Inflicted abdominal trauma to a 6-year-old child, in June 2014 while in the care of mother's partner. Child G lived with their mother, her partner and younger half-sibling, while two maternal half-siblings lived with a family member following a series of safeguarding concerns prior to the birth of Child G. In 2012, mother of Child G allocated a home in Oldham, to assist in moving from an abusive relationship. Over the following ten months, Child G's school made referrals to children's social care, resulting in an initial assessment. In June 2014, Child G presented unwell at school and was taken home. After a serious episode of vomiting, Child G was taken to the GP and then to the regional children's hospital by ambulance. Doctors concluded Child G had been subject to inflicted abdominal trauma, and referred the findings to children's social care. Child G and their half-sibling were placed in foster care. Child G later disclosed that their mother's partner had caused the abdominal injuries in June 2014. Mother's partner charged with assault of Child G and faces criminal trial. Findings include: professionals engaged in multi-agency working must be attuned to non-verbal methods of communication and advocate for a child that is not being heard. Recommendations include: LCSBs must ensure GPs are part of multi-agency safeguarding arrangements; and working directly with men in families must be embedded in professional thinking. Please note that this report was written in July 2016 but was published in February 2018.
      
 Title:  Serious case review report: Child G. LSCB: Oldham Local Safeguarding Children Board Author: Oldham Local Safeguarding Children Board Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                  Serious Case Review Report Child G July 2016               This report will be published in line with statutory guidance. In order to preserve the anonymity for the children in this family, the author has:  used initials to represent people  made no reference to the gender  of children  avoided where possible the use of exact dates  not used any details about local services which could lead to  recognition of the children and family    1. Introduction   1.1 This Serious Case Review (SCR) concerns Child G who was 6 years old when a serious physical non-accidental injury was discovered.  Child G is the third of four children born child to the mother MG, all of the children have different paternity.  Child G has two maternal half siblings who are several years older and live with a close family member following a series of safeguarding concerns prior to the birth of Child G.  1.2 Child G lived with MG and a half sibling S1 who is 13 months younger in age. All four children were born whilst MG lived in a neighbouring Local Authority.  None of the children’s fathers had any substantial involvement in the children’s care, but following the birth of the Child G and S1, MG had a partner MP1 who lived with the family for a period of time.  The relationship between MG and MP1 was characterised by domestic abuse, and in order to assist MG moved away from an unhealthy relationship, MG was allocated a home in Oldham in 2012.  Around this time, MG also met a new partner MP2, and for several months the family moved between his home and their property in Oldham.  MG, MP2 and the two children permanently settled in Oldham in January 2013.  Child G transferred to an Oldham School aged 4 years and 8 months.  1.3 When MG and MP2 first met, MP2 was full time employed whilst MG was a full time carer to the children. After moving to Oldham, MG began working between the hours of 8am - 2pm and MP2 ceased working and became the primary carer for the children.   1.4 Over the following ten months, the School made a total of three referrals to Children’s Social Care, the third of which resulted in an Initial Assessment and a Parenting Worker allocated for a period of three months.  1.5 Six months later in the summer term of 2014, Child G presented as unwell in School and was taken home by MP2.  Concerned by a serious episode of vomiting, Child G was taken to the GP by MG.  Child G was then taken directly to the regional children’s hospital by ambulance.  The symptoms mimicked appendicitis and Child G was treated with an appendectomy, however, once completed the symptoms did not diminish.  A further scan was suggestive of a condition called malrotation and further   surgery took place.  During the surgery, it was discovered that malrotation was not present but that Child G had severe bruising to the duodenum which was the cause of the vomiting and abdominal pain. Paediatric opinion concluded that the most likely explanation for the medical findings was that Child G has been subject to an inflicted abdominal trauma which on balance of probability, and in the absence of any other explanation, was best explained as an inflicted injury. 1.6 The regional Children’s Hospital referred their findings to Children’s Social Care, but were concerned that the response was not as they expected nor in keeping with Section 47 of the Children Act 1989 and associated multi-agency child protection procedures.  1.7 Once the facts were properly established, as a consequence of the injury to Child G, Child G and S1 were placed in foster care.  Child G was six years old and the foster carers reported a number of issues of concern for Child G, this included low weight, speech which was unitary words rather than sentences, a constant need for reassurance and physical affection and a severe lack of confidence which affected the child emotionally and practically.  In contrast, it was deduced that S1 was a much favoured child and that as a consequence of different parenting approaches, their sibling relationship was problematic.  1.8 Once in foster care, Child G’s developmental progress improved considerably, the child gained weight, was managing increased self-care tasks and reaching increased educational attainment.  The sibling relationship improved with both children having a more equal status.  As Child G grew in confidence, the child disclosed that MP2 had caused the abdominal injuries in June 2014.  1.9 MP2 was charged with Assault of Child G under Section 20 Offences against the Person Act 1861.  2.      Decision to Hold Serious Case Review 2.1 The Serious Case Review sub group considered the issues relevant to the case and a      recommendation was made to initiate a Serious Case Review.  The Sub Group was influenced by the following issues:    That Child G was a 6 year old child who was diagnosed as in receipt of a serious and potentially life threatening non-accidental injury;  That concern existed about how agencies had worked together when the serious incident occurred;    That although Child G was not known to Oldham Children’s Services at the time of the incident, previous referrals had been made which indicated prior concerns about physical abuse;  MG had extensive contacts with the police, frequently related to incidents of domestic violence involving a series of partners. 2.2 The Chair endorsed this recommendation and a notification was made to the National Panel about the intention to hold a Serious Case Review.  3.       Methodology  3.1    Oldham Local Safeguarding Children Board appointed an Independent Reviewer to facilitate the Review and provide an Overview Report.  This Review was overseen by a Panel of senior officers from participating agencies which included:  Greater Manchester Police   Oldham Council Children’s Social Care   Pennine Care Foundation Trust   Central Manchester Trust  Oldham Education Safeguarding Advisor for Schools   The OLSCB Business Manager   CCG  Designated Doctor  3.2       Working Together 2013 requires SCRs to be conducted in a way that:  recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;     seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  This SCR was undertaken in line with statutory guidance.  The review focussed on what happened to Child G, but also set out to understand some of the factors that influenced professionals to act as they did or why they may not have acted at all.    3.3       The Review Panel did not set detailed Terms of Reference as they did not want to pre-determine the most significant areas of practice, preferring the key issues to unfold from the analysis of emerging information. The Panel was however keen to explore the following key areas:   To what extent were indicators of risk present and adequately responded to by  agencies working with Child G;   Were multi-agency processes utilised to support agencies to work together to meet Child G’s needs;   Did multi-agency services work together to respond to the critical incident in relation to Child G.   3.4 The Review focussed on the multi-agency activity over a period of eighteen months between January 2013 and June 2014.  The Review Panel made a considered decision to begin the time period at the point Child G moved to Oldham as it was believed that this would generate the best local learning and provide the opportunity to focus on local multi-agency working.   3.5     At the start of the Review, each agency submitted a timeline of interventions alongside a short report which contained a reflective narrative of the single agency responses to the needs of Child G.  The individual agency timelines were combined to illustrate the multi-agency activity, who knew what and when.  3.6 Practitioners were invited to contribute their views directly to the review process by meeting with the Independent Reviewer and a panel member. The following practitioners undertook such a conversation:  Children’s Social Care Manager - MASH Team Manager, Social Work Assessment Team Manager, Social Worker 2, Senior Practitioner;     Pennine Care Foundation Trust – School Health Advisor, Health Visitor, Safeguarding Advisor;  Primary School - Acting Head Teacher, Assistant Head Teacher (designated safeguarding lead);   Greater Manchester Police - Detective Sergeant, Public Protection;   Central Manchester Trust – Paediatrician. 4.  Engagement of Family Members  4.1 The Independent Author was keen to involve both MG and MP2 in the Review.  Early into the Review the Panel was advised that MP2 had been charged and was pleading not guilty to a charge of assault of Child G, and that MG would be a key witness at the trial.  As such a request was made not to discuss the case in detail with either party until the criminal trial was concluded.  4. 2 A court date is in July 2016 when a date for the trail will be set, this could be in 2017.  5. Parallel Processes 5.1 Child G and S1 have been the subject of public law proceedings.  During the proceedings neither MG nor MP2 have accepted responsibility for causing or having knowledge of the injuries to Child G.  5.2 MG and MP2 have been subject to an ongoing police investigation and MP2 now faces a criminal trial.  6. Overview of what was known to Agencies 6.1 MG, MP2, Child G and S1 moved to Oldham on a permanent basis in January 2013. Between 2004 and 2008, MG and her two older children had intermittent involvement with Children’s Social Care in a neighbouring Local Authority and on one occasion, when her second born child was left with an unsuitable babysitter for a lengthy period, Police Powers of Protection were exercised.  Ultimately the two older children were made subject of a Residence Order to a family member.  Two years before the birth of Child G, records describe MG as having sporadic contact with her two older children because of a chaotic lifestyle.    6.2 Prior to moving to Oldham, there are numerous records of Police being called to instances of domestic abuse between MG, various members of her family and several different partners including the fathers of her children.  GMP identified eleven incidents of domestic abuse following the birth of Child G and S1 and found that the children were recorded as being present at three incidents.  One incident described that MG was strangled in public in front of Child G at the age of four years.  No referrals were made by the Police to other agencies on the three occasions the children were known to be present.  There are also a number of occasions when MG reported harassment but did not attend follow up appointments; similarly, referrals in respect of these incidents were not made to Children’s Social Care.  MG was subject to ongoing harassment by MP1 after the relationship ended.  6.3 Prior to Child G’s birth in a neighbouring Local Authority a referral was made by health services to Children’s Social Care which expressed concern that MG was drinking throughout the pregnancy.  An Initial Assessment was undertaken in the knowledge that MG had two children living away from her care and a decision was made for No Further Action.  Child G was born with no additional involvement from specialist safeguarding agencies other than what would be usual for universal services.  S1 was born very premature just thirteen months after Child G.  6.4 The first contact with Child G in Oldham was a movement-in visit by the Health Visitor who ascertained that the family had moved to the area because of fleeing domestic abuse and that that MG had formed a new relationship.  Child G was 4 years and 7 months and was referred for speech and language therapy, audiology and the children’s outreach team because of concerns about the child’s development.  Child G commenced School at around the same time.  6.5 In the following two months, the Health Visitor experienced four no access visits to pre-arranged home visits and the nursery placement that she had organised for S1 was not taken up.  The School Nurse followed up on Child G’s health history and found that Child G has been previously referred for speech and language therapy but that MG had not engaged with Child G’s previous school.  The school’s Special Educational Needs Co-ordinator (SENCO) expressed concern about Child G’s   presentation in school.  This included appearance, punctuality and behaviour which included a tendency to bark like a dog.  6.6 Child G had a health assessment completed by the School Nurse in school.  MG returned a health questionnaire which had been sent to her by the School Nurse which stated that Child G was naughty at home.  The School Nurse noted that Child G was lively and chatty, but that speech and language was poor.  A further referral was made for an orthoptist and audiology appointment as well as for a Special Educational Needs Medical Assessment.  After some failed attempts to speak with MG by telephone, the School Nurse sent a text requesting a conversation with MG which was responded to.  The School Nurse advised of the appointments and urged MG to make an appointment with the School to discuss any worries she may have about Child G’s behaviour.  6.7 The following month (April 2013), Child G attended a Paediatric Audiology Clinic for a hearing assessment, the results were satisfactory and no follow up was needed. 6.8 In May of 2013, the MG’s previous partner MP1 was given a suspended prison sentence and a five year Restraining Order in respect of offences towards MG.  6.9 Six months after moving to Oldham, Child G was registered with a GP.  GP records note that the School Nurse was following up concerns about learning difficulties and speech and was aware that MG had no red child health book and therefore the child may need vaccinations.  6.10 In June, an anonymous call was made to the police reporting that MG had slapped [Child G] so hard it made the child spin round and fall down three concrete steps. The police spoke with MG and Child G and believed this to be a malicious call which related to MP1.  MG stated she had also been receiving unwanted pizza and taxis to her address.  6.11 During the School summer holiday, Child G was seen with MG by the Community Paediatrician and a variety of tests were undertaken.  A request was made for the SENCO to refer to an Educational Psychologist to begin the process of Education Statementing.  Child G was assessed as needing Speech and Language therapy and placed on a waiting list for the service.    6.12 One month into the School term, Child G was noted to have a black eye, an older bruise to the side of the face and a mark under the chin.  Child G said to a Teaching Assistant that [Child G] ‘felt angry when my Dad hits me’ and that this had happened the previous night. This information was referred to Children’s Social Care. MG stated that the bruising had been caused by S1 hitting Child G.  Children’s Social Care advised the School to commence a CAF assessment with a view to identifying possible parenting issues.  6.13 Eight days later, a second referral was made by the School to Children’s Social Care when Child G was noted to have two faded marks to the neck which it was thought resembled grab marks.  At the same time, S1 was observed to have a plaster of paris to the leg. Child G had stated that the marks were from having fallen down a staircase the previous day. The School also reported that the Child G was showing some odd behaviour such as hiding under tables.  An Initial Assessment was undertaken by Children’s Social Care, and both Child G and S1 were spoken to, Child G indicated that the marks had been caused by a child in School and the social worker considered that the marks did not appear to have suspicious causation.  The Initial Assessment noted that Child G had speech, language and cognitive developmental delay which results in frustration and lashing out and that MG requested support with parenting skills.  The assessment concluded that sufficient explanation had been given to account for the bruising and that observations of interaction between MG and the children was positive. A plan was formulated to allocate a Family Support Worker for a short term piece of work.  The Family Worker made four visits to the home to discuss routines and behaviour management before closing the case to Children’s Social Care. The work of the Family Support Worker occurred without the case management of a Social Worker and without using a multi-agency Child In Need approach.  The School subsequently sought support from the CAF team but was advised that due to the volume of Family CAF Assessments being undertaken that they are unable to support the process.  6.14 Two weeks prior to Christmas 2013, Child G was taken by MG to accident and emergency at the local hospital because the child was vomiting with streaks of blood.  Child G was discharged for GP follow up and the letter from Accident and   Emergency to the GP stated that Child G was generally unwell and contained the following comment – ‘GP please do some routine bloods on this patient as presents with multiple bruises’.  Following this there are no records of bloods having been taken; the request was considered to be unusual as bloods are not taken from children under 8 years in the GP surgery.  One week later, after getting no response to phone calls, a letter was sent to MG requesting that she contact surgery for follow up regarding Child G’s recent attendance at A&E.  There is no indication that MG’s failure to respond was further followed up,  that Child G was referred for blood tests, or that that any clarification was sought about the presence of bruising.  6.15 In the first month of the New Year, S1 was taken to Accident and Emergency with a cut to the face which was said to have happened by falling on the radiator, and Child G was taken to an emergency GP appointment because of a further episode of vomiting and abdominal pain. The GP diagnosed viral gastroenteritis and MG was advised to return if the symptoms did not resolve within two days.  6.16 In February the Police were contacted by a neighbour of the family who reported hearing shouting and children crying inside the address, with a male shouting ‘get off them and get out of my face.’ When the police attended MG refused to give her name or that of the children, and stated that the neighbour was causing her problems. The incident was closed, deemed to be malicious and recorded as a verbal augment, with no further actions. This information was not shared outside of the Police.  6.17 In March, Child G was again taken to Accident and Emergency with a temperature and sickness and was discharged with minor medications.  Child G was seen for a second time by the Community Paediatrician for medical follow-up and review associated with the education statementing processes.  6.18 In May, there was evidence that MP1 had breached a Restraining Order by contacting MG over a social networking site. That same month, it was noted that MG arrived at School with a black eye.  6.19 A CAF meeting took place in School with the School Nurse, MG attended.  MG stated that she was struggling with Child G’s behaviour and wanted support.  MG agreed   that a referral should be made to a Consultant Paediatrician with an accompanying report from the School.  The School Nurse followed up the speech and language appointments and it was confirmed that Child G was due to be seen in 6-8 weeks.  6.20 In the month leading up to the serious incident, Child G was noted to have a bruise to the cheek on two separate occasions, and that the School had put in place that a Parent Support Worker who would visit the family home to meet with MG.  6.21 On the day that the serious injury came to light, Child G and S1 were brought to School by MP2 approximately one hour late.  Child G began to complain of stomach ache and appeared in discomfort before vomiting. School staff noted the vomit to be a particularly concerning colour.  The School contacted MG and MP2 collected Child G from school. It was later that afternoon when MG took Child G to the GP surgery from where the child was transferred and admitted to the Regional Children’s Hospital.   6.22 Four days after Child G’s admittance to hospital and after a second episode of surgery whereby the internal bruising was unexpectedly discovered, the Consultant Paediatrician requested that the ward staff make a referral to Children’s Social Care. The referral explained that Child G had been admitted to hospital and had to have bowel surgery as a response to acute abdominal pain and that a Strategy Meeting was required.  The hospital was concerned by the response from Children’s Social Care who determined that a Strategy Meeting was not necessary. The Consultant Paediatrician enlisted the support of the Designated Nurse for Safeguarding within the Hospital Trust who in turn contacted the Named Nurse in Oldham.  The Paediatrician sent a second more detailed referral outlining the nature and potential causes of such injuries.  The Named Nurse in Oldham escalated the concern about the response to Children’s Social Care, and a telephone conversation took place between the Social Worker in the MASH team and the Consultant Paediatrician.  The Consultant was told that Children’s Social Care did not consider a Strategy meeting was necessary at this stage because no disclosure had been made by Child G and therefore other explanations, such as the first surgery could be viable.  6.23 It is specifically recorded in Children’s Social Care records that the manager of the MASH Team made a decision that a Strategy meeting would not be convened but   that a Social Worker and Police Officer would attend the hospital to ‘gather more information’.  In the event three officers attended the Hospital, a Police Sergeant, a Social Worker and the Family Support Worker that had been previously known to the family.  6.24 The Paediatrician recalled that a discussion took place in a corridor seating area about her findings and that she impressed upon the officers the need for a Strategy Meeting.  Although a decision was made not to convene a Strategy Meeting, the discussion was recorded by Children’s Social Care on a proforma recording template used for the recording of Strategy Meetings which the Paediatrician indicated she was not aware of and had never received a copy.  The Detective Sergeant’s view was that a discussion took place but not a Strategy Meeting.  This document recorded the seriousness of the injury, the fact that there was no explanation and therefore it was most likely non-accidental and that further investigation and Strategy Meeting was required.  6.25 Whist in attendance at the hospital, the Detective Sergeant consulted with a Detective Inspector and Police Powers of Protection were invoked for both children. Child G remained in hospital whilst S1 was placed in foster care. Three days later both children were made subject of an Interim Care Order and on this date restrictions to parental unsupervised contact were applied.  6.26 A Strategy Meeting took place four days after the Police and Social Worker had attended at the hospital, the record of this meeting states that it was a second Strategy Meeting. The meeting was attended by the Social Worker, two Police Officers, the School, the School Health Advisor and Paediatrician.  During this meeting, the Consultant Paediatrician raised concerns that child protection procedures were not adhered to following the referral to the MASH and that restrictions to parental contact should have been applied at an earlier point.   7. Analysis The examination of multi-agency working in respect of Child G has identified several inter-agency issues that need to be addressed alongside significant reflections about how judgements were applied at key points of interventions. The analysis is   structured around the particular questions set by the Review Panel and incorporates the key issues that have come to light throughout the Review.  The analysis is drawn from the agency’s written contributions to the Review, the reflections of practitioners, the discussion that occurred within the Review Panel as well as the Reviewers own contributions. 7.1 To what extent were indicators of risk present and adequately responded to by agencies working with Child G  7.1.1 Child G was the subject of a number of referrals to Children’s Social Care which commenced before birth, both prior to and when living in Oldham.  In the eighteen month period  that Child G was permanently resident in Oldham, three referrals are made to Children’s Social Care, two by School and one by a Paediatrician all of which followed observation of physical injuries.  In addition, two referrals were made to the Police by members of the public, neither of which was shared across agencies beyond the Police Force.  When Child G commenced School, teaching staff quickly identified concerns about the impact of a speech and language delay, impairment of cognitive functioning and some unusual behaviour such as hiding under tables and barking like a dog.  Child G was a child high on the radar of the School and they were concerned about Child G long before they considered they had evidential reason to make a referral to Children’s Social Care.  7.1.2 There was good liaison between community health professionals, the Health Visitor had been alerted that the family had moved into the area by their previous Health Visitor and ensured an early contact was made to assist the family to access relevant health and support services.  The Health Visitor alerted the School Nurse of Child G’s family history and heath needs and the School Nurse followed up on the health issues as soon as Child G began School in Oldham.  The School Nurse enlisted additional support by referring Child G for speech and language therapy and by commencing the process of paediatric assessment for a Statement of Special Educational Needs.  Aware that MG had not previously attended Speech and Language therapy with Child G, the School Nurse worked hard to engage MG to access appointments, which was generally a positive strategy.     7.1.3 The Health Visitor and School Nurse were aware that MG had moved to the area because of fleeing domestic abuse in the previous locality, and although diligently following up health issues for Child G, a wider safeguarding perspective would have provided a greater focus on MG’s judgement and vulnerability in terms of relationships and the impact this could have on the safety of herself and her children.  MG had a well-documented history in successive relationships of being both a victim and perpetrator of domestic abuse, and her ability to make safe choices was undoubtedly compromised by her life experiences and the impact many years of abuse had on her expectations of a relationship.  The relationship with MP2 quickly became a co-habiting relationship, and shortly after MP2 took over care of the children and the home whilst MG became employed. The agency records do not signify that professionals at that time were attuned to the risk of recurrent domestic abuse and possibly they were overly re-assured by the presence of a new partner when risk was perceived to be from the previous partner.  7.1.4 Child G did not come to the attention of any other safeguarding agencies until the summer of 2013 when an anonymous call was made to the Police which stated that that MG had slapped Child G and thrown the child into a taxi.  Police Officers spoke with MG and saw Child G and accepted MG’s testimony that the call was likely to be malicious and probably related to her reported ongoing harassment by MP1.  Clearly this was a judgement applied by the Police Officers responding at the time, however, the information gave quite a precise description of how and when this incident took place, and no further enquiries took place either with other safeguarding agencies or by way of investigation such as the local taxi firms.  No referral was made to other agencies and this limited the potential for professionals around Child G to, at a minimum, be additionally alert to signs of physical or emotional distress.  In essence, the Police relied solely on the self-reported information of MG which determined whether information sharing was appropriate. This episode was dealt with by a non-specialist officer and no coding was applied for the matter to reviewed by the Police Vulnerable Persons Unit. 7.1.5 At this time, and particularly following the summer holidays, both Child G and S1 remained high on the radar of concern by the School who were becoming   increasingly concerned that Child G was frequently presenting at School with bruises and injuries that had a ‘plausible’ explanation by MG.  When Child G presented at School with a black eye and an old bruise to the side of the face, and stated to a Teaching Assistant that [Child G]  “felt angry when my dad hits me”, and that this had happened the previous night, a referral was made to Children’s Social Care.  7.1.6 Without a doubt this referral should have resulted in a Section 47 investigation and a Strategy Meeting should have been convened.  The fact that the child had an injury and had made a direct allegation about being hit by a parental figure should also have also alerted professionals to the need for a medical consultation.  Child G could have had injuries not visible when clothed or noticeable to an untrained eye.  At the time of this referral a newly formed Multi-Agency Safeguarding Hub (MASH) had just become operational, with representatives of Police and Children’s Social Care co-located in a first response service. There is no information to suggest that this referral was discussed with the police, but this may well have occurred without being formally recorded. The failure to invoke safeguarding procedures is a flawed judgement and although feeling powerless but to accept the advice, it was clear that the School did not agree with the response when asked by Children’s Social Care to explore the information further with the child. This advice compromised safeguarding procedures in a number of ways. The lack of a Strategy Meeting meant that information known to different agencies was not shared effectively, no joint police investigation occurred and had the child made further disclosures this could have been declared criminally inadmissible without an interview conducted under achieving best evidence conditions.  The response to this referral was misguided by Children’s Social Care, and, although dis-satisfied by the response no effective challenge was pursued by the School.  7.1.6    The School did make a second referral eight days later when Child G presented with another old bruise and marks to the face which they considered had the appearance of grab marks.  Child G told a teacher that the marks had been caused by a child in the classroom.  This referral also referenced the School’s concerns about Child G’s behaviour, and stated that the child was acting strangely in school, refusing to follow normal class routines, hiding under a table, not wanting to talk to familiar adults and   refusing to go for dinner.  This referral presented an opportunity to review the response one week earlier and address the flawed response.  For the second time, Children’s Social Care did not initiate a Section 47 investigation but did commence a single agency Initial Assessment.  The Initial Assessment focussed almost exclusively on MG’s response that she was struggling to manage behavioural challenges by Child G, and disregarded completely the testimony of Child G that the child was hit by Dad. MP2 was not spoken to as part of the Initial Assessment and this was a significant error given what had been said by Child G and the fact that MP2 provided much of the children’s day to day care.  The Initial Assessment permitted MG to direct the course of action when her testimony that Child G was frustrated and lashed out because of speech difficulties was accepted without really considering this information against what was observed by the school.  The observations by the School suggested a distressed and troubled child.  7.1.7   The tendency to overlook the role that men play in families is well documented in many multi agency reviews, and has been previously identified in an Oldham Serious Case Review Child A.  The NSPCC’s analysis of Serious Case Reviews around thematic issues from analysis of Serious Case Reviews found that two categories of hidden men emerged, men who posed a risk to a child which resulted in significant harm and men who were capable of protecting and nurturing the child but were overlooked by professionals. In this instance, it may be that because MG had sole parental responsibility for Child G MP2 was not considered as significant and this became a reason not to involve him, it could equally be however that MG was guarded and deliberately misleading in her response to the issues of concern in an attempt to deter professionals from examining deeper the questions raised by Child G’s statement about MP2.  Whatever the reason for this, the social work intervention should have been sufficiently alert to the dangers of not involving males in assessments, in particular the risks from men involved with children’s mother who don’t have paternity and the impact this can have on understanding or misunderstanding the family dynamics, and ultimately the ability to achieve safety for the child.  Men in families need to be seen as critical to assessments whether or not they have parental responsibility and this needs to become institutionalised in   services.  It is hard to appreciate at this distance from practice why Child G’s statement about MP2 did not alert professionals to the significance of his presence in the child’s life.  This concurs with the Ofsted report, The Voice of the Child: Learning the Lessons from Serious Case Reviews (2011) which concludes that there have been many cases where professionals have evidence from the child’s perspective, but do not listen to what the child has told or interpret the evidence in a way that safeguards the child.  Practitioners are starkly reminded in this report to ensure actions take account of children’s views and to recognise behaviour as a means of communication.  This was a significant omission, as it took a very serious injury and several months in a safe and secure foster placement before Child G found a voice to talk about MP2’s behaviour towards the child.  7.1.8 Given that the Initial Assessment concluded that further work was necessary by the Family Support Team from Children’s Social Care, this would suggest that the conclusion should have resulted in a further period of assessment which would include a Core Assessment and an analysis of the extent to which the Family Support work was considered to address the needs of Child G and the family.  The decision to arrange four sessions of family support work was a plan with no value, without any case management review of its effectiveness or indeed any deeper analysis of the family functioning or parental need for change, the impact and outcome of this work was meaningless.  A robust Core Assessment at this time which effectively consulted with partner agencies would have exposed a number of significant risk factors:  MG’s history of domestic abuse and ability to make safe relationships with limited recognition of the impact upon her children;  That MG had been unable to protect her older children from significant harm;  That MP2 had joined the family in a cohabiting relationship with MG whilst she was highly vulnerable;  That MG had a history of poor engagement with child led services;  That Child G exhibited behaviours at School suggestive of distressed child and was articulating fear of MP2.  The absence of a Lead Professional and the precipitous closure by Children’s Social Care meant that there was no mechanism in place whereby information was shared   on a continuing basis.  This was particularly significant two months later when Child G presented at A & E with gastric pain, and once again safeguarding procedures were not invoked despite medical concern that Child G had unexplained bruising.   7.1.9 Child G’s presentation at the local hospital in December 2013 was precipitated by symptoms similar to those presented when the internal bruising was discovered in 2014.  The absence of any specific explanation or diagnosed condition, along with the hospital identifying that Child G had ‘multiple bruises’  begs the question as to whether undetected injuries could have been present at this time.  Hospital records offer no other information about the ‘multiple bruises’ and no explanation as to why this finding was not further investigated or referred through child protection procedures by the hospital.  The hospital made no welfare checks or referrals to any other agencies, and had this occurred then the information known to Children’s Social Care two months earlier could have been factored into further analysis and judgement, this should have added weight to the need for a Strategy Meeting which in turn would have revealed the anonymous allegation to the Police.  Between October and November 2013 there were three points of lost opportunity to bring together information known across three core safeguarding agencies which, if carefully analysed,  would have raised greater questions about Child G and the child’s experience of family life.  The common denominator across all agencies was a lower level response than was indicated, and this raises concerns about the application of thresholds across the multi-agency partnership.  When the School attempted to initiate a CAF with the support of the CAF team they were unable to achieve this but continued to pursue this process but with a sense of frustration that they were not achieving any true engagement from MG.   7.1.10 The first referral to Children’s Social Care by the Paediatrician when Child G was substantially injured outlined that Child G was in the regional specialist hospital under the care of an experienced Paediatrician.  The referral to Children’s Social Care was made by Child G’s ward staff on 23.6.2014 at 10.30am and the response was escalated to the Paediatrician later that afternoon.  The Paediatrician spoke with a Duty Social Worker in the MASH Team who she recalled was being advised by the   manager whilst on the telephone.  The Paediatrician asked for a Strategy Meeting to take place to commence a joint investigation under Section 47 Children Act 1989. Records from the hospital and within Children’s Social Care both indicate that the decision by Children’s Social Care was to refuse a Strategy Meeting because Child G had not made an allegation.  Frustrated and somewhat alarmed by this response, the Paediatrician reflected on why Children’s Social Care would make such a decision and decided to send a second referral written on a multi-agency referral form to ensure clarity; this was sent by e-mail to Oldham Children’s Social Care at 9am on 24.6.2014. The referral stated that Child G had severe unexplained bruising of the bowel that required bypass surgery, and that with no history of trauma and no medical explanation, and given that such an injury is typically caused by blunt force trauma, there is a concern that a history of inflicted injury is being withheld.  The referral went on to state that no disclosure had been made by Child G who had speech difficulties and was very distressed. The Paediatrician had enlisted the support of the Named Nurse in Oldham who had established through the School Nurse that there was no history of trauma whilst at school.  The multi-agency response to this critical incident is considered in 6.3.   6.2 Were multi-agency processes utilised by agencies to work together to meet Child G’s needs  6.2.1 The LSCB in Oldham has in place comprehensive policies and procedures to support multi-agency working through a continuum of response to need; this includes the Common Assessment Framework (CAF), Child in Need and Child Protection procedures.  Implemented effectively, they support and guide strong multi-agency partnerships around the child.  Multi-agency working relies on sharing of key information across agencies, robust assessment and analysis of risk with targeted planning and review of progress towards the objectives set out in a child’s plan.  6.2.2 There is evidence of good information sharing between health professionals and between health and education, particularly in relation to pursuing a Statement of Special Educational Needs.  There were however three points of missed opportunity to share information that could have benefitted Child G, namely the two referrals to   the Police and the concern expressed by the Hospital that Child G had bruising that required further exploration.  This request to the GP to follow up with blood testing also became lost to follow up when MG failed to respond to contacts.  6.2.3 The opportunity for agencies to work more effectively together was primarily lost through some key decisions taken in Children’s Social Care, these being the failure to identify the referrals from the School as Section 47 investigations and the closure of the case despite identifying further work with the family was necessary.  A further significant lost opportunity was the approach taken by the Hospital following the presentation at the Accident and Emergency Department when concerns and questions about bruising were only further raised with the GP.   The concerns of the School did not diminish, but they were frustrated in their subsequent efforts to achieve an effective multi-agency approach through CAF because of the lack of parental commitment to the process.  Establishments such as schools can feel more isolated in pursuing concerns about a child once a determination is made there is no role for increased intervention or conversely can be  falsely re-assured  that their concerns are unfounded.  In this case the School did continue to try to achieve a meaningful multi-agency plan but could not access the support of the CAF team to achieve this.  This case reminds professionals around children not to accept a position of hopelessness, if a CAF is necessary and parental engagement cannot be achieved then this an indicator that heightens the need for a statutory intervention rather than diminish the likelihood of achieving what is needed for the child.  In such circumstances, professionals close to the child must advocate for that child and use challenge and escalation procedures to a point of resolution.  6.2.4 From November on 2013, the MASH received all referrals for Social Care Services for children, this replaced a previous system whereby referrals were addressed as part of a duty social work arrangement. The purpose of setting up the MASH was to streamline the routes of referrals and notifications of concern to the council, and to create an environment within which safeguarding partners could share information in a dynamic way to support efficient identification of risk, quick decision making and, timely and proportionate interventions. Establishing the service brought   together a range of agencies that had safeguarding responsibilities to support children and families through the whole continuum of need.  6.2.5 Examining the response to the three referrals made to Children’s Social Care suggests either a lack of defined thresholds to support decision making or an error of judgement in applying the criteria. Oldham has, and did have at that time, clear definitions of thresholds and each of the referrals met the threshold for invoking Section 47 investigations. This does therefore raise questions about the judgement in applying thresholds and it is of particular concern that this case shows a pattern over a nine month period.   6.2.6 The Department for Education commissioned a research project which reported in 2014, Clinical Judgement and Decision-Making on Children’s Social Work: An analysis of the Front Door System. The specific question that was set for the project team was ‘what behavioural factors affect social workers decisions and the front door and how can we improve the front door process to help social workers make better decisions’.  The analysis concluded that there are four key behavioural factors that complicate or reduce the efficiency of social workers ability to make complex and analytical decisions. These being:  time and work load pressures increasing reliance on intuition to make decisions,  a range of behavioural biases that compromise objective judgements, including inaccurate probability judgements, confirmation bias and a tendency to judge cases on their relative rather than objective merits,  that many sequential decisions have to be made in the course of a day which engenders ‘decision fatigue’,  that information supplied to social workers is often low quality meaning that significant energy is expended piecing together a full picture leaving less time for analysis.  6.2.7 It is vital that multi-agency professionals, particularly those with the responsibility of making constant judgements are aware of the common pitfalls that affect the quality of decision making, and that safety mechanisms around professionals, such as supervision, inter-agency challenge and feedback offer opportunities for learning and continued development of safer practice.    6.2.8 In this case multi-agency processes were not used to best effect, the precipitous closure by Children’s Social Care without any other multi-agency plan in place limited the initiation of systems around a child that facilitate and promote information sharing across agencies.  For example, although speculative, potentially, had Child G’s voice been heard in a Section 47 investigation, the child may have been subject to a Plan known to the GP which would have highlighted a third significant concern about bruising to Child G in a three month period.   6.3 Did multi-agency services work together to respond to the critical incident in relation to Child G   6.3.1 The repose to the critical injury to Child G is the precipitating reason for this review and it clearly raises a number of concerns about the implementation of Section 47 procedures, the confidence and trust between professionals of different disciplines, and the effectiveness of challenge within the safeguarding arrangements.  6.3.2 Child G was admitted to a regional children’s hospital as a medical emergency in acute pain.  Initially the symptoms were believed to have a medical causation but through a process of elimination and exploratory surgery a very serious injury was detected that had no reasonable explanation. The seriousness of the injury was likened to the impact of a car crash and one that could only have been caused by a blunt impact trauma. The Hospital is a regional children’s hospital, the Paediatrician is therefore highly specialist and experienced in matters of child protection.  The Paediatrician and ward staff identified the need to make a referral to Children’s Social Care and fully expected that standard processes to commence a Section 47 investigation would be initiated.  6.3.3 The Paediatrician advised that she tried to speak directly with the MASH manager and/or Police Officer but her telephone calls were not returned.  Concerned by the response, the Paediatrician tried to understand why a Section 47 investigation had not been initiated and decided to make a second referral with additional detail in case this had not been made clear enough.  Upon receiving the second referral which clearly outlined the severity of the injury, the absence of reasonable explanation and Child G’s distress, the MASH Team Manager, advised that she did   not accept that the threshold was met for Section 47 investigation, but did agree to arrange for a social worker from the CAT Team and a police officer from PPIU to attend the Hospital to gather further information.   The MASH Team Manager did not contact the Paediatrician to seek any further clarification prior to reaching this judgement.  The attending Police Officer recalled that upon arriving at the hospital it was clear that the Paediatrician was unhappy that a Strategy Meeting had not been convened, the Police Officer and the Social Worker advised that they had not been well briefed prior to attending the hospital and had not been aware of the position of the Paediatrician until they spoke with her.  The Paediatrician recalled that the attending officers seemed uninformed and somewhat flustered by her position, however, once she had given them the same information that she had already referred to Children’s Social Care, she was assured that they did appreciate the seriousness of the issues and endeavoured to invoke procedures to protect each child.  The attending officers agreed that both Child G and S1 were at risk of significant harm given the extent of the injury, and the strong likelihood that it was non-accidental, and agreed that S1 needed the protection of being removed from parental care at least until additional facts could be established as to how the injury was caused to Child G.  Both the Police Officer and Social Worker consulted with and advised their respective senior officers of what was needed, and it was agreed that the police would exercise Police Powers of Protection for both Child G and S1.  With the same information that had been available the previous day, the Police Officer and Social Worker both identified a very serious risk and a need to invoke a multi-agency strategy meeting when the MASH Social Worker and Manager had not.  6.3.4 The MASH Team Manager told the Lead Reviewer that there were two reasons why she did not agree that a Section 47 threshold was met and a Strategy Meeting was not convened to manage the process.  The first reason was that it had not been ruled out that the injury could have been caused by the recent surgery, and the second reason was that Child G had made no disclosure and therefore no direct allegation had been made.  These reasons disregard several very important factors, firstly, that the Paediatrician making the referral had expert medical knowledge and was satisfied that this was not an injury caused by surgery, and secondly, that Child G   was a child who was in great distress, had speech and language difficulties and in common with many children in such circumstances was too fearful or traumatised to talk about what had occurred.  A disclosure from a child is not a qualifying determination for a Section 47 investigation and this expectation demonstrated a very poor understanding of the child’s world at that time.  Through discussion with senior officers from Children’s Social Care, the agency has accepted that this was a flawed decision with a poorly analysed rationale.  No other explanation as to why Children’s Social Care took such a rigid position on the matter of convening a Section 47 investigation has been offered which leaves a significant concern about the applications of thresholds, the recognition of risk and the avoidance of a multi-agency approach to planning  in critical circumstances.  6.3.5 Despite clear recording and recall that a Strategy Meeting would not be convened, there is a record completed by Children’s Social Care of the discussion that took place at the hospital with the Police Officer and Paediatrician on a recording format for a Strategy Meeting.  Furthermore, when the first Strategy Meeting did take place six days later, it was recorded as a second Strategy Meeting. Both the Police Officer and Paediatrician indicated that they had not been aware that their discussion had been recorded as a Strategy Meeting and that they had received no copy of this recording. The Social Worker advised that this was completed in this way to reflect that it  was a multi-agency discussion, this was however a misleading record which at worst could be seen as an attempt to backtrack on the earlier decision not to hold a Strategy Meeting and misrepresent the decision making process.  6.3.6 A further consequence of the instinctive rather than planned response through a multi-agency Strategy Meeting with clearer focus on risk is that for three days after Police Powers of Protection were exercised, Child G remained on the hospital ward with unsupervised parental visits. The Social Worker allocated to the case advised that this was occurred because the Department had no legal basis on which to put controls into contact arrangements. This response rests on the belief that the Local Authority needed to acquire Parental Responsibility through and an Interim Care Order to be able to protect a child.  If it is believed that a child needs protection, then it must follow that the Local Authority must use the range of powers and   applications under the Children Act to achieve this, in these circumstances, an application for an Emergency Protection Order could have been considered.  That said, the exercising of Police Powers of Protection under Section 46 Children Act 1989 does allow the ‘designated officer’ to do what is ‘reasonable in all the circumstances of the case for the purpose of safeguarding or promoting the child’s welfare’. In addition Section 46(10) states the designated officer shall allow the child’s parent or anyone living with the child but does not have parental responsibility ‘to have such contact (if any) with the child as, in the opinion of the designated officer, is both reasonable and in the child’s best interests’. It is simply incongruous to believe powers of protection do not allow for the child to be protected. An alternative explanation is that there was an assumption that the hospital and ward staff would take sole responsibility for managing contact between Child G and MG and MP2.  6.3.7  In the three days of unsupervised contact, MG and MP2 could have said anything to Child G designed to maintain the child’s silence or fear or indeed coached the child to adopt an untrue explanation.  Child G was described as highly traumatised and extremely poorly, the absence of considering his needs for protection beyond simply being in a hospital ward were overlooked and the placed the child in further danger and emotional distress.  Only many months later, through feeling safe in foster care was Child G able to talk about what had happened.  6.3.8 At this distance from the incident, and without an understandable explanation from relevant practitioners, it is difficult to appreciate why the clear application of threshold to initiate a Section 47 investigation was not only not applied, but refused in the face of a clear medical opinion about the likelihood that a non-accidental physical injury was the only remaining explanation for the injuries to Child G.  Whilst trying to elicit an understandable reason would be purely speculative, there was undoubtedly a lack of trust and respect for the medical expertise and this represents a petulant position by Children’s Social Care.  The Paediatrician commented that she wished she had mounted a greater challenge, particularly in relation to parental contact, but on reflection may have been so relieved that the issues were being responded to that her guard on the wider safeguarding needs was dropped.     7.  Learning Outcomes  Whilst endeavouring to maintain a multi-agency focus to the review, given the identified limitations in practice, inevitably much of the learning focuses on Children’s Social Care and the implementation of threshold criteria.  It is important to be aware however, that multi-agency working is about enhancing safety though greater collaboration and challenge and with this in mind, the limitations exposed in one agency impact of the whole potential for successful outcomes.  7.1 Professionals engaged in multi-agency working must remain highly attuned to the voice of the child, be attuned to non-verbal methods of communication and advocate on behalf of a child that is not being heard.   This Review has revealed that Child G was unheard as a child in need of protection. This is particularly evident by the poor response to Child G indicating, ‘I don’t like it when Dad hits me’ and by an insufficiently questioning approach to the reasons for aspects of the child’s behaviour perceived to be ‘odd’.  Ensuring the presence and prominence of the Voice of the Child is integral to the work of Local Safeguarding Children Boards, yet there are clear patterns across multi-agency reviews nationally this is an issue on which multi-agency work and partners fall short.  The Safeguarding Board does need to be satisfied that professionals invest time getting to know children with whom they are working and have the skills and confidence to work with children to develop their plans for safety.   Recommendation 1  That the Board undertake a thematic audit which involved practitioners directly in addressing the Voice of the Child to establish how well this is embedded in multi-agency working, share examples of good practice and address the barriers to achieving this.  7.2 There is a need to be satisfied that Children’s Social Care have, and are, consistently and appropriately implementing threshold criteria in relation to their Section 47 duty to investigate.    This Review raises serious questions about the application of thresholds in relation to Section 47. In relation to Child G, this was twice misjudged by Children’s Social Care over a ten month period. Arguably, had a robust investigation been undertaken when the School first referred bruising and an allegation  to Children’s Social Care, this could have changed the critical pathway of events for Child G who went on to experience at least one, and possibly more episodes of significant harm. The high threshold of Section 47 initiation could suggest that one of the unintended consequences of the MASH arrangements were that Children’s Social Care took on a police culture, working to the criminal threshold of beyond reasonable doubt as opposed to the more relevant questions of likelihood and probability.  The findings of this Review in this respect concur with a number of case reviews which suggests that this is a wider issue of practice. The Independent Reviewer has discussed this matter and carefully considered the evidence with the Director of Children’s Services. In accepting the findings of this report, and concerned about the need to establish whether the findings are indicative of systemic or individual influences, the Director of Children’s Services has committed to a review the application of the threshold by the MASH Team during a relevant period to be agreed by audit and sampling, as well as to review the understanding and application of the thresholds by key staff.         Recommendation 2 The Board should be provided with the evidence by Children’s Social Care of the appropriateness of recent application of threshold criteria in relation to Section 47, that any barriers to compliance are addressed and an assurance that current application is sound.  7.3         Children who are at risk of harm need the structure of a multi-agency plan, shared with the Child’s General Practitioner, to promote information sharing and collaborative assessment methods that use past family history, findings from research and current assessment to support analysis of risk.                  Although Child G was not subject to a multi-agency plan when the hospital shared with the GP that blood tests were necessary because of the presence of bruising, arguably the child should have been and may well have been if the Section 47 threshold had been applied robustly and the child’s voice had been heard.  This review demonstrates how if information held by each agency was put together, along with a comprehensive assessment that reviewed MG’s earlier parenting, this history of relationships and domestic abuse, this would have suggested the presence of some risk.  The outcome of the first assessment paved the way to many difficulties, as already stated, the child’s voice became lost, MA’s parenting history was insufficiently explored, MP2 was not involved and the decision to close the case to a social worker but agree a programme of family support without review meant that MG’s tendency to see Child G as the problem became an accepted definition of where problems lay between MG and Children’s Social Care.  Child G was registered with a GP but the GP had no knowledge of any of the interventions or concerns, if the GP had been notified of this then the information about bruising from the hospital may have created a greater alert and need to share information across the multi-agency partnership. Both the A&E Hospital Trust and the Clinical Commissioning Group need to share the overall effect of not sharing information in the way through safeguarding training using this case as a local case scenario.   Recommendation 3  The Board need to be satisfied that GPs are connected into multi-agency safeguarding arrangements across the spectrum of need to ensure the most diligent approach to information sharing about children and their carers.  Recommendation 4  The Named Doctor for Safeguarding Children at Pennine Acute Hospital Trust to present and discuss the case at Peer Review and invite Designated Professionals from the Clinical Commissioning Group to reflect with relevant medical staff the need to share information appropriately, follow up on safeguarding concerns to a point of satisfaction and take definitive action to refer safeguarding concerns which remain unresolved.    7.4 The need to work directly with men in families must be robustly embedded in professional thinking, case planning and single and multi-agency practice.    A great deal of work had been done in Oldham to achieve this aim since the Initial Assessment was completed in respect of Child G.  Nevertheless, it is disappointing to see this issue as a feature of a further review, and this should be used to reinforce the messages given to practitioners about just how significant an issue this is, and how a failure to do this can so easily result in unassessed and growing risk for children.  Recommendation 5 That this case is used as an instructive local case scenarios in multi-agency training to re-inforce the need for safeguarding practitioners to work with men in families and avoid the often easier route of working through women, and the consequences of failing to do so.  7.5 Although Children’s Social Care act as Lead Professionals in multi-agency planning where they have an agency presence, it is evident  that partner agencies find it difficult to offer any meaningful challenge when dis-satisfied by outcomes or decisions.  The Paediatrician at the regional children’s hospital pursued the referral until she received a satisfactory outcome, this took a great deal of time and energy. The Paediatrician found this a frustrating experience but thankfully had the confidence, knowledge and position to enable her to do this. This is not always the case for other multi-agency professionals who see Children’s Social Care as the ‘experts’ on risk and although they may know the child well, as with the School for Child G, find it much harder to construct the basis for challenge.  This case truly demonstrates the need for challenge and in any system model, challenge is an essential part of getting things right and learning for the future.  To this end, it would be prudent to work more pro-actively to create a culture of challenge across agencies and for the Board to be satisfied that the barriers to challenge are understood and mitigated against.      Recommendation 6 The Board to facilitate a series of multi-agency practitioner seminars for the purpose of developing the culture of challenge, promoting the value of challenge in safeguarding terms, modelling techniques to achieve intended responses and sharing the positive and less positive examples of where challenge, or absence of challenge has impacted on outcomes for a child.      