Accidental overdose by a teenage boy who subsequently recovered in June 2020. Learning includes: always consider the impact of domestic abuse and/or adult substance misuse or overdoses on children of all ages, especially when a child is directly affected; consider multiple incidents cumulatively as well as in isolation, and any contradictions between the child's expressed wishes and their lived experience; when undertaking S47 enquiries, preparing for initial child protection conferences or conducting assessments, obtain relevant information from GP records about all adults involved in children's care; need for awareness of the legal implications of a child being subject to a Special Guardianship Order (SGO) in terms of parental responsibility and potential eligibility for support services; consider calling a strategy meeting if a child under an SGO returns to parental care; need for practitioners to discuss concerns with the young person. Recommendations include: ensure that a child's perspective on what being safe physically and emotionally means to them is a starting point for any plan to safeguard them and that thought is given about how multiple plans in use for any individual child could be explicitly linked or streamlined; promote the use of evidenced based tools to better support practitioners in understanding family dynamics and support for children including who is best placed to do any direct work with a child or young person; raise awareness of the legal implications of a child being subject to a Special Guardianship Order in terms of parental responsibility and potential eligibility for support services; ensure relevant information about adults involved in caring for children is obtained from GP records at all stages of the child's journey; ensure that the response to neglect adequately focuses on the needs of adolescents.
      
 Title:  Child safeguarding practice review: Fred. LSCB: South Tees Safeguarding Children Partnership Author: Karen Perry Date of publication: 2021  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.                           Final Version 17 May 2021   0                                                   CHILD SAFEGUARDING PRACTICE REVIEW  Fred    Date agreed by the partnership: 17.05.2021  Lead Reviewer: Karen Perry   Prepublication reports are not to be shared beyond those people who are in direct receipt of it as part of the process of the review   Date of publication 04.06.2021            Final Version 17 May 2021   1CONTENTS 1. Introduction                                                                                                              page 2 2. Details of the family and child’s story                                                          page 2 3. Thematic analysis                                 page  4 4. Positive Practice                                 page 20 5. Conclusion                                                                                        page  21 6. Recommendations                                 page  21 Final Version 17 May 2021   2INTRODUCTION   1.1. This Child Safeguarding Practice Review is in respect of Fred, an older teenager, who was found unconscious in the street after what is believed to be an accidental overdose. He was admitted to hospital, where tests were positive for a combination of alcohol, and drugs which could have had serious consequences; fortunately, he has made a full recovery.  1.2. All learning points are listed in section 4, at the end of each theme. What follows is a summary of the most significant learning from this review. The nature of the impact of domestic abuse and/or adult substance misuse or overdoses on children of all ages should always be considered, especially when a child is directly affected.  Where there are several incidents, these need to be considered cumulatively as well as in isolation, and any contradictions between the child’s expressed wishes and their lived experience fully explored and considered. Emotional abuse and neglect of adolescents tends to be less readily recognised than that of younger children. When undertaking S47 enquiries, preparing for Initial Child Protection Conferences or conducting assessments it is important to obtain relevant information from GP records about all adults involved in children’s care (consent maybe needed to achieve this).   1.3. Awareness of the legal implications of a child being subject to a Special Guardianship Order in terms of parental responsibility and potential eligibility for support services is variable amongst practitioners working with families. Where a child subject to a Special Guardianship Order returns to the care of their parents, consideration should be given to whether a strategy meeting under the safeguarding procedures should be called. Especially for older children it is helpful to develop any plan to safeguard their wellbeing from the starting point of what being safe physically and emotionally means to the young person. This does not prevent practitioners also discussing their concerns with the young person. 1.4. The South Tees Safeguarding Children  Partnership (STSCP) will ensure that learning is widely disseminated locally and published on the partnership website. To avoid unnecessary disclosure of sensitive information, details in this report regarding what happened focus only on the facts required to identify the learning. The Child Safeguarding Practice Review takes into account multi-agency involvement from 1st August 2019 (when Fred returned to live with his mother and Stepfather) until July 2020 (just after the Review Child Protection Conference after the incident that prompted this review).  1.5. The South Tees Safeguarding Children Partnership  (STSCP) agreed to undertake this review using a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted as they did at the time.1 Family members were also offered the opportunity to speak to the lead reviewer, but no-one wanted to.   2. DETAILS OF THE FAMILY AND THE CHILD’S STORY   2.1. Family members will be referred to by their family relationship e.g., Mother, Stepfather, Paternal Grandfather etc.  At the time of the incident that prompted this review Fred was living with Mother and Stepfather in Local Authority one.   Fred has been described as a polite and likeable young man, who is chatty and reflective when relaxed and keen to look ahead to his future.  2.2. Some information prior to August 2019 is relevant. Fred and his siblings were known known to council Children’s Services in Local Authority one for a few years. Longstanding concerns about neglect, physical abuse, domestic abuse and parental drug misuse resulted in care proceedings                                                            1 There has been an unavoidable delay in finalising this Child Safeguarding Practice Review because of delays in procuring an author Final Version 17 May 2021   3which concluded in 2013; Fred was made subject to a Special Guardianship Order2 with the intention that he lived with his Paternal Grandparents for the rest of his childhood in another town (Local Authority two) nearby. This arrangement appeared to be satisfactory for several years; there was no significant ongoing involvement by any agency other than those which provide services to all children.  2.3. Due to tensions in the relationship with his grandparents, in the summer of 2019 Fred spent more time with his Mother and her partner. This became a full-time arrangement in August 2019. In mid-August 2019 Fred had been reported missing from his Paternal Grandparents home.  2.4. During the period under review there were four incidents of domestic abuse reported to agencies. In September 2019 Mother called police to the house alleging Stepfather had assaulted her and Fred. In November 2019 Stepfather called the police alleging Mother had assaulted him and that she was “smashing the house up”. In mid-February 2020 Fred contacted the police on behalf of his mother to report domestic abuse against her by Stepfather. In March 2020 Stepfather made a further allegation of assault against mother.  2.5. During the period covered by the review there were three incidents of self- harm by Stepfather: Two overdoses, one in September 2019 and one at the beginning of November 2019 and an attempted hanging the beginning of March 2020. On this second occasion, records show that Fred had found Stepfather, cut him down and called an ambulance.  2.6. After the overdose by Stepfather in November 2019 the police made a referral to Local Authority one Children’s Services. This precipitated a Child and Family Assessment3 which was undertaken by Local Authority two, as this was deemed the area of Fred’s permanent residence. This was the first occasion that Children’s Services in either area were aware that Fred was living in Local Authority one. The outcome of the assessment in mid-February was that involvement be continued on a Child in Need4 basis in South Tees due to the history of neglect and current concerns about drug use by Mother and Fred and domestic abuse. 2.7. At the beginning of January 2020 Fred, and a young person of a similar age who had been staying in the household for 3 months, were arrested after a fight in the street. This resulted in prompt response by the Youth Offending Service (YOS) as an alternative to prosecution. The Work Readiness Team also became involved in January 2020. During February 2020, having completed an Asset Plus assessment,5 the YOS worker made a referral to Forensic CAMHs who promptly became involved using the Trauma Informed Pathway.6                                                              2 Special Guardianship is a court order which places a child or young person with someone permanently and gives this person parental responsibility for the child. A Special Guardianship Order is seen as being less permanent than an Adoption Order because it does not end the birth parents legal relationship with a child as adoption does but the Special Guardian(s) have the right to make all major decisions about the child without consulting the parents (except consent to adoption and change of child’s surname)  3 A Child and Family Assessment is an assessment to establish whether a child is in need of local authority services (under section 17 of the Children Act 1989) to achieve or maintain a reasonable standard of health or development or to prevent significant or further harm to health or development. 4 A Child in Need is one who needs local authority services (under section 17 of the Children Act 1989) to achieve or maintain a reasonable standard of health or development or to prevent significant or further harm to health or development. 5 AssetPlus is an assessment process approved by the Youth Justice Board which aims to: identify strengths. identify needs and problems. facilitate planning of appropriate interventions for children who have offended or are at risk of offending, both in custody and the community. 6 The Trauma Informed Pathway actively seeks to understand the impact of previous adversity on current functioning, emotional experience, and relationships; to develop bespoke intervention planning to reduce the risk of recreating or reinforcing traumatic experiences for the young person. This is a small service which has been commissioned specifically by YOS from the end of 2019 so only available to young people involved in offending behaviour. Final Version 17 May 2021   42.8. On more than one occasion during the period under review there was evidence to suggest drugs might be being sold from the property, although Mother always denied this. A police search conducted in mid-January 2020 resulted in both Mother and Fred being arrested for possession of cannabis.  Mother was cautioned and no further action was taken against Fred as Mother stated the drugs were hers.  2.9.  After the February 2020 incident of domestic abuse Local Authority one Children’s Social Care commenced an assessment. This was escalated via a strategy meeting under the safeguarding procedures to S47 enquiries7 after the hanging by Stepfather incident in March 2020. At an Initial Child Protection conference at the end of March 2020; Fred was made subject to a Child Protection Plan (category neglect).  2.10. In mid-June 2020 Fred was found unconscious in the street by a passerby. This is the incident that prompted this review. Fred was admitted to the Intensive Care Unit.  On the following day Mother was admitted to the Emergency department after an overdose. By this time Fred was medically fit for discharge and discussions had begun about safe arrangements.  Fred became distressed after Stepfather told him about Mother’s overdose and absconded from the ward. Since then Fred has been living with his Maternal Grandparents in stable circumstances.   3. THEMATIC ANALYSIS   3.1. The learning from this review was identified from information and opinions provided in the agency reports and at the practitioner event.  The themes are:    Responding to mental ill-health, domestic abuse and substance misuse   Engaging, safeguarding and supporting teenagers   How practitioners and agencies worked together; referrals, assessments and plans  Assessing the role of extended family members  Theme:   Responding to mental ill-health, domestic abuse and substance misuse   3.2. Many parents with mental health issues can care successfully for their children, especially if they have treatment and support. However, some potential features of mental health issues: erratic behaviour; mood swings; lack of emotional availability; difficulties establishing routines and boundaries; neglect of personal and household hygiene; can result in emotional abuse or neglect. Children of parents with mental health issues are also more vulnerable to stressful life events like divorce and separation, homelessness, unemployment, discrimination, and lack of social support. Risks to children are compounded if mental health issues co-exists alongside domestic abuse and abuse of drugs or alcohol; the so called “toxic trio”, as was the case for Fred’s family.8 A recent survey of local authorities indicated 65-90% of children in need cases involved all three of these factors.9                                                                7 Under S47 of the Children Act 1989 the local authority has a duty to investigate where there is reasonable cause to believe a child may have suffered or be at risk of significant harm  8 Cleaver, H., Unell, I. and Aldgate, J. (1999) Children's Needs - Parenting Capacity: The Impact of Parental Mental Illness, Problem Alcohol and Drug Use, and Domestic Violence on Children's Development. London: HMSO. Cited in Sidebottam P et al (2016) Pathways to protection: a triennial analysis of SCRs 2011-14 DfE  9 ADCS (2016) Safeguarding pressures phase 5: research report. Manchester: ADCS cited in  https://www.nspcc.org.uk/preventing-abuse/child-protection-system/parental-mental-health/ Final Version 17 May 2021   53.3. Since the time period covered by this review guidance on parental mental illness within Tees multi-agency safeguarding procedures10 has been reviewed. This includes a description of the symptoms of the most common illnesses, and the risks for children according to age. It also points out that mental ill- health does not always have an adverse impact on children and the consequent importance of case-by-case assessment. To assist with this STSCP has developed a toolkit which has been adopted by other safeguarding partnerships in the region. This gives guidance to practitioners to support them in exercising their professional judgement about levels of risk, including whether a child is at risk of significant harm, and issues of consent to share information, including dispensing with it, if this is necessary to safeguard a child’s welfare.   3.4. Whilst helpful, the toolkit is reliant on practitioners having accurate information about individual’s caring responsibilities and a wider perspective on their circumstances. This can pose challenges for practitioners whose primary role is addressing the mental health issues of the adult. For example, staff at the Emergency Department made referrals to Children’s Services regarding the most serious incidents of self-harm: the attempted hanging; and Mother’s overdose after the incident which prompted this review. However, they did not make a referral in response to Stepfather’s overdoses in September and November 2019 because Stepfather told staff that Fred was only an occasional visitor. This review was told that it is not uncommon for patients at the Emergency Department to minimise or not disclose contact with children. Reasons might include a fear of what agencies might do in response, especially where there are younger children, or fear of scrutiny of other aspects of their lives (eg where there is criminal activity) or simply not seeing it as relevant, “not your business”. Even where patients do disclose children in the household, the episodic nature of Emergency Department treatment, with no facility to pull together family records, which makes it harder for ED practitioners to recognise circumstances where making a referral might be appropriate.   3.5. On each occasion of self-harm Emergency Department staff completed a full discharge summary which was sent to the GP. However, the discharge notice for Mother went to the wrong GP. This could have been due to an out-of-date record which she was not fit to update at the time. The notice should have been returned to the hospital for redistribution but appears instead to have been linked to the old record. The discharge summaries included detail about the medication taken, some of which was only legitimately available by prescription, but which had not been prescribed for the person who has taken it. The GP representative told this review that where GPs became aware that a patient had taken an overdose of medication prescribed for them it would be normal practice for them to restrict future supplies to a weekly script. If the overdose were by a patient registered with the local specialist GP practice for people misuse substances it would be routine practice to contact any patient who had taken an overdose. These however are a minority of those who take overdoses and the GP representative thought that the response was variable for patients registered at non specialist surgeries. In this case the response by Stepfather’s GP was robust in terms of reviewing his prescriptions and the self-harm/suicide risk management plan. The response included discussions with him about self-medication and obtaining drugs, however there is no evidence of consideration of the impact on any children in the household.   There is no protocol/guidance, local or national, for how a GP should respond to becoming aware that a patient has overdosed on prescription medication that has not been prescribed for them, including the potential impact on children in the family. The named GP for the partnership told this review that they intend to explore what is happening locally and what a proportionate response might look like. The police made referrals to Children’s Services for all the adult self-harm incidents but would only list any medication taken, if there was clear evidence of what that might include (eg empty pill packets).                                                             10 https://www.teescpp.org.uk/procedures-and-guidance-on-specific-issues-that-affect-children/parental-mental-illness-procedure/ Final Version 17 May 2021   6 3.6. There is no evidence of detailed consideration of the nature and impact on Fred of Stepfather’s mental health or potentially that of Mother. Stepfather was known to be taking medication for depression and prone to self-harm with potentially serious consequences. Mother was open about her long-term use of medication to help her sleep. Considering her known adult history, it would be a reasonable assumption that she might have mental health problems. Consent to seek information from GPs about Fred was sought in Local Authority two, but not about either parent.   The social worker told this review that it was not usual to seek information about parents during assessments but that they could see the benefit for future similar families. Mother did provide consent for the Local Authority one social worker to seek information about herself and Fred from their GP. However, there is no record of this being received at their GP practice, for reasons which are not known, and no consent was sought from Stepfather due to his lack of engagement not providing the opportunity. The subsequent request for information from the GP for the assessment was relied upon to seek information for the Initial Child Protection Conference; it being assumed that Stepfather had the same GP, which was not the case for this family. Social workers told this review that the recently improved arrangements for GP reports to Child Protection Conferences (described in paragraph 3.28 below) should ensure that GPs flag up if parents are registered elsewhere. However, they also gave other examples which collectively suggested obtaining information from GP records is problematic throughout the child’s journey: assessment, strategy meetings, and step down from Child in Need and Child Protection plans.  They thought there maybe barriers about expectations by GPs for payment and misunderstandings about the legal basis for consent for information sharing not being needed for child protection cases.   3.7. It was not until early April 2020 that it was established by the FCAMHS worker that neither Mother nor Stepfather had any current involvement from mental health services. It was agreed that they should be encouraged to take up support from their GP if they were not already doing so and the social worker was requested by email to explore what support Mother and Stepfather were receiving from GP, in particular was the GP prescribing medication or were they self-medicating which might raise issues about how the drugs were being obtained as well as the impact on their health. This does not seem to have been followed up or recorded in the detailed way necessary. Records are limited to information presented to the Core group, held in early April 2020,that Stepfather was under the care of the GP and prescribed (unnamed) medication.  3.8. Fred was directly or indirectly affected by all of the domestic abuse incidents that were reported to agencies, although at the time his comments suggested he either did not recognise this or minimised the impact. For example, when seen by the Local Authority one social worker after the incident in February 2020 records refer to Fred minimising the domestic abuse incident and saying it did not scare him.   In September 2019 police records indicate Fred left the house for his own safety: Mother initially told the police both he and herself had been assaulted. Police records show Fred witnessed the November 2019 incident.  In mid-February 2020 Fred reported to the police an incident he had heard on the phone. In none of the domestic abuse incidents do police records include a description of his thoughts, wishes or feelings. There is also no evidence of any analysis of the nature or the domestic abuse. Was it, for example, to do with exercising power and control, or situational.  Both Mother and Stepfather were alleged perpetrators in the reports made to the police, alcohol was always a factor in each incident and two incidents were followed by overdoses by Stepfather within hours.  3.9. Fred was also directly affected by all the self-harming incidents reported during the period under review. He was present in November 2019 when Stepfather was taking an overdose and had barricaded himself in the house along with Mother and Fred. In March 2020, regarding the attempted Final Version 17 May 2021   7hanging, it was Fred who cut Stepfather down and called the ambulance. Practitioners had suspicions, never proved and denied by Mother,  that she was dealing prescription drugs. Whilst Fred never disclosed this to anyone, records show that he was observed to seem anxious when the phone rang or someone came to the door.  3.10. Regarding Fred’s own drug use, adolescents in general are likely to engage in some level of risk taking behaviour due to their stage of development and this tendency is exacerbated for young people like Fred who have been harmed by neglect in their early childhood.11  With support, whether from their immediate or extended families or services, most teenagers emerge as functioning adults. However, risk taking behaviour is less likely to be modified by parents who are distracted by their own problems. Where similar activity is part of their own lifestyles, eg drug taking, this sets a poor example and/or may lead them to be more tolerant of their children using drugs and can make access to drugs easier (Fred admitted smoking his mother’s cannabis in January 2020).    3.11. Whilst it is more difficult for individual practitioners to challenge parental denial of misuse of alcohol and substances without observing direct evidence of it, there was sufficient information about drugs being taken by Mother and Stepfather to explore why and when they were being taken, and how they were obtained and stored in terms of harm reduction for Fred.  There is limited evidence of this being attempted until the Initial Child Protection Conference when the Chair asked Mother about this.  Although it is difficult if parents minimise or deny drug misuse as these parents did, these kinds of issues (and the link with alcohol and violence) should have been explored more in social worker’s assessments and used to inform Safety Planning with Fred; all the incidents reported to the police involve adult use of drugs and/or alcohol.  There was also a credible occasion of suspected drug dealing in the home reported by a practitioner to the police in Spring 2020, not long after the incident which prompted this review. This was logged as “single strand” police intelligence, for future consideration should there be other similar information reported. The practitioner also shared what they observed with Fred’s social worker a couple weeks later (the delay was a one off due to oversight). There is no evidence of exploration of drugs misuse with Stepfather; social workers told this review the focus was more on his mental health. This is understandable as the drugs he took were mostly, but not all, of a kind not typically used for recreational purposes. However, they did include prescription drugs which were not prescribed for anyone in the household, which raises questions about how they were being obtained and any risks that might pose to Fred.   3.12. There is also limited evidence of challenge or support regarding Fred’s use of cannabis, although the YOS service was persistent in ensuring sessions were delivered on what the emergency services staff face related to substance and alcohol misuse and the effects of drugs and alcohol respectively after two unsuccessful attempts to get Fred to engage in group work sessions regarding the impact on emergency services staff. The sessions had to be completed by phone due to covid restrictions. The cannabis use was an ongoing worry expressed by Paternal Grandfather and admitted to occasionally by Fred but usually minimised by him as one off or not being recent. Fred stated that the use was historical because he had used it to cope with the stress of living with his Paternal Grandparents. Coping with stress or anxiety is a common reason for use of cannabis and practitioners told this review they hadn’t reflected at the time about the implications of this as a potential re-emerging/future coping mechanism for Fred, but would recognise it in future as a vulnerability for other young people. Details of what Fred had taken before the incident that precipitated this review were contained in the discharge summary sent to his GP by the Emergency Department. The letter was highlighted and shared with all GPs at the practice for information. There is no local or national guidance that lays down expectations of a GP taking any specific action in these circumstances. The named GP for the partnership told this review that they intended to explore what a proportionate response might look like locally.                                                             11 Research in Practice (2014) Final Version 17 May 2021   8 3.13. Records show that Mother consistently minimised the severity of domestic abuse and self-harm incidents, the impact on Fred and the likelihood of them recurring; there is no evidence of practitioners explicitly challenging this in conversation with either parent. For example, in November 2019 Mother told the social worker that Fred was asleep in bed when Stepfather barricaded the house, yet records show Stepfather assaulted police officers who had had to force entry into the house. Mother also told the police in November 2019 that she had no concerns once the effects of the drugs and alcohol had worn off and also that Stepfather would leave the property. This never happened despite being also included in the Child Protection Plan in April 2020.    3.14. Research shows that nationally emotional abuse and neglect of adolescents is often either not recognised by practitioners or not taken sufficiently seriously.12 This is partly because young people tend to be seen as more resilient than young children. This belief persists although the research evidence does not support the theory that the impact of neglect is less for adolescents.13 A study involving practitioners and young people from 12 areas in England identified that this was due to a combination of factors some  of which have some relevance in Fred’s case. These were young people being perceived as; able to escape the situation (including self-refer); more able to cope than younger children; contributing to or exacerbating the problems through their own behaviour for example through conflict with parents or resisting attempts at supervision and putting themselves at risk ( or wanting to live with Mother in Fred’s case). Challenges for intervention in adolescent neglect include the elusiveness of a definition given the importance of considering a young person’s age and capabilities and the lack of appropriate tools for practice which tend to be focused on the needs of younger children. It is positive that Fred was offered support on the Trauma Informed Pathway by FCAMHS, as he was considered to be at risk, in the context of his early life and parenting experiences, and that the adults’ mental ill health, alcohol and drugs misuse, and domestic violence was part of the formulation for the FCAMHS work with Fred.  However, no agency regarded Fred to be at sufficient potential risk of significant harm to request or arrange a strategy meeting under the safeguarding procedures until the incident of attempted hanging by Stepfather. This was despite the domestic abuse; poly substance misuse and mental issues of Mother and Stepfather being known to agencies from the first referral to Children’s Services in November 2019.  3.15. There were a number of factors that hindered the calling of a strategy meeting by social care before March 2020, the first is that incidents were seen in isolation and none of the previous incidents were as serious as the one in March 2020. In addition, not all of the incidents reported to the police were shared with Children’s Social Care; because they were considered in isolation by the police, the risk threshold was not considered to have been met. Nonetheless by early January 2020 Fred had been arrested twice, and there had been two incidents of domestic abuse and two incidents of self-harm by Stepfather. Strategy meetings can be requested by any agency but should be arranged by the local authority “in which the child is found” which was Local Authority one.   This was a complicating factor while Local Authority two remained involved. By the time of the first referral in November 2019 it was clear Fred had been living with a parent not only from whose care he had been removed but also where the concerns had been serious enough for a court to decide that he should live with others (Paternal Grandparents) for the rest of his childhood. This would have been sufficient justification to consider calling a strategy meeting, especially as the Paternal Grandparents were not exercising the parental responsibility given to them by the court through the making of an SGO. YOS practitioners told this review that when staff contacted the social worker in Local Authority two they were told that involvement was in the process of being transferred to Local Authority one, and that,                                                            12 NSPCC (2014) Core info; Neglect or emotional abuse in teenagers aged 13-18 13 Ibid and Raws P (2017) Thinking about adolescent neglect; A review of research on adolescent neglect Final Version 17 May 2021   9in all the circumstances, including the SGO not being adhered to, this might have been a point where they should have given consideration to requesting a strategy meeting.   When Local Authority one became involved to do an assessment because of the February 2020 incident, a strategy meeting could have been considered in the light of the history. At that point the social worker from Local Authority two would have been involved which would have given a fuller picture of the family as a foundation for the Local Authority one assessment. Practitioners also told this review that they thought that a strategy meeting might have been called earlier had Fred been younger.   Summary of learning: Responding to mental ill-health, domestic abuse and substance misuse    The importance of obtaining information from GP records about adults involved in children’s care; when undertaking S47 enquiries, preparing for Initial Child Protection Conferences or conducting assessments (when consent maybe needed).     It should not be assumed that all family members are registered at the same GP practice.    The nature of the impact of domestic abuse and/or adult substance misuse or overdoses on children of all ages should always be considered, especially when a child is directly affected.      When there are several incidents of domestic abuse and/or adult substance misuse or overdoses, these should be considered cumulatively as well as in isolation.    Emotional abuse and neglect of adolescents tends to be less readily recognised by practitioners than for younger children     Challenging parental denial of drug misuse is difficult when there is limited evidence to support practitioner’s suspicions. However prompt attempts should be made to explore how drugs are used, obtained, and stored to assist harm reduction for children of the household.    Responses by GPs to overdoses of prescription medicine not prescribed to the person who has taken it are not supported by any local or national guidance, neither are GP responses to overdoses by young people.    Should a child subject to a Special Guardianship Order return to the care of their parents, consideration should be given as to whether or not a strategy meeting under the safeguarding procedures should be called.     See recommendation D & E  Theme:  Engaging, safeguarding and supporting teenagers, including the voice of the child   3.16. Service users in general are more likely to engage if services are accessible and responsive. It can require courage to request help, or agree to receive it, and the moment where they are most willing to engage may pass quite quickly. This effect can be multiplied for young people as adolescence in general is a time of rapid physical development, which can be out of kilter with maturation of the brain with the “executive” function, (which is responsible for planning, reasoning and impulse control) being the last to fully develop. Adolescents also tend to want to fit in with their peers.14 In terms of successful service delivery for adolescents, this means that the offer needs to be accessible, normalised/non stigmatising and offered in a timely and persistent way.                                                             14 Blakemore SJ (2018)Inventing Ourselves: The Secret Life of the Teenage Brain Transworlddigital Final Version 17 May 2021   10 3.17. One of the challenges of working with children as they get older is being sensitive to their ability to form their own views and have them taken increasingly seriously. Seeking the views of even very young children and taking them into account according to their age, maturity and understanding is enshrined in various legislation and national guidance. In practice, once children are 16 years old, they are treated as being able to make their own decisions, unless doing so would cause them serious harm. There are several examples of practitioners seeking Fred’s views e.g about his current circumstances, his future and how he wanted services to be delivered. For example, social workers asked where he wanted to live and went through the content of the social work case conference report with him and the FCAMHS worker asked about the best way to deliver sessions. Practitioners were also responsive to an expressed change of view: e.g. when he wanted to move out from his mother’s; when he wanted to re-engage with the FCAMHS service; and when he changed his preference from attending college to enroling with an alternative training provider. However, there is limited evidence of attempts to discuss his views in detail, or explore the reasons for them, until after he moved to his Maternal Grandmother. There is also limited evidence of reflection on his lived experience with Mother and Stepfather, and the contradiction between this and his strongly expressed wish to remain there, rather than exploring alternatives.   3.18. More reflection about the likely impact on him of witnessing the domestic abuse, self-harm and the drug related visitors to the house suspected by practitioners, might have prompted more efforts to consider alternative family placements earlier. This could have included more rigorous testing of whether the relationship with Paternal Grandparents could be repaired and, if this was not a possibility, consideration of other family members that he might be able to live with, e.g, the uncle with whom he occasionally stayed or with the Maternal Grandparents where he eventually moved.  In March 2020 Fred began to ask for help to get alternative accommodation. Records show Fred told his social worker that he wanted to move because he was “having to live with his mother” and he told his YOS worker that he was costing his mother too much money and wanted his own space.   After he moved out other reasons for his change of mind became apparent from subsequent comments to practitioners. Records variously refer to: his parents being “scary”; finding it hard to sleep due to the arguments and worrying about this and; that he had felt on edge living with his mother and wasn't comfortable with their lifestyle; that people came and went from the property 'at all hours' which made him uncomfortable. In August 2020, when the social worker explored what had made the difference to his mood and overall reported improved wellbeing, he said that Maternal Grandmother was consistent, and that Maternal Grandfather made him feel safe.  3.19. A recent study commissioned by the Office of the Children’s Commissioner for England15 involved young people as co-researchers to explore young people’s perspectives on disclosing abuse; what helps and what hinders.16 The research identified that young people weigh up the advantages and disadvantages of disclosure, and consider their previous experience of how practitioners and agencies have responded to disclosures, as well as their experiences within their families and in the community.  3.20. Regarding who to confide in, duration of the relationship was a key component of trust for the study participants, alongside the personal qualities of kindness, empathy, competence and being non-judgemental. Also, teachers, like social workers and youth workers, were viewed by study                                                            15 Cossar J et al(2013) ‘It takes a lot to build trust’ Recognition and Telling: Developing earlier routes to help for children and young people Office of the Children’s Commissioner for England 16 The study involved a literature review, analysis of content of a peer support website, detailed interview with 30 vulnerable young people aged 11-20 years and focus groups of a broader same of young people not known to be vulnerable  accessing services and parents and practitioners  Final Version 17 May 2021   11participants in a more holistic way, rather than, for example, doctors for medical support.  Another study, which involved interviews of young people who were the subject of formal child protection processes17, also identified that a consistent long-term relationship with a professional throughout the referral and safeguarding process was the most important factor in disclosure and protection, whilst important barriers included the lack of consistency of social work contact and the large caseloads held by individual social workers. Fred had three different social workers in quick succession, changes of which were due to organisational issues: transfer of involvement from one local authority to another, and then transfer from the social work team that conducts initial assessments to one that provides a service to children needing ongoing involvement when subject to a Child Protection Plan. Each of these changes involved a delay/discontinuity in service provision which might have been mitigated by attempting better handover processes involving at least one joint visit, although this might not have succeeded as all practitioners experienced many failed visits, even when these were pre-arranged. Other services were able to offer one consistent practitioner, although there was a point around the time of the Initial Child Protection Conference that Fred expressed a view that there were “too many” professionals involved in his life and that he was “on show”.   3.21. Practitioners made good use of practical support to enable opportunities to spend time with Fred alone (e.g., opening a bank account).  Practitioners told this review they felt that the recent development of youth work capacity within the Early Help service would assist by providing targeted support for individual young people, and that in recent years there were more male staff within the Early Help service which was positive for engaging young males. One important consideration for building a relationship with any service user is linked to a safe and confidential environment. Covid restricted the ability of practitioners to offer private face to face contact and Fred declined to engage in video conferencing. Records show there were times when he found it difficult to ensure he was alone when taking a phone call, and even a socially distanced walk may not have felt sufficiently safe to disclose concerns.  It was possible nonetheless for some practitioners to form positive relationships with him. Records show his expressed views about two of them; that the YOS worker was “proper nice” and the new SW was “alright” and there was evidence of other practitioners establishing a rapport with him, (see section 4 good practice) including the FCAMHS worker, who had the most consistent contact with him over several months.   3.22. The Children’s Commissioner’s study identified five main barriers to disclosure identified by the young people. In order of importance these were: “an emotional barrier, e.g. shame, embarrassment, not being able to face telling, finding it hard to find/say the words; worry about the family knowing, loyalty to family and the impact on family members; thinking their situation was not problematic enough to disclose to others; threats from the abuser; and fear of not being believed if they were to tell.”18  The literature survey also identified an additional barrier to disclosure as being a fear of a loss of control over decisions. Fred had decided to stay with his Mother.  In addition, the breakdown in the relationship with his Paternal Grandparents had reduced his most obvious escape route. Practitioners told this review that during the earliest few months of their involvement Fred was clear and consistent about wanting to stay with his Mother, where he told them he felt wanted in a way he hadn’t recently at his Paternal Grandparents. Practitioners believed he feared that expressing concerns about his circumstances might result in being removed from his Mother’s and that he did not want that, which they believed sometimes made him avoid appointments or be guarded about what he said. There is also evidence throughout the period under review of Fred being worried about                                                            17 Rees G, et al (2010) Safeguarding Young People: Responding to young people aged 11 to 17 who are maltreated. London: The Children’s Society cited by Research in Practice (2014) Strategic Breifing; Risk taking adolescents and child protection. 18 Cossar J et al (2013) Op cit page v Final Version 17 May 2021   12his mother and feeling protective toward her. Fred was not always seen alone (e.g there is no evidence he was seen alone during the assessment by the Local Authority one social worker as he should have been). Covid restrictions meant that more engagement by practitioners had to be by phone (including the Initial Child Protection Conference) or face to face visits limited in duration (social work visits in Local Authority one were restricted to 15 minutes). This meant that Fred might not have always been able to express his views freely and that, where contact was not face to face, practitioners’ ability to identify this through his body language was hindered.  3.23. Evidence from records provides several examples of Mother’s reluctance to have agencies involved. After Stepfather’s suicide attempt in November 2020, she told the police that she did not want her details passed onto other agencies. After the attempted hanging by Stepfather incident social work records describe Mother’s behaviour as being agitated and verbally aggressive as she did not want social workers involved. These views were undoubtedly influenced by her anger at the care proceedings many years previously, which Fred will have been aware of, and which may also have influenced him directly; Fred told the FCAMHS worker in March 2020 that he “hated social workers” as he believed they “messed his life up 9 years ago”. Awareness of and or agreement with his mother’s views will likely have been an additional barrier to Fred expressing negative views about his living arrangements while he was living with her. Records also show that Mother’s support for Fred to engage with agencies was inconsistent. The FCAMHS and YOS workers agreed it was important to resume meeting with Fred alone, especially without Stepfather being present after hearing him teasing Fred when he was speaking to practitioners by phone due to covid restrictions and noticing Fred engaging better when he was not present.  Summary of learning: Engaging, safeguarding and supporting teenagers, including the voice of the child   The importance of making opportunities to build trusting relationships between practitioners and children    It is helpful for practitioners to be aware of research findings about the five main barriers to children making disclosures: emotional discomfort; worry about the family knowing; underestimating the seriousness of the concern; threats; and fear of not being believed.   The importance of reflection on any contradictions between the child’s expressed wishes and their lived experience.   Theme:   How agencies worked together: referrals, assessments and plans   3.24. There were two occasions where more follow-up and/or referral to Children’s services would have established earlier that Fred was living in Local Authority one and then prompted some reflection on the suitability of the arrangement and an opportunity to mediate between him and his grandparents at a point when the new living arrangements might have been viewed as more like an extended visit rather than a permanent change.  In mid-August 2019 Fred had been reported missing from his Paternal Grandparents home. Because his whereabouts were known, and that these were being with his mother and because he had not been reported missing by his Paternal Grandparents, the incident was closed by the police without obtaining more information which would have revealed the historical and current concerns that Paternal Grandparents had about Fred living with his mother. Had a missing report been submitted to Children’s Services in both the home and host authority (i.e as per local guidance 19  this would have prompted the offer of a Return Home Interview or an                                                            19 https://www.teescpp.org.uk/procedures-and-guidance-on-specific-issues-that-affect-children/children-who-go-missing/ Final Version 17 May 2021   13assessment by a social worker if Fred went home to his grandparents or refused to return to them respectively. Either might have enabled mediation at a stage before positions on both sides hardened. An earlier social work assessment might also have been prompted had the police made a referral about the domestic abuse in September 2019. Whilst the information was shared once the social worker assessment commenced in November 2019, this was not done at the time because the assessing police officer did not think the incident met the risk threshold. Their view might have been different had they known that Fred had been prevented by the SGO from living there until very recently.  3.25. Referrals made to Local Authority one were promptly shared with Local Authority two. However social workers’ attempts to engage the family were not always prompt in either authority and the pace of assessment and intervention was delayed due to transfer between local authorities and staff.  There is no evidence of any attempt to contact Mother and Fred until 2 weeks after the referral in November 2019, for reasons which are not known, when a successful home visit was made a few days later. Local Authority two had accepted the referral because theirs was initially considered to be Fred’s area of permanent residence due to the SGO, consideration should have been given as to whether involvement should have been a joint approach with Local Authority one or undertaken alone by Local Authority one given Fred had been living with his Mother for more than 3 months by the time of the referral. Social work managers from both areas told this review that discussions about the need for or timing of any transfer were not unusual, and it is not known why one was not had in this case.    The first social work assessment was concluded in mid-January 2020. The assessment and consequent Child in Need plan did not include anything about the YOS involvement because social worker did not become aware of it until contacted by the YOS worker at the end of January 2020.   3.26. The assessment was delivered by hand by the social worker from Local Authority two after several unsuccessful attempts to visit to share it with Mother and Fred. Mother had agreed that a referral could be made to Local Authority one; Local Authority two made the referral to Local Authority one in mid-January 2020. They were requested to send a copy of the assessment, the CIN plan and any meeting minutes. Although there is evidence this was sent, neither the referral nor the information is on Fred’s record for reasons which are not known.  There is no evidence of any consideration by either authority of any kind of handover meeting or joint visit. Whilst the family were not responding to attempts to visit, given that Mother had given consent to a referral, it would have been good practice to have tried to arrange a handover. Joint working would have ensured that the Local Authority one social worker had a better understanding of the impact of the history on Fred’s current circumstances and the nature of intervention recommended.  If Mother had refused to engage then the impact of this could have been considered as a risk factor i.e., whether this meant Fred was at potential risk of significant harm.  3.27. In mid-February 2020, Local Authority one Children’s Social Care decided to commence their own assessment after a further referral from the police about domestic abuse, having clarified that Local Authority two was no longer involved. First contact with Fred was not made until two weeks later, this was due to a combination of the assessment being given a lower priority (with senior manager oversight) due to capacity to meet service demand, plus two unsuccessful visits.  Sight of the Local Authority two assessment might have informed the priority rating for a first visit and would subsequently have informed the Local Authority one assessment. At the time the Assessment Team was undertaking what practitioners described as “screening assessments”20 before handing over to the long-term team to put a plan in place to deliver intervention. The context for this approach was a fast-increasing demand after some necessary work to review thresholds for referral after an Ofsted inspection the previous November 2019 which had rated Local Authority one Children’s Services as                                                            20 This was a pragmatic response to difficult circumstances not an actual policy  Final Version 17 May 2021   14inadequate. The assessment was also conducted by a team manager, rather than a social worker, in a newly constituted team, newly arrived in post with a large caseload and without the local knowledge that facilitates engagement with other practitioners and knowledge of other potentially relevant services for children and families.   In other words, the social worker was under additional pressure due to being newly in post with a dual role and without the independent oversight and sign off that assessments should have.   The result was a relatively superficial assessment which did not include referring to previous records regarding the care given to Fred as a young child and likely impact of this, nor was Fred seen during the S47 enquiries prompted by the attempted hanging incident as he should have been. Because the decision to convene an Initial Child Protection Conference was made soon after this latest referral, within a very short time the focus was on transferring the case rather than providing any other intervention. The newly allocated social worker did not attend the ICPC and there was no handover in person. This coupled with the lack of detailed assessment would not have helped the new worker “hit the ground running”. There was no plan to address significant gaps in the social work assessment until these were discussed in supervision in June 2020.  3.28. A strategy meeting was convened in Local Authority one on the day of the attempted hanging incident by Stepfather in March 2020, followed by a visit by a social worker to Fred. There was no health representation at the strategy meeting; the FCAMHS worker and the school nurse were both invited but were unable to attend due to the (necessary) short notice, although the FCAMHS sent an update regarding their involvement to date with Fred and future plans. There is no evidence of information being sought from a GP about Fred or either adult; the latter was particularly relevant given the nature of the incident and history.  Information about Fred’s health was sought and received via the “Healthy Child” electronic information sharing system in preparation for the Initial Child Protection Conference (ICPC). This system does not provide information about parents, a separate request had to be made, which it was in this case, but not received as previously described. A request was also made for a GP’s report to the ICPC, which was not received, for reasons which are not known. Since the period covered by this review, considerable work has been done with the 80 GP practices and the 4 local authorities which comprise the South Tees Safeguarding Children Partnership to improve communication with GPs about child protection conferences and the rate and consistency of their written contribution to them by use of a standard template for reports. This includes a clear expectation that GPs should provide relevant information about parents. This has improved the rate of reports received and there are plans to conduct an audit on the quality of them during 2021.  3.29. The Initial Child Protection Conference (ICPC) was held four days late, and by phone conference due to Covid restrictions. It was a unanimous decision that a Child Protection Plan was necessary. The category of abuse was Neglect, for reasons which are not clear.  The social work report had recommended a category of emotional harm whilst noting elements of neglect and records show practitioners talked about emotional harm rather than concerns about the quality of the basic care Fred was receiving, where the gaps were essentially to do with dental care, missed immunisations and attendance for education and training. Fred and his mother did not share practitioners’ views about the high level of concern. Practitioners told this review that it is increasingly unusual for an older teenager to be made subject to a Child Protection plan. This is because the risks for that age group tend to be community based, where alternative approaches are more effective, rather than due to the care given by and/or circumstances of the parents. Whilst practitioners appropriately explored any signs of vulnerability to exploitation in the community, they were clear that a Child Protection Plan was necessary due to the risks pose by the behaviour and characteristics of Fred’s parents.   3.30. The first child protection core group was held within 10 days of ICPC, as it should have been, and attended by Mother Fred, FCAMHs and SW.  The second Core group in early May 2020 was Final Version 17 May 2021   15cancelled and rescheduled a week later but terminated early due to the SW’s difficulty dialling others into the meeting. There is no evidence that a Core Group was rescheduled until after incident that prompted this review, for reasons that are not known.   3.31. Overall, the Safety and Child Protection planning for Fred was not sufficiently robust or joined up.  The content of child protection discussions and plans were over-reliant on Mother and Stepfather engaging despite ample evidence of longstanding concerns including their reluctance to engage.  Records show a specific conclusion at the Initial Child Protection Conference that their capacity to change was assessed as being low. Records show they refused all services related to domestic abuse or substance misuse. In March 2020, the social worker had referred Stepfather to the mental health charity MIND for support at his request as an alternative to community mental health services which he had refused for reasons that are unknown; there is no evidence that MIND got in touch with him before the incident that prompted this review, possibly due to the impact of Covid on capacity.       3.32. For younger children consideration would have been given to the need for care proceedings, given Fred’s age and wishes this would not have been possible without his co-operation.  Especially given his age, a good strategy would have been to engage Fred specifically in individual safety planning work to identify his own safe people, places and strategies. The FCAMHS worker devised a wellbeing risk management plan in collaboration with Fred which indicated steps Fred would take according to the level of concerns he had about his mood, sense of safety, risk of suicide and self-harm. The FCAMHs worker helped Fred put relevant phone numbers for her/the CAMHs service into his phone and thought Fred had a good understanding of this “traffic light” system; he made contact appropriately when he felt he needed to.  3.33. The benefits to children of the formal use of written Safety Plans was highlighted in the previously mentioned Ofsted inspection of Local Authority one in November 2019. These plans began to be promoted in early 2020 and their use to support children’s safety accelerated after the arrival of Covid.21 Safety Planning in Local Authority one has evolved from the use of written agreements,22 which tend to start with the perspective of the agencies about the concerns.  Safety Plans will not be effective unless the parents and older children engage; Both Fred and his mother refused to sign the one produced after the child protection conference. For older children an approach to Safety Planning which started with what the concept of “safe” physically and emotionally meant to them might be more effective. This does not prevent practitioners also sharing their concerns. It would be important to do this work with a young person alone to give consideration as to whether and when the whole or any part of Safety Plans should be shared with parents; there maybe elements that would reduce the young person’s safety if the parent were to be aware of them. Practitioners told this review that Safety Plans were living documents which were updated when an incident indicated this was necessary whereas Child Protection Plans are more overarching and reviewed at the Core Group.23 Child Protection plans are a recognised longstanding multi-agency tool whereas the Safety Plans and FCAMHS risk management plans respectively, are single agency tools. Whilst                                                            21 The Safety Plan produced at the end of March 2020 includes one action specifically relating to Covid; increasing visiting frequency and Fred being available on his phone. It does not address the potential impact of Covid on the family or the level or nature of the risks.   22 A Written Agreement is a tool for monitoring parents behaviour, they will usually outline the concerns that the Local Authority have with regards to the care and wellbeing of the children, and what they would like the parents to do to address these concerns.  It should also outline what the Local Authority will do to support parents.  For a Written Agreement to be effective they should be properly drawn up, monitored and evaluated. These are not a legal document, however they can be used as evidence in evidence in Court that parents are not working honestly with professionals and/or not making the necessary changes to provide adequate care of safeguard their child 23 A Core Group is the group of family members and practitioners involved with the child and family  who meet regularly when a child is  the subject of a Child Protection Plan. Final Version 17 May 2021   16practitioners told this review that their contents were shared verbally with other practitioners working with Fred and used to inform each of the plans, they felt that having three separate documents was potentially confusing both to practitioners and to the family. Whilst having arrangements to streamline plans into one was recognised as a challenging aspiration, attempting this could also address the need for any plan to be in a child friendly format.    3.34. Fred did not receive any education or training from September 2019 until the end of January 2020. When arrangements were put into place with a training provider his engagement was poor, and unfortunately the provision had to close before the end of March 2020 due to Covid restrictions.  The gap in provision during the autumn term is important because, apart from having a right to an education, being in education or training is usually a protective factor for young people, providing opportunities for: social contact with peers; trustworthy adults to turn to (who will also notice changes in behaviour); stimulation and occupation; and supervision during the day when otherwise young people can go missing; or, as in Fred’s case, relief from potential exposure to inappropriate or frightening behaviour by adults. Fred’s initial wish to attend college was delayed by the need to obtain a birth certificate. The Work Readiness Team (WRT) became aware of his presence in Local Authority one due to notification from Local Authority two via the national data base. Because Fred was subject to a SGO, someone with parental responsibility could have asked for support and advice for him from the Virtual School.24 This might have enabled him to get involved education or training provision earlier.  3.35. The WRT were persistent in their support to enable access to appropriate training. However, Fred’s attendance at the training provider was poor and a lack of follow up by the WRT meant that this was not addressed. As a result of this review the WRT has developed a tracking procedure for 4 weeks post placement to reduce the chance of young people not engaging or dropping out of provision at an early stage. Initially the WRT practitioner was working in isolation and without knowledge of Fred’s background and circumstances because they had not carried out checks about who else is involved or consider whether the young person might benefit from an Early Help Assessment.25   Such checks would have revealed the involvement of YOS and that there had been recent contact with Children’s Services in Local Authority one, which should have led to steps to establish more details of the nature of any concerns and involvement. When Fred told the WRT worker that YOS was involved, the WRT worker contacted the YOS and explained that Fred had recently commenced a course with NACRO.  After Fred was discussed at VEMT in April records suggest that the WRT were asked to make further contact with Fred, but this did not happen for reasons which are not known.   3.36. Several practitioners told this review that home visits to Mother and Stepfather’s home were quite intimidating, often lots of adults outside some with dogs and men would wolf whistle. The school nurse told this review that when she had arrived during a visit by paramedics, they expressed concern that it was not safe for her to be there alone. When home visits were necessary, a number of practitioners made arrangements to visit in pairs including making good use of joint visits for practitioners from different agencies.   Practitioners told this review that agencies in Local Authority one had a longstanding positive culture of identifying and managing potential risks to staff, and that this included good support in supervision, and careful risk assessment and preparation in the social work assessment teams when making visits to families that were not known, especially if referrals contained indicators of potential risks to staff. In exceptional circumstances this includes involving the police. At the same time practitioners were conscious of the dilemmas of joint visiting; that these can be perceived as heavy handed by families and therefore counterproductive. They reflected that                                                            24 Virtual School staff provide children who are or have been in care with advocacy, support and advice on educational issues 25 During the period covered by this review it was not a routine expectation that staff carry out checks about who else might be involved or screen to establish whether young people might benefit from an Early Help Assessment. Final Version 17 May 2021   17looking back, despite the precautions they took, that visits were shorter than they ideally should have been which prevented opportunities for more in-depth work. Practitioners recognised that, if they felt intimidated, that this could apply also to children living in the household, which Fred did disclose once he was no longer living there, and that explicit discussion about the impact of intimidatory behaviour on staff and on children as a “team around the child” over and above sharing information with Each other about risks, could be helpful. Practitioners discussed the benefits to children of explicitly opening discussions with parents about how they/their circumstances come across to practitioners and how this could affect the effectiveness of the work or the kind action that agencies might take. They described the value for example of agreeing with parents’ specific ways of managing the intimidatory behaviour, for example that on pre-arranged visits person X will not be present. They also recognised that these are conversations for a confident and experienced social worker, and which should be planned carefully in advance.  3.37. Summary of learning: how agencies worked together, referrals assessments and plans   Children and young people are sometimes subject to more than one plan to safeguarding their welfare both single agency and multi-agency. This can be confusing for the family and practitioners; there would be benefits in considering how to develop more streamlined arrangements.    Especially for older children it is helpful to develop any plan to safeguard them from the starting point of what being safe physically and emotionally means to the young person. This does not prevent practitioners also discussing their concerns with the young person.    The potential value of confident and experienced social workers explicitly addressing intimidatory with parents.   See recommendation A   Theme:   Assessing the role of extended family members    3.38. Paternal Grandparents had a Special Guardianship Order (SGO); whilst this does not end the birth parents’ legal relationship with a child or remove their parental responsibility entirely, it gives the Special Guardian(s) the right to make all major decisions about the child throughout their childhood. Whilst it was necessary for every social worker to try to engage with Paternal Grandparents because they had parental responsibility, more importantly, Fred had been living with them since 2011, for more than half of his life. Whilst there is some evidence that the relationship was strained from both parties’ perspectives (each felt rejected by the other, for example) and practitioners knew that Fred felt some sadness at the loss of contact with his Paternal Grandparents, there is little evidence of systematic or sustained efforts to assist Fred to reflect on what was an important relationship, and the merits of trying to repair it, irrespective of where he was living.  3.39. Practitioners told this review that whilst social workers would ask about family relationships in assessments this was only occasionally done systematically through using a tool like an Ecomap26 or “Inner Circle”27 model, which is also sometime used by YOS practitioners. Early Help (council) practitioners do use Ecomaps on open family cases.  Ecomaps are diagrams which show the relationships which are significant to children (or parents). These can include family members, friends, neighbours, community resources like school, practitioners or even pets and should be                                                            26 http://www.socialworkerstoolbox.com/ecomap-activity/    27 A Diagram using concentric circles which puts the child in the centre with others placed nearer or further according to the significance of the relationship  Final Version 17 May 2021   18completed with the child (drawn freehand or using a template). They can be very helpful for use by any practitioner, not just social workers, in doing direct work with even very young children to better understand family dynamics and support. Practitioners suggested the benefits of including consideration of relationships with practitioners to shape decisions about who is best placed to do any direct work with a child or young person.  3.40. Parents as well as children can respond better to visual techniques for gathering and making sense of information as an alternative to answering questions, however sensitively put. Use of an Ecomap or other similar tool with Fred might have teased out who was significant to him now and who made him feel safe to inform safety planning as well as identifying relationships that were difficult in some way, where support might be needed to help him manage them.  3.41. The social worker from Local Authority two told this review about Family Safety Network meetings, which had come into being in their area since the period covered by this review. Social workers have been trained to lead meetings involving extended family members and friends identified by the parent/child to produce a Family Safety Plan. Local Authority one has a system of Family Group Conferences28 (FGC) which are intended to perform a similar function. These were available during the period covered by this review but a FGC was not suggested before June 2020 by the team manager in supervision when taking stock of the case just before the incident which prompted this review. It is not known why a FGC was not considered before.  3.42. Practitioners only appear to have had one detailed conversation with Paternal Grandparents during the whole period under review. This was the occasion in November 2019 when Paternal Grandfather attended the office to meet the social worker from Local Authority 1. He told the social worker that he and his wife had tried to get Fred back, however Fred had refused by text and told them he could make up his own mind now he was 16 years old. Especially given there was no evidence of any advice or support to Paternal Grandparents on improving the relationships with him or encourage him to return home, the recommendation of the Local Authority Social Work Assessment in February 2020 that they “exercise their parental responsibility to safeguard Fred” seems unrealistic. There is some evidence of the social worker from Local Authority two in particular subsequently trying to contact the Paternal Grandparents, to no avail, and that they had moved without providing a new address to any agency working with Fred. However, members of the extended family still had their contact details; records show that Paternal Uncle tried to encourage contact for Fred around Christmas time. More could have been done to try and engage them via him.  3.43. After the attempted hanging by Stepfather a Local Authority one social worker contacted Paternal Grandfather to ask if Fred could return there. Paternal Grandfather said due to downsizing they no longer had a spare bedroom but that the family could find him somewhere if needed. This offer does not seem to have been explored with either them or with Fred. Fred might have been receptive to the idea as, by April 2020 at the latest, his comments to practitioners suggest he had come to recognise that living with his Mother was not the best place for him. It is not known which family member(s) Paternal Grandfather was referring to. Records show that some practitioners were aware that Maternal Grandparents and Paternal Uncle were in contact with Fred from as early as November 2019 but there appear to have been no enquiries about his relationship with them or their capacity to support him while living with his Mother, or indeed as an alternative place to live.  The first evidence of family members being considered as a resource to support Fred was not until shortly before the incident which prompted this review, when the team manager asked the social worker in supervision to make a referral for a Family Group Conference.29 There is no evidence of contact by any practitioner with Maternal Grandparents until after Fred began living with them in June 2020.  Social                                                            28 https://www.frg.org.uk/involving-families/family-group-conferences 29 Support from an independent agency to help family members make a plan to protect and support a child or young person  Final Version 17 May 2021   19workers told this review that this would have been more likely in different contexts, for example had the Family Safety Network meetings been in place in Local Authority two or the workload been less demanding in Local Authority one respectively.  3.44. Practitioners told this review that social workers were likely to know what a SGO was, but that awareness amongst other practitioners was patchy.  The circumstances when this matters include those where it is important to know that the guardian(s) has the right to make major decisions about children’s lives, including where they live, and about any service entitlement.  Practitioners told this review that awareness amongst non-specialist police officers was likely to be low; and that this may have affected the response from the police when Fred was reported missing in August 2019.  3.45. Government guidance for Special Guardianship Orders30 was amended in the light of research and consultation in 201531 that identified that three quarters of respondents thought that the assessment process and support for Special Guardians before, during and after the making of a SGO, should be improved. The current guidance stipulates that local authorities are required to make provision for Special Guardianship Support Services which include counselling, advice, financial support and assessment of need. The financial support includes local authorities considering access to the adoption support fund; most children subject to SGOs have the same needs for therapeutic help as adopted children, and it is not unusual in both cases for needs to rise during adolescence.  3.46. Under regulations in place since before the time Fred was made the subject of an SGO, for three years after the making of an order the duty to provide support services applies to the local authority which last “looked after” the young person i.e Local Authority one initially in Fred’s case, and then subsequently to the local authority in which they reside. Whilst Fred lived with his Paternal Grandparents the support duties would apply in Local Authority two, should he or his grandparents have requested help. Those children subject to a SGO who were “looked after” (in care) immediately before the making of the SGO are “qualifying care leavers” under section 24 of the 1989 Act which entitles them to advice and assistance, which can include cash, from the local authority who “last looked after” them (i.e Local Authority one in Fred’s case) if they are between the ages of 16 and 21 years as Fred was/is. During the period under review Fred’s needs met the threshold to be assessed and supported under S17 of the Children Act 1989, so his rights regarding being subject to a SGO are less relevant. Where they do have relevance is prior to that time, when relationships were breaking down between himself and the Paternal Grandparents, and in the future up until the age of 21 years.  3.47. At the point of the Special Guardianship order being made it would be usual to provide a support plan which, at the very minimum, would explain to Guardians local authority responsibilities if they needed (additional) help in future.  It is not uncommon for there to be no need or request for this for a number of years by which time guardians might not recall what they were told, and/or, as in Fred’s case, legislative entitlements had changed. Practitioners confirmed to this review that Special Guardians would not therefore know what they are entitled to unless they came to the notice of the local authority and when Paternal Grandparents did, there were limited opportunities to discuss this with them due to their lack of engagement. There is no evidence of anyone telling Fred’s mother about any entitlements due to the SGO status, including rights as a “qualifying care leaver”. Social workers told this review that, at point of ceasing involvement early in January 2021, Fred was advised how to obtain further support regarding education should he need but there is no evidence that he or the Maternal Grandparents with whom he is living has been explicitly informed of his rights as a “qualifying care leaver”. Children’s Social Care staff intend to do this as a result of this review.                                                               30https://www.gov.uk/government/publications/special-guardianship-guidance 31 https://www.gov.uk/government/consultations/special-guardianship-review Final Version 17 May 2021   20 Summary of learning: Assessing the role of extended family members   Awareness of the legal implications of a child being subject to a Special Guardianship Order in terms of parental responsibility and potential eligibility for support services is variable amongst practitioners working with families.    More systematic exploration of a child’s significant relationships including with extended family and practitioners would be assisted by use of Eco maps or similar tools.    Children and extended family members may each need advice, support and encouragement to repair relationships; this should be given early consideration and kept in mind where the relationship is a significant one.    See recommendation B&C  4.  POSITIVE PRACTICE  When undertaking a review, it is important to also consider the kind of positive practice   that has broader applicability to protecting or supporting other children and families.  Examples of positive practice include;    The soclal worker in Local Authority two overcame Fred’s nervousness in speaking with her and gained his views    YOS worker made joint visit with the FCAMHS worker to introduce her and liaised with the training provider about Fred’s poor attendance at training   The FCAMHS clinician was tenacious in her attempts to engage with Fred, including through the challenges of covid  Despite Fred having previously declined a Health Assessment by the school nurse, this was offered again after the incident that prompted this review, and face to face contact with Fred successfully achieved   Use by FCAMHS of the Trauma Informed Pathway   Historical social care files from Local Authority one were sought and reviewed to gained a perspective on family history and functioning   Educational needs were recognised by the Work Readiness Team who supported him to access appropriate provision   The work readiness team provided a range of support, including to open a bank account, explaining his options and getting him a place with a training provider   The training provider kept Fred’s place open despite poor attendance   Chair of the child protection conference asked relevant questions of mother about her substance abuse   When called to incidents of domestic abuse the police usually made prompt positive interventions eg arrest of alleged perpetrator of domestic abuse Final Version 17 May 2021   21 When Fred was arrested for his role in an assault a prompt referral was made by the police for YOS intervention to prevent further offending  For each attendance by Mother or Stepfather at the Emergency Department, home circumstances were explored to identify any safeguarding issues   Fred’s mental health was assessed by Liaison and Diversion Team both times he was in police custody   Regular communication between both Local Authority one social workers and the YOS and FCAMHS workers to sharing information in a timely way between meetings; use of dedicated professionals email    FCAMHS worker providing written information about their involvement to the strategy meeting as they could not attend.   practitioners appropriately explored any signs of Fred being vulnerable to exploitation in the community. 5. CONCLUSION  5.1 Fred made the decision to move to live with his mother apparently due to the strained relationship he had with Maternal Grandparents with whom he had lived several years under the auspices of a Special Guardianship Order. Whilst it is appropriate to take seriously the views of a young person of his age, practitioners did not reflect sufficiently collectively or with him about the contradictions between Fred’s expressed wishes and his sometimes distressing or frightening lived experience. Although his mother and stepfather were misusing substances there was no clear evidence of significant or ongoing substance misuse by Fred; the incident which prompted this review was out of character. Whilst there are several learning points from this review which will be useful to improve services for children and families in South Tees, there was also considerable evidence of good practice in this case from all agencies.   6. RECOMMENDATIONS    6.1 To address the multi-agency learning, this Child Safeguarding Practice  Review identified the following recommendations for South Tees Safeguarding Children Partnership (STSCP).  A) That STSCP considers how best to ensure that a child’s perspective on what being safe physically and emotionally means to them is a starting point for any plan to safeguard them and that thought is given about how multiple plans in use for any individual child could be explicitly linked or streamlined. B) That STSCP considers how best to promote the use of evidenced based tools to better support practitioners in understanding family dynamics and support for children including who is best placed to do any direct work with a child or young person. C) That STSCP considers how best to raise awareness of the legal implications of a child being subject to a Special Guardianship Orders in terms of parental responsibility and potential eligibility for support services is improved across all practitioners who work with children and families.   D) That STSCP considers how best to ensure relevant information about adults involved in caring for children is obtained from GP records at all stages of the child’s journey.  Final Version 17 May 2021   22E) That STSCP ensures that the current work to improve the local response to neglect adequately focuses on the needs of adolescents F) That STSCP seeks assurance from each agency involved in this review that learning points have been identified and action has been/or is being taken to address and disseminate them.        