Non-accidental head injury to a 2-year-old boy, Child A, in February 2016. The injury was discovered during an unannounced visit by a social worker. His mother had no explanation for the injury and had not sought medical help. Child A lived with his mother and older brother (Child A1) who was born in 2007. Both children were subject to Child Protection Plans under the category of risk of emotional harm on two separate occasions. Reports of incidents of domestic abuse as well as the physical abuse of older brother by mother. Evidence of mother's complex mental health issues, drug and alcohol abuse and series of abusive relationships. Child A1 is described as a young carer for his mother and younger brother. Ethnicity or nationality of Child A is not stated. Lessons learned include: the seriousness of the concerns and risks to the children were not effectively communicated, shared or addressed; professionals need to retain open minded curiosity and consider all potential risks to children; and professionals should be supported in considering the impact on them of working with people who present as aggressive or with challenging behaviour. Recommendations include: conduct a multi-agency review of the use of the category of emotional harm in child protection plans; ensure that professionals understand the purpose of the Core Group and Child Protection Conference; and recognise the impact on practice when working with adults with violent and aggressive behaviour or disguised compliance.
      
 Title:  Overview report: serious case review: SCR Case A 2017. LSCB: Leicestershire and Rutland Safeguarding Children Board Author: Sue Gregory Date of publication: 2019  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 March 20191       OVERVIEW REPORT  SERIOUS CASE REVIEW  SCR Case A 2017                Independent Chair and Author: Sue Gregory                    Final March 20192 Contents                                                                                     Page                                                                                           Section 1                 Introduction         3  Section 2                 Methodology         4                                  Section 3                 Key events during scoping period      5  Section 4                 Analysis and practice learning      5  Section 5                 Conclusions       10  Section 6                 Learning Points      11  Section 7                 Recommendations      12  Section 8                 Actions to date      12   Appendix 1              Terms of Reference      16                               Final March 20193 1. Introduction  1.1 Child ‘A’ was born in 2014 and lived with his mother and his brother, Child ‘A1’, who was born in 2007.   1.2 On 21/2/2016, Child ‘A’ was found with an untreated head wound by a Social Worker (SW) during an unannounced visit to the family home. His mother had no explanation for the injury and had not sought any medical attention. A medical examination at Leicester Royal Infirmary found he had a depressed fracture to the frontal parietal bone of his skull which was suspected to be a non-accidental/unexplained injury. A full investigation was undertaken in accordance with S47 of The Children Act 1989. Child ‘A’ and Child ‘A1’ were subsequently placed with their respective fathers where they have remained. Child ‘A’ has recovered from his injuries.  1.3 Both children were subject to Child Protection Plans (CPP) under the category of risk of Emotional Harm at the time of Child ‘A’s injury. This was the second episode of them being subject to a CPP.   1.4 The Leicestershire and Rutland Local Safeguarding Children Board (LSCB) commissioned a Serious Case Review (SCR) in accordance with Working Together to Safeguard Children 2015 and the Local Safeguarding Children Board Regulations 2006. The Terms of Reference (TOR) for this SCR are found in Appendix 1.  1.5 The LSCB appointed Sue Gregory as Independent Chair and Overview Author for this review. Sue is a Health and Care Professions Council (HCPC) registered SW with over 30 years’ experience, predominantly in children’s services and, in particular safeguarding, as front line worker, manager, child protection co-ordinator, head of safeguarding and director. She has worked independently as MatthewThomas Associates since 2009 and has extensive experience of undertaking independent reviews in both children and adult services.  1.6 This report seeks to provide an analysis of what happened, what could be done differently and what has already changed. The specific questions to be considered in this review were identified by the LSCB as:  Were all assessments and interventions timely?  Were all risks and the source of those risks to the children identified and addressed?  Was there sufficient professional challenge of mother and her behaviour?  Was Emotional Harm the right category of risk for these children and therefore was the protection plan appropriate and relevant to address the risks?  In addition, the Independent Chair of the L&R LSCB requested:  Scrutiny of the step down process from CPPs  and to clarify whether this was followed through and was effective in this case  Consideration of any required improvements in local pathways to respond to Domestic Abuse (DA).      Final March 20194 2. Methodology  2.1 All agencies to whom Child ‘A’, Child ‘A1’ and their mother were known have participated in this review.   2.2 Agencies were asked to complete a detailed chronology of their involvement with the family during the scoping period, 1/1/2014 to 21/4/2016. They were also asked to identify any relevant information prior to this period, in particular, issues relating to DA, Adult Mental Health, Child Protection and Alcohol/Substance misuse. Sue Gregory met with the authors of these reports.  2.3 The Serious Case Review Panel, chaired by Sue Gregory, met on four occasions to plan and deliver the review, and formulate the findings and conclusions. Membership of this panel is found in the TOR in Appendix 1.  2.4 A multi-agency meeting of staff who had worked directly with the family contributed significantly to the accuracy of facts, analysis and learning. This was also an opportunity for operational staff to feel part of the review process as well as provide a sounding board and challenge to the Independent Chair and Overview Author’s findings at that point.                         Final March 20195   3. Key Events during the Scoping Period  3.1 The scoping period can be divided into 4 phases of activity:  January 2014 until first Initial Child Protection Conference (ICPC) on 21/8/2014  ICPC and CPP until removal of CPP on 6/5/2015  End of CPP and beginning of Children in Need Plan (CiN) until second ICPC on 26/2/2016  ICPC and CPP until incident on 21/4/2016.   4. Analysis and Practice Learning  4.1 This section sets out to analyse practice in the context of the specific questions set out in the TOR for this review and will address each in turn.   4.2 Were all assessments and interventions timely?                4.2.1 There had been 11 Social Care led assessments in respect of the family up until the incident that led to this review. While there is no indication that these were not completed within the required timescales, there is concern about the robustness and outcomes of these assessments. A significant example of this is the Core Assessment that was noted as being completed on 25/3/2014 in respect of concerns about Child ‘A1’ as a result of the reports of incidents of DA. The children’s mother was known to be 4 months pregnant at the time of the assessment. The SW’s assessment appropriately identified that the threshold of significant harm was met in relation to DA, mother’s mental health and that Child ‘A1’ was describing supporting his mum after Child ‘A’s father had upset her. In addition the children’s mother was in denial about the concerns. It is of concern that the manager’s decision was not to proceed to ICPC but that a Signs Of Safety (SOS) meeting should be convened and that support should be given to the children’s mother and Child ‘A1’ regarding DA issues and risks to the new baby.   Learning Point: An ICPC should be convened whenever the outcome of an    assessment is that the threshold of significant harm has been reached and  there is no evidence that the risks to the child, including unborn child,  have not been minimised or removed. A SOS meeting does not replace the requirement for an ICPC.         4.2.2 The referral to Social Care by the Midwife on 7/4/2014 should have been recorded as a referral and should have at least prompted a review of the decision not to proceed to ICPC less than 2 weeks earlier.          4.2.3 The children’s mother’s attendance at hospital on 14/4/2014, following trauma to her abdomen and fear about her unborn baby, should have been referred to Social Care. Similarly, the Midwife’s concerns, noted on seeing the children’s mother on 30/4/2014 when she had a broken thumb and scratches allegedly as a result of a fight, should have been referred to Social Care. This would have provided another opportunity to review earlier decision making.          4.2.4 The S47 enquiries leading to the first ICPC were conducted in a timely manner and the meeting was arranged within required timescales.    Final March 20196        4.2.5 Child ‘A1’s disclosure of being physically abused by his mother just 8 days after the first ICPC and being placed on a CPP were appropriately investigated under S47. However, a visit should have been made to the family home and the child seen on the same day and not completed 3 days later, particularly as the intervening time was a weekend and therefore Child ‘A1’ could not be monitored in school. The Police referral following the DA incident on 11/1/2015 assessed as Medium Risk was not followed up by Social Care. It would be expected that the children would have been seen.  Learning Point: The decision not to see the child on the same day following a disclosure of physical abuse was not compliant with the LSCB procedures. While these should have been followed, it was even more pertinent for a child who was already on a CPP. Similarly, the children should have been seen following the referral from Police.         4.2.6 Child Protection Review Conferences were held within required timescales. The decision was made at the second review conference on 6/5/2015 that a CPP was no longer needed and that outstanding work, including completion of Social Care assessments and direct work, would be completed under a CiN plan. This appears to have been made on the basis that: there had been no reported incidents of DA since January; a belief that the children’s mother and Child ‘A’s father were no longer in a relationship; and that the children’s mother was co-operating with professionals. It is of concern that the SW records meeting Child ‘A’s father soon after the review conference “as agreed in the CiN plan”, and gathering information about his background, parenting experience and wishes in connection with Child ‘A’. It would have been expected that this should have been completed to inform the previous CPP. There is no evidence of this information being placed in the context of an assessment.         Learning Point: On the basis of information available to this review, this        decision was over optimistic and the sustainability of a safer environment        had not been thoroughly assessed or tested.         4.2.7 The School promptly and appropriately referred the injuries seen on Child ‘A1’ and his disclosure on 8/2/2016. The information was correctly investigated under S47 and resulted in the second ICPC. It is unclear why legal advice was not recommended or sought given the history, lack of real change and lack of impact planning.  Learning Point: Legal advice should be sought where there is a long history of   concern with no evidence of real change.         4.2.8 The SW should have visited the home and seen the children after being informed about the injury to Child ‘A’ and the subsequent hospital visit on 3/3/2016. There should have been more professional curiosity about the incident in the context of him already being on a CPP.               Learning Point: as 6.2.5         4.2.9 It is of concern that it is only noted at the Core Group meeting on 14/3/2016 that parenting assessments should be completed in respect of all of the parents. Such assessments should have been undertaken much earlier.         4.2.10 All health related assessments in respect of the children’s mother, including her mental health, appear to have been completed appropriately and timely in a context of the children’s mother cancelling and DNA some appointments.   Final March 20197        4.2.11 Most appropriate health assessments were completed in respect of both children although the children’s mother missed some significant appointments for example Child ‘A’s 1 year assessment. All appointments were rearranged by Health professionals and assessments were eventually completed.         4.2.12 DASH (Domestic Abuse, Stalking & Harassment and Honour Based Violence Risk Assessment Checklist) risk assessments were completed appropriately in the majority of incidents.  4.3 Were all the sources of risks to the children identified and addressed?         4.3.1 Throughout the scoping period, there appears to have been a held view that the risk to the children was as a result of the incidents of DA when the children’s mother was in a relationship with Child ‘A’s father. The belief that this relationship had ended, and therefore the risk had been removed, informed the removal of the first protection plans in May 2015. It is of concern that the evidence of the children’s mother’s own violent behaviour was not addressed or considered in the assessments or decision making.          4.3.2 Throughout this period there was a wealth of information about the children’s mother’s multiple complex issues which included mental health, diagnosis of Unstable Personality Disorder, Eating Disorder, and alcohol and drug abuse. There is no evidence that the impact of all of this on her ability to provide safe care for her children was robustly assessed.        4.3.3 There were a number of occasions when information was available about both parents of Child ‘A’s drinking, as well as potentially driving while under the influence of alcohol, but no evidence of questioning whether the children were with them at the time or who was caring for them.  Learning Point: All professionals need to retain open minded curiosity and consider all potential risks to children.         4.3.4 It is of concern that Child ‘A1’ was identified and labelled as a ‘Young Carer’ and was referred to Barnardo’s for support as such. This potentially masked the real issue which was that the children’s mother inappropriately required him to undertake a caring role for Child ‘A’ (there was evidence of him scalding his hand warming milk and another time when the children’s mother was angry with him for overheating it). Child ‘A1’ also reported that he comforted his mum when she had been arguing with Child ‘A’s father and suggestions that he thought of himself as her protector.   Learning Point: Caution should be used when referring to children living with parents with mental health and substance misuse issues. An assessment of whether their needs are being met and whether they are at risk should always be undertaken and inform the appropriate pathway.  4.4 Was there sufficient challenge of mother and her behaviour?  4.4.1 There is little doubt that the children’s mother had complex needs and was a victim of abuse. There was, however, significant evidence of her being a perpetrator of verbal and physical aggression. Her mood and behaviour were inconsistent and were likely to have at times been affected by her use of prescribed medication / alcohol / illegal substances. At times she was described as unstable and unpredictable while, other times, she was clearly able to engage with staff. It is clear that her behaviour impacted on staff and while some  Final March 20198 continued to engage with her and provide appropriate challenge, e.g. the Head teacher, others were able to say it was impossible e.g. Home-start.   Learning Point: All professionals should be supported in considering the impact on them of working with people who present as aggressive / with challenging behaviour.   4.4.2 There are points when the relationship between the children’s mother and her SW was concerning. For a period of time, a significant amount of communication was conducted via text messages. There is also evidence that, on more than one occasion, the SW was asking the children’s mother’s permission to visit the house, thanking her for allowing the visit and apologising for upsetting her. It is not clear how much this was influenced by the children’s mother’s behaviour or was just poor practice but it is understood the issues have been addressed with the individual worker.  Learning Point: The use of texting as a means of communication should be used appropriately to provide factual information and reminders and not to replace a telephone call or face to face conversation.  4.5 Was Emotional Harm the right category of risk for these children and therefore was the protection plan appropriate and relevant to address the risks?         4.5.1 On the basis of information provided to this review, it is clear that the category of ‘Emotional Harm’ was used in recognition of the evidence that living with DA is emotionally harmful. There is no doubt that the environment that both these children had lived in since birth, whether the children’s mother was in a relationship or not, was emotionally damaging and potentially the cause of long term harm. However, the immediate and short term risk to these children was of Physical Abuse, both as a result of the violence within the children’s mother’s relationships or perpetrated by the children’s mother herself. It is clear that some professionals held a clear view that the children were at risk of physical harm with at least one challenging the decision at conference. They report being told that ‘Emotional Abuse’ would cover all risks which would be addressed in the protection plan. Attendees at the focus group believed that they had a voice in the decision whether or not a child should be made subject to a protection plan but that the decision about the category of harm is the responsibility of the chair.   Learning Point: The purpose of naming a risk is to place professionals’ and the family’s attention where it should be and, in this case, should have been physical harm. All forms of abuse are inherently emotionally harmful but Emotional Harm is not intended to be used as a catch all category.          4.5.2 The protection plan did not appropriately address the presenting risks and the sources of those risks to these two children because they had not been properly identified. The plan was not SMART and it was therefore difficult to measure its effectiveness. There is evidence that the frequency of Social Work visits, and the children being seen by SWs, did not meet the requirements of the plan or comply with LSCB procedures. This should have been picked up in meetings of the Core Group and Social Work supervision. It is of concern that the Core Group meetings were noted as reviewing the plan when the purpose is to review the implementation of the plan and address any challenges. It is suggested that it is the purpose of the Review Conference to review the plan and make any significant changes.   Learning Point: Plans should be SMART. The distinct purpose of both the Core Group and Review Conference should be clear. Compliance with the plan should be monitored by the Core Group and in professional’s supervision.    Final March 20199 4.6. The effectiveness of step down processes from CP to CiN  4.6.1 The step down from CP to CiN was premature in this case and evidence suggests there remained confusion about whether actions were to protect the children or provide support to the children’s mother and the children. While there was a plan on the SW file, there was no evidence of any multi-agency meetings to agree the content and implementation of the plan. In this case it meant that, although there remained a great deal of activity by all agencies with evidence of some communication and sharing of information, there was no agreed and understood sense of purpose or co-ordination of that activity.    4.6.2 It is of concern that Health and Education colleagues on the panel and the focus group reported that the experience in this case was not unusual.  Learning Point: CiN plans are a statutory process under S17 of the Children Act and are intended to provide multi-agency plans to provide services to promote a child’s welfare. They should be afforded a clear focus of attention, be formulated by a multi-disciplinary meeting and be SMART.  4.7 Are improvements required in the local pathways to respond to DA where there are children in the family?   4.7.1 All but one of the incidents reported to the Police were appropriately identified as DA. A DASH risk assessment was completed and appropriate referrals were made to Children’s Social Care. An appropriate referral was made to ‘Project 360’ which resulted in a Victim Support Worker visiting the children’s mother. Concerns about the children on that visit were passed to the SW. An appropriate referral was made to Wallaction for ongoing support though the Independent Domestic Violence Advisor (IDVA) service but, despite numerous attempts to contact the children’s mother, she failed to engage. The concerns were referred to a Multi-Agency Risk Assessment Conference (MARAC), but lack of capacity meant that Child ‘A’s father and risk to the children’s mother were not discussed for 2 months.  Learning Point: On the basis of interventions in this case, it appears that the local pathways are adequate; however there should be consideration given to the capacity of the MARAC and whether it can meet local need in a timely fashion.   4.8 Other issues   4.8.1 Supervision: there is evidence of key Health staff accessing safeguarding supervision. There is also evidence of the SWs accessing regular supervision with the team manager. However, there is concern that many of the sessions appeared unfocused, did not provide adequate challenge or reflection and did not meet the policy requirements or standards.   4.8.2 There is evidence of good direct work with Child ‘A1’ by the School Nurse (SN) who used a variety of tools to ascertain his wishes and feelings. This elicited a great deal of information about what life was like for him and his relationship with his mother, including that he was scared of her and at the same time sought to support her.   5. Conclusions   Child ‘A’ and his brother had lived in a high risk environment since birth where there was evidence of, at times, uncontrolled violence   Final March 201910  That the children’s mother had a long history of mental health issues and alcohol abuse and that there was a long history of a series of abusive relationships    Although the family were visible and well known to a range of universal and specialist services, the seriousness of the concerns and risks were not effectively communicated, shared or addressed    That the children’s mother did, in the main, meet the basic needs of her children (a roof, clothing, food)   There is evidence of professionals being committed to engaging the children’s mother and working hard to support her needs, but that sometimes the primacy of the safety and well-being of the children was lost   There is evidence of some good practice, particularly by the School staff and SN, to hear Child ‘A1’s voice and represent that to Social Care who had a duty to investigate. Child ‘A1’ was able to tell his story of what life was like for him and Child ‘A’ and the responsibility he felt (and was placed on him by the children’s mother) to support his mum and brother. This responsibility was compounded by professionals who regarded him as a “Young Carer”   That the focus of Social Care assessments and interventions was based on a belief that the source of risk was from the violence within relationships and, when these ended, the risk was reduced. It appears that professionals did not maintain open minded curiosity and did not hear / see the complexity of risks that were present despite there being a wealth of information readily accessible.   It is suggested that the numerous Social Care led assessments either did not ask the effective questions or use all of the available information. Although it was outside of the scoping period, it is hard to believe that the threshold of significant harm was not previously met in relation to Child ‘A1’    The use of Emotional Harm did not accurately reflect the risk to the children. This is of particular concern at the second conference that had been convened following a physical assault on Child ‘A1’ by the children’s mother. It is suggested that poor assessments and an inappropriate category contributed to the ineffectiveness of the Protection and CiN plans in achieving sustainable change.   As a result:    Both children remained at risk of physical harm.   Final March 201911  6. Learning Points  An ICPC should be convened whenever the outcome of an assessment is that the threshold of significant harm has been reached and there is no evidence that the risks to the child, including unborn child, have not been minimised or removed. A SOS meeting does not replace the requirement for an ICPC.  The decision not to see the child on the same day following a disclosure of physical abuse was not compliant with the LSCB procedures. While these should have been followed, it was even more pertinent for a child who was already on a CPP. Similarly, the children should have been seen following the referral from Police.  On the basis of information available to this review, this decision, at 4.2.6 regarding the CPP being no longer needed, was over optimistic and the sustainability of a safer environment had not been thoroughly assessed or tested.   Legal advice should be sought where there is a long history of concern with no evidence of real change.  All professionals need to retain open minded curiosity and consider all potential risks to children.   Caution should be used when referring to children living with parents with mental health and substance misuse issues. An assessment of whether their needs are being met and whether they are at risk should always be undertaken and inform the appropriate pathway.  All professionals should be supported in considering the impact on them of working with people who present as aggressive / with challenging behaviour.   The use of texting as a means of communication should be used appropriately to provide factual information and reminders and not to replace a telephone call or face to face conversation.   The purpose of naming a risk is to place professionals’ and the family’s attention where it should be and, in this case, should have been physical harm. All forms of abuse are inherently emotionally harmful but Emotional Harm is not intended to be used as a catch all category.   Plans should be SMART. The distinct purpose of both the Core Group and Review Conference should be clear. Compliance with the plan should be monitored by the Core Group and in professional’s supervision.  CiN plans are a statutory process under S17 of the Children Act and are intended to provide multi-agency plans to provide services to promote a child’s welfare. They should be afforded a clear focus of attention, be formulated by a multi-disciplinary meeting and be SMART.  On the basis of interventions in this case, it appears that the local pathways are adequate; however there should be consideration given to the capacity of the MARAC and whether it can meet local need in a timely fashion.   Final March 201912   7. Recommendations   9.1 That the LSCB:   Commission a multi-agency review of the use of the category of Emotional Harm, that the findings and recommendations are reported to the Board and that the Board seeks assurance that recommendations are implemented   The Board seek evidence that professionals in all agencies understand the distinct purpose of the Core Group and Child Protection Conference   That consideration be given to how the Board can be assured that CPPs are both SMART and robustly implemented   Consideration is given to Board to seek assurance that management supervision in all agencies recognises the potential impact on standards of practice when working with adults with violent and aggressive behaviour or disguised compliance   The Board to seek assurance of evidence that staff in all organisations are supported in being aware of the impact of working with violence and aggression, and in mitigating against it, affecting practice and interventions     For the LSCB to be assured that robust information sharing pathways are designed to ensure all agencies, including GPs, are informed about serious and medium risk DA incidents.   8. Actions taken to date  Commission a multi-agency review of the use of the category of Emotional Harm, that the findings and recommendations are reported to the Board and that the Board seeks assurance that recommendations are implemented  The LSCB has formed a multi-agency group, led by the Leicestershire Children’s Social Care Head of Children’s Safeguarding, to manage a case file check of cases which have used the Emotional Abuse category in either the last six months or last 20 cases. This is to establish if Emotional Abuse was the appropriate category to be used in the circumstances of the case. This group will report back to the LSCB in order to provide assurance to the Board.   In addition, as part of the SCR process, all Independent Reviewing Officers (IROs) were spoken to by the Individual Management Review (IMR) author. As a result, it is felt that IROs have a better understanding of the issues and are more likely to use the category of Physical Abuse when it is appropriate.          Final March 201913 The Board seek evidence that professionals in all agencies understand the distinct purpose of the Core Group and Child Protection Conference  The LSCB has instructed safeguarding leads in partner agencies to ensure relevant staff, who may attend Case Conferences and Core Groups, are fully aware of their role and responsibilities at the meetings. The main agencies involved are:    Children’s Social Care (CSC)  Police  Education  Leicestershire Partnership NHS Trust (LPT)  University Hospitals of Leicester NHS Trust (UHL).  The intention is that CPPs can be managed more effectively to reduce risk. This will be monitored through the IROs reviewing CPPs and raising quality assurance alerts on the CPP to ensure it is effectively managed by core groups to reduce risk.  The Safeguarding Boards’ publication, ‘Safeguarding Matters’, will also highlight this issue for staff across all local agencies.    A new training course for safeguarding professionals that will cover the responsibilities of Core Groups and CP Conferences is the Tier 3 Working Together Course that is in the process of being commissioned. This is expected to be delivered during the first quarter of 2019.   That consideration be given to how the Board can be assured that CPPs are both SMART and robustly implemented  Work is being undertaken with Case Conference chairs and the Children’s Social Care Safeguarding Unit to ensure that CPPs are both ‘SMART’ and robustly implemented.  A learning session has been delivered to all team managers on ‘SMART’ action planning.  The practice excellence team have provided a training session to the IROs.  As a result, IROs have been made aware of the issues and are more likely to use the category of Physical abuse rather than Emotional abuse when it is appropriate.   Consideration is given to Board to seek assurance that management supervision in all agencies recognises the potential impact on standards of practice when working with adults with violent and aggressive behaviour or disguised compliance  And  The Board to seek assurance of evidence that staff in all organisations are supported in being aware of the impact of working with violence and aggression, and in mitigating against it, affecting practice and interventions    Safeguarding leads in partner agencies have agreed to ensure managers and supervisors are aware of these issues. The main agencies involved are:    Final March 201914  CSC  Police  Education  LPT   UHL.  The LSCB undertakes a regular programme of multi-agency case file audits; as a routine part of these audits, case supervision notes are viewed and commented on.  As part of the ‘Growing Quality’ framework, management oversight and supervision are an integral part of all quality assurance.  Further work is planned by Local Authority Learning and Development to focus on disguised compliance, managing aggressive behaviour and the impact on professional curiosity.  The messages previously published in the Safeguarding Matters publication under ‘25 things to consider’, which currently includes disguised compliance, will be republished adding a reference to the fear of violence/ intimidation.    When the above actions are complete, a review of progress and outcomes is to be reported to the LSCB to provide assurance.  For the LSCB to be assured that robust information sharing pathways are designed to ensure all agencies, including GPs, are informed about serious and medium risk DA incidents.  All agencies will review their current position on Domestic Abuse information sharing pathways to allow for progress and outcomes to be reported to the LSCB to provide assurance. The agencies involved are:    Police   LPT   UHL  GPs  Local Authorities (Social Care & Education)  Progress on this recommendation includes:  Leicestershire Children’s Social Care is currently developing a new integrated multi-agency approach in information sharing pathways. This applies specifically to Domestic Abuse incidents. They have daily meetings with the Police over reported DA incidents.  The Leicestershire Education Service, CSC and the Police have Operation ‘Encompass’ in place with schools to enhance communication between the Police and schools where a child is at risk from domestic abuse.  Further information can be found at: http://lrsb.org.uk/about-operation-encompass   The local Clinical Commissioning Groups are working with the Police and GP practices to further develop Domestic Abuse pathways for reporting incidents which affect children and young people.    Final March 201915 Key areas include the development of referral forms and letters that can be accessed via the GP clinical system to support:   GPs providing information from patients’ records to MARAC   MARAC informing GPs when their patients have been discussed at MARAC.                                              Final March 201916   TERMS OF REFERENCE    Appendix 1    1. Composition of SCR Panel:  Sue Gregory    Independent Chair & Author  Chris Nerini Head of Service, Safeguarding Improvement & Quality Assurance, Children & Family Services Leicestershire County Council  Janette Harrison Designated Nurse, Children and Adult Safeguarding, Leicester City Clinical Commissioning Group (CCG) Hosted Safeguarding Team  Carolyn Corbett Professional & Clinical Lead Safeguarding Children Leicestershire Partnership NHS Trust  Siobhan Barber   Serious Crime Partnership Manager Leicestershire Police  Lisa Morgan Schools Effectiveness Officer  Targeted & Intervention  Leicestershire County Council  Michael Clayton Head of Safeguarding  University Hospitals of Leicester NHS Trust  Chris Tew Board Officer Leicestershire & Rutland Safeguarding Board Business Office  Sue Hughes Administration Leicestershire & Rutland Safeguarding Board Business Office    Final March 201917  2. Agencies requested to submit IMR/Chronology Reports :   Leicestershire Police   Leicester City Clinical Commissioning Group (GPs)   Leicestershire Partnership NHS Trust   Leicestershire Education (School and College)   Leicestershire Children’s Social Care   University Hospitals of Leicester NHS Trust (UHL)   Leicestershire Adult Social Care   Wallaction (Domestic Abuse)   Cafcass  3. Scoping period:  1st January 2014 to the 21st April 2016  There is an expectation that any information which is outside the Scoping Period but relevant to the SCR will be included in the Chronology / IMR in particular in relation to any issues relating to:   Domestic Abuse  Adult Mental Health  Child Protection incidents  Alcohol or other substance misuse.  4. Agency Chronology:  The attached Chronology / IMR template should be completed and used as the basis to consider the specific areas below. Information included in the Chronology should be succinct.  The attached record of single agency actions should be completed where issues are identified during the Chronology / IMR process that requires noting by the overview author or further action by the agency.  6. Specific areas to consider in relation to this case:    Were all assessments and interventions timely?   Were all the risks and the source of those risks to the children identified and addressed?  Final March 201918   Was there sufficient professional challenge of mother and her behaviour?   Was ‘emotional harm’ the right category of risk for these children and therefore was the protection plan appropriate and relevant to address the risks?  In addition, the Independent Chair of the LSCB requested:  Further scrutiny is made of the step-down process from CPP to CiN support and in this case, to clarify if this was followed through and how effective it was.    Also, the independent author will be asked to consider what improvements may be required in the local pathways to respond to DA where children are in the family.  Policies and Procedures:  Was the work in this case consistent with:  The Agency’s Policies and Procedures for safeguarding and promoting the welfare of children.   LSCB’s multi-agency Policy and Procedures.  Professional standards.   7. Legal Grounds for Information Sharing: The LSCB Regulations 2006 set out the functions of the LSCB which include undertaking SCRs.   The Regulations also confer the power on the Board to engage in any other activity that facilitates or is conducive to the achievement of its objectives.  Section 14B Children Act 2004 provides that if the LSCB request a person or agency / organisation to supply information to the Board then that agency / organisation is under a statutory duty to comply with that request provided that:   the request is made to assist the Board to perform its functions and;   the request is made to a body who the Board consider are likely to have relevant information;   and    the information requested relates to a person in respect of whom  the agency / organisation exercises a function / engages in activity   to the agency / organisation to whom the request is made   to the functions / activities of the agency / organisation to whom the request is made. 