Death of a 4-month-old child in October 2019. Child K was found dead in the family home, after having been asleep on the sofa. Learning includes: need for greater focus on children's lived experiences and the emotional impact of substance misuse; need to develop practice of 'respectful uncertainty' as a means to combatting disguised compliance, particularly where substance misuse is a concern; risk to children was increased by parental drug misuse going undetected; need for consideration of reasons for grandparent's caring role as this can help professionals with their work with the family and the plans they develop; need for multi-agency approach to assessment of risk. Recommendations include: safeguarding children partnership to ensure all agencies are using age appropriate tools in all assessments to understand children's lived experience, and incorporating children's lived experiences into all plans; to ensure all partners incorporate disguised compliance into all safeguarding training, supervision and managerial sessions with frontline workers; seek assurance from children's social care and local drug services that changes to service design, and ways of working have improved the reliability of testing, communication, information sharing and risk assessing of parents who are misusing substances; ensure that, where grandparents are playing a significant caring role, this is fully explored as part of assessments and contained within all action plans; explore ways of ensuring information about risk is provided by all relevant services and incorporated into safeguarding assessments and plans. Please note that this report was written in May/2021 but was published in 2022.
      
 Title:  Child K: local child safeguarding practice review. LSCB: Kirklees Safeguarding Children Partnership Author: Nicki Walker-Hall Date of publication: 2022  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.                            THIS REPORT IS STRICTLY CONFIDENTIAL AND MUST NOT BE DISCLOSED TO THIRD PARTIES WITHOUT DISCUSSION AND AGREEMENT WITH THE KSCP PRIOR TO PUBLICATION. THE DISCLOSURE OF INFORMATION BEYOND THAT WHICH IS AGREED, WILL BE CONSIDERED AS A BREACH OF CONFIDENTIALITY FOR THE SUBJECT AND A BREACH OF CONFIDENTIALITY OF ALL THE AGENCIES INVOLVED.  Kirklees Safeguarding Children Partnership  Child K LOCAL CHILD SAFEGUARDING PRACTICE REVIEW   Safeguarding Adults Review   Month 2020   Nicki Walker-Hall  Version 2, May 2021   2 | P a g e    Table of Contents   1. Introduction          3 2. Summary of learning themes        3 3. Context of Child Safeguarding Practice Review     3 4. Succinct summary of case        4 5. Methodology          5 6. Terms of Reference         6 7. Engagement with family        7 8. Review timeline         7 9. Analysis of the Key Lines of Enquiry       7 10. Conclusion          14 Appendix i – Key to acronyms/ abbreviations     15 Version 2, May 2021   3 | P a g e   1. Introduction  1.1 This case was referred to Kirklees Safeguarding Children Partnership following the death of Child K aged 4 months. Child K was one of three siblings. Sibling 1 was 3 years old and sibling 2 (Child K’s half-brother) was 10 years old when Child K died. At that time all three children were subject to Child Protection Plans under the category of neglect; both parents were known to be misusing substances. Mother and father were both arrested for causing or allowing the death of a child. Father was further arrested for possession of heroin.  1.2 This case was referred for Rapid Review in accordance with Working Together 20181. The Rapid Review Group concluded that this case met the criteria for a Child Safeguarding Practice Review (CSPR) as abuse or neglect was suspected.  1.3 The Chair of Kirklees Safeguarding Children Partnership (KSCP) endorsed this decision and the Review was commissioned. 1.4 This CSPR will take into account the guidance in Working Together and the principles of the systems methodology recommended by the Munro review.2  1.5 The review covers the period from 26.10.18 to 27.10.19. This period encompassed the start of Child in Need for siblings to the date of Child K’s death.  2. Summary of Learning Themes  2.1 The following are the main learning themes. • Greater focus on children’s lived experiences • Develop tools and skills in the practice of ‘respectful uncertainty/healthy scepticism’ as a means to combatting disguised compliance – increase professional curiosity • Develop a joint approach to drug using parents  • Recognise, assess and support family members in caring roles • Develop comprehensive joint risk assessments 3. Context of Child Safeguarding Practice Reviews 3.1 The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel and at local level with the safeguarding partners. Working Together to Safeguard Children 2018 contains the statutory guidance for undertaking Child Safeguarding Practice Reviews (CSPRs) when a serious child safeguarding case has been reported. These are cases in which:   1 HM Government (2018) Working Together to Safeguard Children https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 2 The Munro Review of Child Protection: Final Report: A Child Centred System (May 2011).  Version 2, May 2021   4 | P a g e   • abuse or neglect of a child is known or suspected and  • the child has died or been seriously harmed 3.2 Meeting the criteria does not mean that safeguarding partners must automatically carry out a local Child Safeguarding Practice Review. It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice.  3.3 This review will be cognisant of the following requirements: • recognise the complex circumstances in which professionals work together to safeguard children;  • seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  • be transparent about the way data is collected and analysed;   • make use of relevant research and case evidence to inform the findings.  • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;  • be written in plain English and in a way that can be easily understood by professionals and the public alike; and  • be suitable for publication without needing to be amended or redacted, ensuring that the subject child and/or family cannot be identified.   4. Succinct summary of case  4.1 The family had a long history of involvement with statutory services in relation to parental substance misuse, offending behaviour and child protection concerns. Both father and mother were class A substance misusers, primarily crack cocaine and prescription drugs for both, and additionally heroin for father. From 2008 – 2014, mother attended Children’s Centre Activities and, for a time, was allocated a family support worker. Further support was sought during mother’s pregnancy with sibling 1 in recognition of previous alcohol issues, mental health issues, and to work on routines for sibling 1. The case was closed in October 2015. Further support was provided around toileting for sibling 1 and sibling 2 in 2017; closing in September 2017.  4.2 Immediately prior to the review period (Oct 2018) mother had been charged, and was on bail, for an offence of robbery and was due to go to trial a month after the birth of Child K. Maternal grandmother had raised concerns regarding who would care for the children if mother received a custodial sentence, which was thought likely. Partner agencies started to work together to explore the options in the event mother was incarcerated; the children were placed on Child in Need (CIN) plans. Version 2, May 2021   5 | P a g e   4.3 Mother was referred to Support for Women and Antenatal Service (SWANS) during all three of her pregnancies. Mother indicated she had last used substances in October 2018 and maintained she was not using substances throughout the pregnancy. Mother expressed concern that she may relapse after Child K was born. Mother was not accessing the support offered for her substance misuse and did not engage well with services, including specialised antenatal care, provided by SWANS, throughout her pregnancy. She did though give some negative drug tests during pregnancy, she also lied about her drug misuse despite evidence suggestive of continued drug use e.g. unclear drug test results, financial difficulties and third party information.  4.4 Father was accessing support for his substance misuse through the local drugs agency, CHART. Father indicated he was not injecting substances; this was untrue as he was a regular attender at the needle exchange service. Father’s significance was not realised by professionals; father was not residing in the family home.  It was thought sibling 1 did not have a relationship with father; this perception was later challenged when father was excluded from the family home and sibling 1’s behaviours deteriorated.  4.5 Consideration was being given to alternative care arrangements for all 3 children. Maternal Grandmother, who had provided considerable support to the whole family had said she would take the older siblings but would be unable to care for a new born baby. Alternate carers within the family were explored via family group conferences. 4.6 The case changed from one of considering alternative placements if mother received a jail sentence when Child K tested positive for crack cocaine and opiates at birth and was treated for drug withdrawal. An Initial Child Protection Conference (ICPC) was held and all 3 children were made subject to a Child Protection Plan under the category of Neglect.  4.7 Siblings were noted to have injuries just prior to this incident that raised concerns, however, the paediatric medical assessments subsequently found no sign of non-accidental injury or neglect. 4.8 The children’s father’s role within their lives were latterly explored and contact arrangements agreed. There had been previous domestic violence incidents between parents and in former relationships which was of concern. 4.9 Child K had a bottle of milk around 9.00pm and fell asleep on the sofa.  Mum advised that she had used crack cocaine between the hours of 8.00 and 9.00pm.  Child K was left to sleep on the sofa.  It would appear that mum also slept on the sofa and she had noticed that the other child in the family had come down from their room and was asleep on the living room floor.  When mum woke around 7.00am she noticed that Child K felt cold and that she was not responding.  Mum called for an ambulance and through their instruction dad attempted to give CPR. Child K was taken to hospital where she was declared dead. Mother later informed the police she and father had been drinking and had misused substances the previous night. Child K was found to have bruising to her back; following the post mortem the cause of death had been recorded as “Unascertained (history of co-sleeping). Version 2, May 2021   6 | P a g e   5. Methodology   5.1 A group representing partner agencies of the Kirklees Safeguarding Children Partnership developed the terms of reference in line with Working Together to Safeguard Children (2018), and West Yorkshire Safeguarding Children Procedures, Chapter 10.1 (8.20). The following agencies were identified as having been involved with Child K and Child K’s family.  • Kirklees Children’s Social Care  • Police • Calderdale and Huddersfield Foundation Trust • Locala: Health Visitor Service / School Nurse • Education  • Support for Women and Antenatal Service (SWANS) • CHART  • Greater Huddersfield CCG 5.2 Agencies provided a chronology with analysis of significant events between these dates and a summary of significant interventions prior to 26.10.18. Agencies provided a list of practitioners and managers involved in the family’s care. Nicki Walker-Hall, an experienced Serious Case and Learning Lessons Review author from a health background, was commissioned to undertake the review.  5.3 A narrative of events was developed by the reviewer. Two separate practitioner and two separate manager learning events were held in January and March 2020 in order to understand the single and inter-agency practice in this case. The reviewer has only been able to gain limited insight into the perceptions of the family and how the different agencies related to them through discussion with practitioners. 5.4 A draft report was produced for consideration by the KSCP sub-group. 5.5 Further Terms of reference were agreed, and a more concise and focused report produced. 6. Terms of Reference  6.1 Originally, the terms of reference and Key Lines of Enquiry provided to the reviewer for this review were as follows:  Sustaining services and support:  • The rule of optimism • Child-centred practice • Supervision  Assessment of risk:  Version 2, May 2021   7 | P a g e   • Quality and timeliness of assessments (inc. Pre-birth Assessments and Child Protection Plans) • Analysis in assessment and risk • Quality and timeliness of decision-making • Contingency planning 6.2 Following submission of the first draft report and a change in personnel, the following Key Lines of Enquiry were agreed: • Listening to children’s lived experience • Working with families with disguised compliance • Substance misuse • The role of extended families • Professional curiosity • Multi-agency working and managing risk  7. Engagement with family  7.1 The reviewer would have liked an opportunity to speak with the family to gain an understanding of their experience of the services offered. To date this has not been possible. This case was subject to a number of parallel processes (coroners inquiry and police investigation) which have inhibited the reviewer’s ability to speak with the family. 8. Review timeline  8.1 Working Together 2018 suggests that Child Safeguarding Practice Reviews should be completed within 6 months of initiating it, unless there are good reasons for a longer period being required. This review has not met the expected timeframe. Illness, bereavement, change of personnel, and Covid-19 have all added to significant delay.  9. Analysis of the Key Lines of Enquiry  Listening to children’s lived experience 9.1 There is limited information regarding the children’s lived experiences. Assessments provide a real opportunity for practitioners to understand a child’s lived experience. In this case, sibling 1 was thought too young to be spoken to alone. When sibling 2 was spoken to alone, he spoke of being bullied at school but mentioned nothing about mother or his home life. Assessment tools, devised to elicit the voice of either child, were used on one occasion within school; however, the environment was not conducive for the child to talk. These tools were not used within the Child and Family Assessment. 9.2 Practitioners were able to describe the children but there was no clear understanding of their lived experiences. Practitioners talked about aspects of the children, for example, Sibling 1 was reported to be chatty, and would show his toys, Sibling 2 was reported to have a close relationship with mother, grandmother and siblings, but did not have a positive relationship with father who was not his biological father. Practitioners could identify Version 2, May 2021   8 | P a g e   changes in sibling 2’s behaviours; these were reported to be dependent on the level of contact he was having with grandmother; grandmother was viewed by professionals as a positive, stable influence. Sibling 2 spent a lot of time with grandmother; practitioners were not sufficiently curious as to the reasons behind this arrangement. Practitioners had not had any concerns regarding the care of the children until grandmother raised her concerns. 9.3 In this case, sibling 2 was of an age where he was able to articulate concerns. When he did so, these concerns were not ignored but nor were they proactively responded to within assessments and investigations. At the practitioner’s event, a discussion was had around gaining information from children. Discussions with the children were too often focussed on the concern and were not widened to explore their lived experience.  9.4 There is evidence of professionals striving to maintain focus on the child. This is particularly evident within the school and nursery and during each Child In Need meeting. The children’s health and emotional wellbeing were discussed and plans made to address their needs progressed. However, as a result of the practitioners not understanding the children’s lived experience, the focus was on the minutiae and not the bigger picture. Sibling 2 was displaying behaviours suggesting his emotional health was being impacted, and both siblings were displaying behaviours that suggested they were witnessing behaviours in adults likely to cause them harm. It is imperative that when professionals are identifying indicators that children are being exposed to harmful behaviours, they maintain a healthy scepticism, explore the origins of the behaviours, and consider the risk to the child and what actions may be required to keep them safe? 9.5 Children may speak to a number of professionals during the course of an assessment or investigation. If the alleged perpetrator or someone supporting the alleged perpetrator continues to have access to the child during this time, the child may be unduly influenced to change their story. The lack of understanding of the couple’s relationship meant professionals did not give sufficient thought as to whether mother or father might exert pressure on sibling 2 to change or retract his allegation. Mother’s lack of response to attempts by the police to speak with sibling 2 during the investigation should have given rise to heightened concern for the children but didn’t.  Learning point 1: There is a need for greater focus on children’s daily lives, their lived experiences, and the emotional impact of substance misuse. Meetings need to maintain focus on the child whilst considering the adults’ issues and the impact the adults’ behaviours were having on the children. Recommendation 1: KSCP to seek assurance from all agencies that: • age appropriate tools are being used with all children within assessments and on-going work, to understand the children’s lived experiences and  • that all plans are child focussed with evidence of consideration of the impact of adult behaviours on the child  Professional curiosity and working with families with disguised compliance Version 2, May 2021   9 | P a g e   9.6 Disguised compliance describes the process of parents hiding dangerous or poor parenting practice by actively working to deceive and undermine professional involvement. There is evidence of disguised compliance on behalf of both parents. Throughout her pregnancy, mother did not disclose substance misuse to any professionals. Indeed, any tests that indicated she had, were met with denial; she openly lied. Father was not truthful about the mode of his drug misuse, always indicating he was not injecting, but making frequent use of the needle exchange service. Professionals were presented with situations where they could have been more curious. A number of referrals/third party intelligence were received indicating mother was misusing drugs. These occasions all provided opportunities for further in-depth assessment. Previously, Serious Case Reviews (SCR’s)3 have found children would be better protected by agencies being receptive to information being plausible, either until it is proved to be unfounded or where good assessment finds no substantiation. This process requires critical thinking and professional curiosity to reach a confident judgement. 9.7 In this case, the couple’s parenting capacity was not assessed, and this allowed them to hide or down play the negatives from statutory agencies. They exhibited tokenistic engagement by presenting themselves when they were well on several occasions. Professionals maintaining a culture of ‘healthy scepticism’ and practising to embed this as a cultural norm is essential to practitioners recognising and tackling this subversive behaviour. This review has enabled multi-agency professionals to reflect on how mother and father managed to mislead professionals with apparent ease. The review has also shown, more disturbingly, however, that, despite the significant history known to various agencies, no single practitioner or service knew what life was like for these children. 9.8 It is not unusual for clients to present themselves in a more favourable light. The challenge when working with families who on the surface appear to cooperate but are not, is identifying this so it can be challenged. Lack of inclusion of all local drug services within multi-agency meetings allowed mother’s protestations that she hadn’t misused drugs to remain unclear.  9.9 Father was not known to school, nursery or the SWANS service and his role within the family was not fully recognised whilst the case was being managed as Child in Need. Successive biennial analyses and more recent Serious Case Reviews4 warn that professionals too often overlook the presence of males in families.  9.10 Father was spoken to as part of the Child and Family Assessment. However, the concentration was on mother and father’s drug and offending behaviours which they placed in the past. This had an effect of lowering practitioners’ perceptions of the risks.  9.11 It is essential that systems are set up in ways that make it easy for professionals to identify non-compliance. It is only by identifying deception and naming it, that those who are not being truthful and are saying what professionals want to hear, can be challenged.  3 Serious case review report: Child T (2017) North East Lincolnshire NSPCC SCR Repository 4 Hidden men: learning from case reviews: Summary of risk factors and learning for improved practice around ‘hidden’ men NSPCC 2015 Version 2, May 2021   10 | P a g e   This couple were missing medical appointments, asking for needle provision without undergoing tests, not providing adequate explanations, all behaviours heavily suggestive of non-compliance. Often it is difficult for a lone professional or single agency to identify disguised compliance. Sharing information with, gathering information from, and making best use of partner agencies’ expertise, is essential to uncovering non-compliance; professionals were deceived.  9.12 Providing practitioners opportunities for reflection and consideration of whether a family are being compliant, through supervision and managerial oversight, can aid detection of disguised compliance.  Learning Point 2: Multi-agency professionals need to develop tools and skills in the practice of ‘respectful uncertainty/healthy scepticism’ as a means to combatting disguised compliance, particularly in safeguarding children where parental substance misuse is a cause for concern. Recommendation 2: KSCP and its partners to incorporate disguised compliance into all safeguarding training, supervision and managerial sessions with frontline workers.   Substance misuse 9.13 Whilst parental substance misuse does not automatically indicate child abuse or neglect, it can have an impact on children in a number of ways, which includes impairment on the development of an unborn child. A parent's practical caring skills may be diminished by substance misuse and withdrawal from substance misuse may give rise to mental states or behaviour that put children at risk of injury, psychological or emotional distress or neglect. Children of parents experiencing withdrawal are known to be at increased risk of significant harm5 . Substance-misusing parents may find it difficult to prioritise the needs of the children over their own, and money available to the household to meet basic needs may be reduced. Children may be at risk of physical harm, or death, if drugs and drug paraphernalia are not stored safely and children have access to them. 9.14 Drug and alcohol services were working with both mother and father and mother was receiving midwifery care, including care via the specialist midwifery service for drug and alcohol users. They missed many appointments with these practitioners and failed to cooperate in what was asked of them. Drug and alcohol service practitioners were not invited to take part in CIN meetings, thus an opportunity for them to share information and their expertise was missed.  9.15 CHART and the needle exchange service, whilst based in the same building, used separate entrances and separate recording systems. This allowed the situation of father indicating he was not injecting to the recovery co-ordinator and then obtaining a significant amount of needles and syringes, demonstrating very regular injecting, to go undetected.  5 Altobelli & Payne, 2014 https://www.bacp.co.uk/bacp-journals/bacp-children-young-people-and-families-journal/march-2014/noticing-the-hidden-harm/  Version 2, May 2021   11 | P a g e   There has since been changes to the way the two parts of the service work and record that should prevent this situation arising again. 9.16 Roles, responsibilities and the way services were configured were confused and, as a result of commissioning arrangements and a failure to resolve funding arrangements, social workers were undertaking drug testing without the training and expertise to understand the results. Drug testing equipment was not being stored and monitored safely. This presented significant risks and, in this case, masked evidence that mother was using illicit substances. Learning point 3: The way drug and alcohol services were configured and the interface between drug and alcohol services and CSC heightened the risk that problematic drug use would go undetected and unaddressed in such a way as to increase risks to children. Recommendation 3: KSCP to seek assurance from CSC and local drug services that agreements regarding funding, changes to service design, and ways of working have improved the reliability of testing, communication, information sharing and risk assessing of parents who are misusing substances. The role of extended families 9.17 Grandmother volunteered information to practitioners and discussed her concerns. Grandmother was upfront about mother’s drug use and made a number of referrals. Referrals from family members should be deemed as significant events. Relatives making referrals is particularly difficult where, as in this case, the family were also involved in offering ongoing support.  9.18 Initially, practitioners wondered whether there might be a malicious element to grandmother’s referrals and considered these referrals in the context of motivation and the credibility of the referral. The thinking was, “Is this a concerned grandparent or is she just frustrated and exasperated with mother?”.  9.19 Grandmother was quickly viewed by professionals as very significant within the family although her role was not entirely clear. Grandmother was reported by practitioners to be very caring and protective of the children; she was said to have a particularly strong bond with sibling 2, for whom she acted as an advocate. Grandmother was articulate, intelligent and an ex-teacher. Grandmother indicated she was torn with regards to her relationship with mother.  9.20 Grandmother took on a carer role and was supporting mother and the children financially, emotionally, and physically. Often involvement of extended families is viewed as positive, however it can also be a negative and have the impact of leaving a parent impotent.  9.21 Professionals needed to explore the reasons for grandmother taking on her caring role. Was this at the behest of mother? Instigated by grandmother? Why did mother require such assistance to care for her children?  9.22 The unintended consequence of grandmother’s care of the children was to obscure professionals’ view, leading to an underestimation of the magnitude of all the issues. Version 2, May 2021   12 | P a g e   Learning point 4: Grandparents who take on a caring role for their grandchildren do so for a variety of reasons. Some because of a shortfall in parents’ capacity to care for the children, some because of their own controlling behaviours, and some for purely practical reasons. Understanding the reasons helps professionals within their work with families and in the plans they develop.  Recommendation 4: KSCP and its partners to articulate and ensure that, where grandparents are playing a significant role in the care of their grandchildren, this needs to be fully explored as part of assessments and contained within action plans, and ensure this is embedded in practice.  Multi agency working and managing risk 9.23 Research highlights the importance of professionals from all agencies working collaboratively, sharing knowledge and expertise6. There were a number of different meetings being held by and between different agencies and different disciplines within agencies. The interface between all these different meetings (CP, CIN, SWANS risk assessment meetings, FGC, etc.) was not clear.  9.24 In this case, key professionals from key agencies were not invited and/or not in attendance at key meetings. Lack of inclusion of CHART/SWANS within CIN and CP meetings lost opportunities for experienced drug and alcohol professionals to provide partner agencies with clarity on the meaning of the drug test results and, ultimately, mother’s drug use. This is particularly relevant when, on occasions, there were queries regarding the validity of results, and when a drug was found on testing which counteracts the effect of other drugs. When hair strand testing was discussed at meetings, mother would cut her hair. This behaviour was suggestive of on-going drug use and potential increased risk; this needed greater challenge. 9.25 Assessment of risk in safeguarding is complex and requires the assessor to be objective and analytically skilful. There are a number of factors that had the potential to impact the assessment of risk in this case. The initial referral to CSC, during the review period, was made by grandmother. There was scepticism regarding the validity and motivation for the referral. Munro found that there was a striking difference between the response of CSC when referrals were made by relatives or neighbours to those made by professionals. Those made by professionals were treated much more seriously and with an initial expectation that it might be true, leading more often to a thorough investigation7.  Robust assessment requires practitioners to:  • Be open minded and take an independent approach to the evidence  • Reflect and critically analyse all of the information   6 Social work assessment of children in need: what do we know? Messages from research DFE March 2011  7 Munro, E. (1996) Avoidable and unavoidable mistakes in child protection work. London: LSE Research Articles Online. Available at: http://eprints.lse.ac.uk/archive/00000348/   Version 2, May 2021   13 | P a g e   • Collate and coordinate large amounts of information to extract key findings  • Deploy knowledge and expertise in child protection and social work theory  • Be given and to take the time and opportunity for rigorous critical thinking  9.26 Lack of full understanding of mother and father’s drug taking was a significant factor that affected the assessment of risk. Both mother and father were not honest with professionals.  9.27 With hindsight, it is clear mother was a largely functioning drug user. Professionals, although aware of mother’s offending, didn’t consider this sufficiently in context of her drug use. There was a lack of focus on finances; this could have provided professionals with a clearer understanding as to whether financial difficulties were due to a lack of money coming into the household or because of drug use. The significant financial support mother was receiving from grandmother also masked the extent of the problem.  9.28 After Child K was born, mother’s drug use could no longer be denied, and practitioners became more aware of her deception. The relationship between mother and father remained unclear. The fact that father was not residing in the family home appeared to skew professionals’ view. Father was not considered fully in the analysis of assessments and when considering risk.  9.29 Latterly Sibling 2 made a comment around father injecting in his groin; this was a clear indicator that father was injecting illicit substances and a key point where parents should have been robustly challenged. 9.30 None drug and alcohol practitioners had a perception that, as father was attending the drug and alcohol service, this meant he wished to become abstinent; this was erroneous. Father never indicated or behaved in a way that led drug and alcohol workers to conclude he wished to achieve abstinence. Father was clear he enjoyed and wished to continue his drug use. Had drug and alcohol practitioners been aware of this, they would have been better placed to make more accurate risk assessments. 9.31 Mother, as a self-confessed addict, would always be at increased risk of using illicit substances whilst she maintained the relationship with father. Mother was skilled in hiding her lifestyle from those around her.  9.32 The reviewer learned that risk was considered by all professionals attending review conferences. Each element of the plan was discussed, and consideration given as to whether the risk was reducing or changing. Whilst that is positive, it was felt that whilst there was some challenge in ICPC meetings, done in a restorative way, there needed to be more challenge in all meetings. A barrier to this was the perceived negative impact it might have on building relationships with families, and practitioners not wanting this to break down. When working with families, professionals need to provide both high support and high challenge to be effective. Learning point 5: Accurate assessment of risk is dependent on the assessor being in receipt of all the information available across agencies and services, and on having the skills and Version 2, May 2021   14 | P a g e   input from those with additional knowledge. Currently some services are not included in requests to provide information when there are safeguarding concerns. Different agencies and services are carrying out single-agency assessments of risk. It is not clear how these separate assessments of risk are being brought together to provide a clear multi-agency assessment of risk on which plans of action are based. Recommendation 5: KSCP and its partners to explore ways of ensuring information pertaining to risk is provided by all relevant services and incorporated into safeguarding assessments and plans.   Examples of Good Practice:  The section 47 enquiry in June 2019, following the birth of Chid K, was of a good quality. It provided much greater clarity regarding disguised compliance and recognised that the couple’s drug usage was unknown, that mother was regularly borrowing money for her own needs, and that mother was dishonest with professionals. Within this assessment, there was a greater sense of the children and the children’s relationships with mother and father and there was clear analysis. This assessment led to a decision to escalate the case to CP.  School and nursery staff demonstrated good knowledge and safeguarding practice in relation to referring concerns and following MASH advice.  10. Conclusion 10.1 The death of Child K was unexpected by the professionals involved. There is evidence that many of the professionals involved had worked hard to support the children and family. However, opportunities to increase professionals understanding of the children’s lived experiences were not always taken.  10.2 Professionals were not sufficiently curious, and did not routinely challenge mother when they had evidence to support their concerns; they were too accepting of mothers explanations.  10.3 Issues in the way services were configured, allowed father to report no IV drug use whilst obtaining needles, and professionals without sufficient knowledge and expertise to interpret drug test results; this impacted on professionals ability to challenge both parents.  10.4 The children’s grandmother was extremely supportive of the children and unwittingly masked some of the evidence that would have helped professionals recognise the level of risk to the children. The difficult position grandmother found herself in was not fully acknowledged. Grandmother was not sufficiently supported and was relied on by professionals.  10.5 Development of a comprehensive joint risk assessment would have helped partners to identify the full risks in this case.  Version 2, May 2021   15 | P a g e   Appendix i – key to acronyms/ abbreviations    CIN Child in Need CP  Child Protection CSC Children’s Social Care CSPR Children’s Safeguarding Practice Review FGC Family Group Conference ICPC Initial Child Protection Conference KSCP Kirklees Safeguarding Children Partnership SCR Serious Case Review SWANS Support For Women and Antenatal Service  