because of the amount of preparation and planning that is required to take place in the ‘pre-proceedings’ stage. In this case, the pre-proceedings planning had been initiated some 10 months before the proceedings commenced, which was too long for a child to remain in a situation that was believed to be causing significant harm. This delay led directly to the Court’s refusal to remove the children once the proceedings were issued. Even with this lengthy preparation period, the proceedings themselves lasted 40 weeks which, once again, was well outside the timescales. 10.4  It is common practice when care proceedings are commenced to remove child protection plans. That was not possible in this case because the children remained within their extended family. As a result, the core groups and child protection conferences continued to run alongside the care proceedings.  Throughout this period concerns were raised about the ineffectiveness of the child protection plan, but the plan was not amended and nothing actually changed for the children.  10.5  Head teachers have spoken about being resigned to the fact that the staffing problems within CSC meant that they could rarely get hold of the children’s social worker. They did not consider using the escalation process. 10.6  Patricia’s statement and symptom of possible sexual abuse should have been investigated more fully given the existing concerns about the Aunt’s ability to protect her. As soon as Patricia moved to live with extended family members they should have been helped to understand the concerns about the grandfather.  It is unsurprising that extended family members do not intuitively understand the secrecy around sexual abuse and the way in which children and their carers can be groomed. In the absence of this work it is difficult to understand why Patricia was not spoken to and why a strategy discussion was not held. If the Children’s Guardian had requested the outcome of the enquiries she understood to be taking place, she could have challenged the social worker’s failure to investigate them thoroughly. This was a further missed opportunity to try to understand what either had or was still happening to Patricia.  10.7  It is not unusual for Local Authorities to decide not to oppose a Guardian’s recommendation in care proceedings, even when they disagree. This is because it is widely accepted that the Court generally favours the Guardian’s opinion over that of the Local Authority. However, given the ongoing and serious concerns about the Aunt’s ability to protect Patricia, held not only by the allocated social worker but by the whole core group, the supervision order provided the ideal means to provide the specialist help recommended by the Children’s Guardian and then to monitor the carers’ ability to understand and practise what they had learnt. If those concerns still existed as the supervision 14  order was about to expire, the Local Authority would have been able to evidence better their concerns and seek either a further extension of the supervision order or variation to a care order. 11. The Children’s Lived experience 11.1  What is striking about both the subjects of this review is that they were able and willing to talk to professionals about their life at home. Despite both children having quite significant language delay, their views were quoted on a regular basis by both the teachers at Patrick’s school and the workers at Patricia’s nursery and reported to their social worker.  11.2  Although Patrick’s vocabulary was described as immature and impoverished, his school reported that he had no difficulty in speaking his mind and expressing what he wanted and was generally a happy and cheerful child who had a good attitude to his work. He enjoyed talking to school staff and had a particularly close and trusting relationship with the SENCO, often calling into her room for a general chat. Patrick was often described by his school staff as “resilient”.  11.3  Patrick talked during the earlier period of this review about the violence at home when he lived with his birth father.  11.4  Similarly whilst there are numerous statements about Patricia’s speech delay, she was repeatedly quoted with regard to her descriptions of concerning events which might indicate sexual abuse, her sexualised behaviour and her distress whilst having her nappy changed. No attempts were made to explore the various statements that she made. 11.5  However during the times that the children were on child protection plans, few opportunities were taken by the allocated social workers to spend time with either of them in order to understand what was happening to them.  11.6  There are no records of any social worker speaking to Patricia in order to understand more clearly the very concerning statements she was making to nursery workers.  11.7  Later on, as part of the care proceedings, Patrick was asked about where he would like to live on several occasions and every time he was adamant that he wanted to remain with his grandparents. The Guardian even helped him to write a letter to the Court to that effect. Presumably Patrick was led to believe that some weight might be given to his views. However, given that both the Guardian and the Local Authority thought he should move, it was extremely unlikely that his wishes would be granted.  11.8  It is difficult to imagine how Patrick must have felt after months of anxious waiting to discover that despite everything he had said, he was to leave his grandparents’ care. Whilst this may have been the correct outcome in the long-term, Patrick deserved a more timely process which should have included explanations throughout the duration of the proceedings about why it may not be possible to grant his wishes. 11.9  Patrick never did understand why he might have to move. His teacher stated that once this possibility became known to him, ‘his educational progress slowed down, his cheerfulness diminished, and he began to complain of aches, pains and anxieties as well as a series of minor 15  injuries’. Whilst the circumstances were undoubtedly difficult to explain, this could not be sufficient reason for him not to be given an explanation. 12. Themes Emerging from the Review Understanding the risks posed by adult sex offenders 12.1  There is a difference between the risk of reoffending and the risk of harm that a convicted sex offender might pose to a child in his family. Whilst this statement might seem obvious, the only time in this case when this question was asked was on leaving jail as to the risk the grandfather might pose to the father. Without this knowledge, assumptions were made about the risks posed by both the grandfather and the father from Patrick’s birth until nine years later when a specialist assessment was finally completed. These assumptions changed over time and were likely to have been inaccurate throughout that nine year period. 12.2  Social workers were tasked with updating the risk assessments on the father and grandfather on seven occasions over a nineteen month period but they were not commenced until the care proceedings had been formally initiated. 12.3  Whilst there is some guidance within the LSCB’s child protection procedures for managing individuals who pose a risk to children, it describes the current arrangements for managing offenders and was not relevant to the circumstances of this case. Not only did the social workers not have the skills to update historic assessments, but funding for externally commissioned assessments was refused.  12.4  It is pointless for case conference chairs and managers to require social workers to update and review sex offender risk assessments if there is no means by which they can achieve this requirement. 12.5  Patricia was taken to the GP with symptoms that could have indicated sexual abuse on five occasions over a period of just under two years. Despite detailed information about the family situation, on not one occasion did any of the GPs who examined her consider that this might be a sign of sexual abuse. Similarly, when the GP records were reviewed by peers they also failed to identify the need for a proactive response. 12.6  New concerns regarding Patricia, which could have been indicative of sexual abuse, occurred towards the end of the care proceedings but it was not too late to advise the Court about this new information, provided it had been fully explored. Instead, CSC failed to investigate them, and the Guardian made assumptions about their origin which were not tested and may have been inaccurate. Given the general difficulty of establishing whether or not Patricia had been or still was being sexually abused, a more robust approach was needed.  Recommendations:   The Local Safeguarding Children Board (LSCB) should: I.  Ensure that the section of the child protection procedures regarding managing Individuals who pose a risk to children is reviewed and amended so that it includes guidance about: 16                a) Where practitioners can seek appropriate advice with regard to the risks posed by adult sex offenders and alleged sex offenders when they are not subject to MAPPA arrangements.               b) How practitioners can undertake ‘persons posing a risk assessments’. ii)  Amend the Child Protection procedures to state that when a child is subject to a child protection plan and a parent or carer is on the sex offender register, their sex offender manager should be a member of the core group. Children’s Services should: i) Develop criteria for the use of externally commissioned risk assessments.  The CCG should: i)  Review the training it gives to GPs with regard to identifying possible sexual abuse. CAFCASS should: i) Remind all Guardians that:  a) They must challenge the Local Authority if new information is received and appears not to have been fully investigated.    b) New information must be taken into consideration at all stages of court proceedings and especially when the parties have not agreed the final care plan.  The ease with which case records summarise historical risk 12.7  During the nine year period covered by this review, there were periods when historic risk was ‘lost’ and then re-emerged.  12.8  The agencies responsible for safeguarding these children have very different recording systems, most of which have changed significantly since Patrick’s birth. Within schools there is more than one system in use. Overall, practitioners were of the opinion that their current systems enabled them to quickly identify historic risk and significant past events. The exception was practitioners in community health and in the hospital, where the identification of significant events could only be achieved by scrolling through masses of historic information. 12.9  Given the frequency with which practitioners changed both within children’s services and the GP practice in particular, it is essential that records enable a new practitioner to identify quickly the risks in a particular case. Recommendation: The LSCB should seek assurance from partners that their case recording systems enable practitioners to easily identify significant past events. The category of the Child Protection Plan 12.10  The underlying concern in the two years that Patricia was on a child protection plan was the risk of sexual abuse and yet the category for both children throughout their time on child protection plans was ‘neglect’, the most commonly used category. If the category had been changed to ‘risk of sexual abuse’ for Patricia following the concerns of signs of possible sexual abuse it might have 17  raised the awareness of the GPs, thereby prompting them to not only consider the possibility of sexual abuse when they examined Patricia but also to alert CSC of her visits to them. Recommendation: The LSCB should advise conference chairs that when children’s names are on a Child Protection plan and there are concerns about possible sexual abuse, risk of sexual abuse is the most appropriate category. The use of written agreements 12.11 The use of written agreements has been a learning point from an earlier SCR. In this case there were two occasions when written agreements were drawn up with the family but on neither occasion was there any evidence that they were ever monitored or reviewed. 12.12 It is doubtful whether a written agreement can be very effective when a number of the family members have learning difficulties. Certainly, the family’s ability to read and understand any such agreement would need to be established before it is implemented. Recommendation: The LSCB should seek assurance that the current use of written agreements by Children’s Social Care is effective and appropriate. The role and function of Core Groups 12.13 Whilst Core Groups met regularly and were generally well attended, they were more a means of sharing information rather than actively monitoring, and where appropriate, amending the detail of the child protection plan. Their role was hindered by the behaviour of the father and grandfather, both of whom have been reported to be hostile and intimidating. It is easy to see how the various social workers struggled to both effectively chair and minute meetings where the way forward was complex to establish, and the family were so disruptive. If the behaviour of the family is compromising the role of the core group, this must be addressed. If one of the head-teachers had chaired some of the meetings, for example, more might have been achieved. 12.14 Core groups were rarely minuted and practitioners advised during the practitioner events that this is still the case. The practice was, and still is, for practitioners to make their own record of a meeting. This practice means that the family do not receive a record of the meeting and individual core group members may not have a shared understanding of what decisions have been made. Recommendation: The LSCB should:             a) Seek assurance from Children’s Social Care that there is a written record for all core group meetings.             b) Consider whether practitioners have sufficient guidance with regard to the management of disruptive family members within core groups. 18  Escalation 12.15 The use of the Escalation Policy has been widely promoted by the LSCB following similar findings from other SCRs. However, there were still practitioners at the meetings for this review who were unfamiliar with the policy. 12.16 In this case, colleagues in other agencies seemed to be resigned to the difficulties within CSC and saw little point in escalating their concerns. The schools for example tried to compensate for what they saw as the failure of CSC to deliver a consistent safeguarding service by supporting the children as best they could from their own resources. 12.17 Similarly within CSC, case conference after case conference identified that particular actions were needed and simply noted that they were outstanding when they had not been achieved by the next meeting. 12.18 There has to be a more robust approach to not only identifying actions that have not taken place but also to identifying the reasons behind the failure, together with remedial action to move the situation forward. Recommendation: The LSCB should continue to promote the use of its escalating concerns policy. The effect of organisational change & the role of the LSCB 12.19 The problems experienced by CSC during the latter part of the review onwards are well documented. There is little doubt that the repeated changes of both social worker and team manager throughout this time prevented these children from being effectively safeguarded. There was similar turbulence within the medical centre, with seventeen different GPs having contact with the children and adults who cared for them. It is hardly surprising that each of those personnel did not gain a full picture of this complex family history before dealing briefly with the family. 12.20 What is more surprising is that the LSCB was not aware of the effects of the changes within Children’s Services and that other Board members were not escalating their concerns to the Board. The LSCB’s slow response and lack of robust challenge to the impact of these changes has been addressed as part of an overall effectiveness plan. Measures have been put in place to ensure that the LSCB can now monitor the effectiveness of front line practice and does so. 13. Action that has already been taken   With regard to Patricia   13.1 The police have revisited all the existing information with regard to Patricia, her statements and her behaviour. 13.2 At the first practitioner meeting, professionals continued to express their concern about Patricia and her carers’ ability to protect her. As a result of this concern, there was a strategy meeting and a case conference. Within CSC 19  13.3 The plan template for Child Protection and Child in Need Plans has been reviewed and now focuses much more on outcomes as well as building on strengths within the family, based on the Signs of Safety Model.  13.4  Revised terms of reference have been drawn up for Legal Planning Meetings to ensure that there is an up to date assessment before entering the legal arena. There is now a case progression manager in post who is responsible for tracking all LPM decisions. Feedback suggests that this provides workers with clear guidance and is proving effective in reducing drift. 13.5  The introduction of a single assessment team has resulted in assessments of higher quality, and more manageable caseloads for social workers managing child protection and care proceedings. 13.6  Action has been taken to stabilise the workforce and address performance problems, including at management level with improved frequency and effectiveness of supervision and management oversight. 13.7  Advanced Practitioners have added capacity for reflective supervision and also provide a practice lead on a range of issues. 13.8  A new case escalation process is in place for independent case conference chairs 13.9  Senior managers have begun to move away from the previous ‘top down’ management style and to encourage more authoritative social work practice at the front line. Within the Hospital 13.10 Training has already taken place within the Maternity Service for staff ensuring that concerns are now passed to the Safeguarding Midwifery Team.  An electronic Records System for safeguarding cases was introduced during the period under review.  All cases and communications are now recorded on a secure database and are immediately accessible to members of the team.  13.11 Training has already been undertaken within the Emergency Department regarding staff awareness of the need to complete referral forms when concerns are raised regarding an adult’s presentation to hospital.  A prompt has now been included with Emergency Department admission paperwork to remind staff to complete a referral for when safeguarding concerns are present. Monthly spot check audits are undertaken. General Practice 13.12 GPs have been asked to record who brought a child to the surgery and whether that person had parental responsibility.    20  14. Recommendations  The Local Safeguarding Children Board (LSCB) should: 1. Ensure that the section of the child protection procedures entitled ‘Managing Individuals who pose a Risk to Children’ is reviewed and amended so that it includes guidance about: a) Where practitioners can seek appropriate advice with regard to the risks posed by adult sex offenders and alleged sex offenders when they are not subject to MAPPA arrangements. b) How practitioners can undertake ‘persons posing a risk assessments’. 2. Amend the Child Protection procedures to state that when a child is subject to a child protection plan and a parent or carer is on the sex offender register, their sex offender manager should be a member of the core group.  3. Seek assurance from partners that their case recording systems enable practitioners to easily identify significant past events.  4. Advise conference chairs that when children’s names are on a Child Protection plan and there are concerns about possible sexual abuse, risk of sexual abuse is the most appropriate category. 5. Seek assurance from Children’s Social Care that there is a written record for all core group meetings.  6. Consider whether practitioners have sufficient guidance with regard to the management of disruptive family members within core groups. 7. Seek assurance that the current use of written agreements by Children’s Social Care is effective and appropriate. 8. Continue to promote the use of its escalating concerns policy. Children’s Services should:  Develop criteria for the use of externally commissioned risk assessments.  The CCG should:  Review the training it gives to GPs with regard to identifying possible sexual abuse. CAFCASS should: Remind all Guardians that:    a) They must challenge the Local Authority if new information is received and appears not to have been fully investigated.   b) New information must be taken into consideration at all stages of court proceedings and                                especially when the parties have not agreed the final care plan.   