Physical abuse of a 3-year-old girl, Grace, and her 10-month-old sibling, Georgina. In February 2018 Georgina was taken to hospital with severely infected chicken pox; examinations revealed non-accidental fractures. Siblings were placed in foster care. A Finding of Fact concluded that Mother had physically abused Grace. Parental history of adverse childhood experiences; ADHD and mental health problems; Mother had partial deafness. In 2013, Father convicted for assault on Mother, and Grace was made subject to Child Protection plan; closed in 2015 due to Mother seeking non-molestation order on Father's release from prison and proactively seeking support; later found to be disguised compliance. Pre-birth Child Protection Plan for Georgina attributed greater risks to Grace's Father than to Mother's parenting; stepped down to a Child in Need Plan in September 2017. Grace is White British; Georgina is White British/Palestinian. Learning focuses on: understanding and working with carers who have complex histories; communicating with and responding to the children; responding to physical abuse in infants; management of risks after stepping down from child protection; and consideration of multiple forms of abuse. Recommendations include: consider raising awareness and refreshing understanding of the risks to infants of physical abuse for children at all levels of intervention; consider how well the reality that children can be harmed in different ways by more than one perpetrator is understood within the multi-agency partnership and what can be done to develop best practice; review the way that the category of emotional abuse is used for children subject to Child Protection Plans.
      
 Title:  Serious case review: Grace and Georgina. LSCB: Wandsworth Safeguarding Children Board Author: Sian Griffiths Date of publication: 2020  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.                           Official   Official                                Wandsworth Safeguarding Children Board   SERIOUS CASE REVIEW         Grace and Georgina                        Independent Author: Sian Griffiths  Report Date: May 2019Official 1 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official TABLE OF CONTENTS   1. INTRODUCTION    2  SECTION 1.1 THE CIRCUMSTANCES LEADING TO SERIOUS CASE REVIEW  2 SECTION 1.2 THE CHILDREN AND KEY FAMILY MEMBERS 3 SECTION 1.3 METHODOLOGY 3   2. SUMMARY OF CASE AND GENERAL AGENCIES INVOLVED   4  SECTION 2.1 BACKGROUND INFORMATION  4 SECTION 2.2 JANUARY 2014: REFERRAL TO CHILDRENS SOCIAL CARE 5 SECTION 2.3 SUMMER 2016: GRACE AGAIN MADE SUBJECT OF CP PLAN 6 SECTION 2.4 SPRING 2017: GEORGINA BORN 8  3. THE CHILDREN  11  4. APPRAISAL OF PRACTICE AND ANALYSIS  12  SECTION 4.1 INTRODUCTION  12  SECTION 4.3 UNDERSTANDING & COMMUNICATING WITH THE CHILDREN  27 SECTION 4.4 IDENTIFICATION & RESPONSE TO PHYSICAL ABUSE IN INFANTS 31 SECTION 4.5 MANAGING RISK WHEN STEPPING DOWN FROM CHILD PROTECTION 34 SECTION 4.6 CO-EXISTENCE OF OTHER FORMS OF ABUSE 39   5. CONCLUDING COMMENTS   42  6. RECOMMENDATIONS FOR THE BOARD  44  APPENDIX A  45                                              SECTION 4.2 UNDERSTANDING & WORKING WITH PARENTS WITH COMPLEX HISTORIES13Official 2 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official       1.      INTRODUCTION   1.1      The circumstances that led to undertaking this Review   1.1.1     In February 2018 10-month-old girl (Georgina) was taken to a South London Hospital with severely infected Chicken Pox. A chest x-ray undertaken as part of her treatment revealed that she had healing fractured ribs. Further fractures were then identified, and the injuries judged to be non-accidental.     The resulting Police investigation was unable to conclude who had caused the injuries given the time period in which they would have taken place.   Both Georgina and her 3-year-old sibling, Grace, were immediately subject to Child Protection Procedures and placed in Foster Care. The Local Authority applied for Care Orders for both children. Care Proceedings were ongoing at the time of writing this report. 1.1.2     The cases of Grace and Georgina were referred by the Hospital to the Serious Case Review Group of the Wandsworth Safeguarding Children Board which met in May 2018. A Recommendation was made that the criteria for a Serious Case Review as identified in Working Together to Safeguard Children 2015 (the Statutory Guidance in place at the time) had been met, in that there was information that:  •  abuse or neglect of a child is known or suspected; and  • either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  1.1.3     The Independent Chair of Wandsworth Safeguarding Children Board formally decided to undertake a Serious Case Review on 19th June 2018. An Independent Reviewer was commissioned that month    and the first meeting of the Review took place in July 2018.Official 3 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official       1.2   Children and key family members  The individuals referred to in this Review are as follows:  Name/Identifier Relationship and age Ethnicity GRACE Subject Child, age 3, sibling of Georgina White British GEORGINA Subject Child, age 10 months at time of injury Dual heritage: White British/Palestian Ms. G Mother of Grace and Georgina White British Mr. A Father of Grace White British Mr. B Father of Georgina Palestian MGM Maternal Grandmother White British Aunt G Sister of Children’s Mother White British Uncle G Aunt G’s husband White British   1.3   Methodology   1.     There was an agreed methodology used for this Review, including the Terms of Reference. 2.     The timeframe under consideration was:  January 2014 – February 2018  The timeframe identified began when a referral was made regarding unborn Grace.  The timeframe ended after the injuries to Georgina had been identified and the children’s safety secured. 3.     The involvement of the children and key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. The mother, Mr. A and Mr. B were informed that the Review was taking place.  However, the Review was not able to involve any of the family members in contributing to the Review because of the ongoing criminal investigations and Family Court Proceedings.   2 SUMMARY OF THE CASE AND AGENCIES’ INVOLVEMENT WITH THE FAMILYOfficial 4 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      The following is a chronological summary of what was known about the children; their family and the key contacts between them and the relevant agencies.   As far as is possible the summary will identify what was known to professionals at the time.   2.1.      Background information  2.1.1.   The children’s mother was living with her own mother at the time she became pregnant with Grace. She is identified as white British. Both the Police and Children’s Services became involved with her as a result of several incidents of domestic abuse, involving different family members which the mother was either witness to or directly affected by. There were also concerns that at 15 years old the mother was having a relationship with a 19-year-old man, who was physically abusive resulting in the mother receiving serious injuries on at least one occasion.  The 19-year-old man subsequently received a custodial sentence and a Non-Molestation Order.  2.1.2.   In late 2013 Ms. G, who was pregnant at the time, was physically assaulted by her stepfather, leading to her having hospital treatment and a referral being made to Children’s Social Care.  An assessment was undertaken, and work began with the mother under S171.  2.1.3.    Ms. G was recorded as having been diagnosed with ADHD when she was 5 years old and was referred by her GP to CAMHS (Children and Adolescent Mental Health Service).    There is also reference to her being partially deaf, but no further information to identify the seriousness or significance of this to her.  There is no explicit information that the mother identified with a faith, or what aspects of community or culture were important to her.  2.1.4.   There is very little information regarding Mr. A. He is identified as white British and it is recorded in medical records that he had ADHD and mental health problems, the extent and significance of which was not widely known. There is no information as to whether he identified with a faith or what aspects of    1 Section 17 of the Children Act 1989 (S.17) gives local authorities the power to provide accommodation and financial support to families.Official 5 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      community or culture were of importance to him.   Mr. B is known to be of Palestian heritage and was described by the mother and her sister as being from a family of ‘strict Muslims’.  No information has been made available to this review from Mr. B himself about what aspects of family, faith or culture were important to him, or whether there were other relevant issues, such as health.  2.2.       January 2014:  Referral to Children’s Social Care  2.2.1     Children’s Social Care (CSC) initiated a Child Protection Conference regarding unborn Grace in March 2014 after an allegation of serious assault on the Mother by the father of unborn Grace.  At the same time there were concerns that her previous partner was about to be released from prison and as such both she and unborn Grace were potentially at risk from these two men.  Unborn Grace was as a result made subject of a Child Protection Plan on the grounds of risk of physical abuse.  2.2.2     Grace was born in April 2014 and remained on the Child Protection plan until March 2015.  A MARAC2    was undertaken in relation to risk of very serious domestic abuse from the Mother’s previous partner.   However, the contact between them soon appeared to have ceased. For several months there were also concerns about the risks to both Ms. G and Grace from Mr. A, with the Police called to the house on more than one occasion.    Mr. A’s level of involvement in the family at this time is unclear.  In September 2014 he was arrested for assaulting the mother and in October 2014 was given a short custodial sentence and a Restraining Order was put in place.  Ms. G told the Social Worker that she had ended the relationship.  She applied for and was granted a Non-Molestation Order. It was agreed that there could be no contact between Grace and her father without a Social Worker present and a safety plan was agreed.  Towards the end of the year Mr. A was understood to have moved to live with family in Wales.     2 MARAC: Multi Agency Risk Assessment Conference. Multi-agency assessment meeting in relation to serious domestic violence.Official 6 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     2.2.3     At the beginning of 2014 Ms. G referred herself to a project for parents with mental health issues run by a voluntary organisation.  This was supported by her Health Visitor.    The nature of her mental health problems at this time is not entirely clear, although it is known she was taking anti-depressants. During the year she attended a Domestic Abuse course run at the centre as well as a group called Next Steps for young parents.  2.2.4     By March 2015 Ms. G and Grace had been provided with a tenancy of their own. Given the mother’s engagement with the voluntary organisation and the actions that she had taken in seeking a Non-Molestation Order the case was then closed to Children’s Social Care, with the Health Visitor now becoming the lead professional.  2.2.5      In August 2015 Ms. G reported Mr. A to the police for breach of his Non- Molestation Order for which he was charged and fined.   Ms. G said that he had come to see his daughter before moving to Wales. Mr. A however told a Social Worker that he had been living with Ms. G since being released from prison the previous year.  2.3      Summer 2016:  Grace again made subject of a Child Protection Plan  2.3.1.    In July 2016 Ms. G told her Health Visitor that she was pregnant again, that she was feeling stressed and that the father, who she did not name, did not want to be involved with the child.   Later the same month an anonymous referral was made to Children’s Social Care.  The referrer said that Grace’s eye had been hurt by her mother, that Grace was poorly supervised and that her mother was verbally abusive to her.  A S47 assessment was undertaken and at an Initial Child Protection Conference Grace was made subject to a Child Protection Plan under the category of physical abuse.  2.3.2.   There was a significant level of concern, particularly in relation to the involvement or otherwise of Mr. A, including that Grace referred to “daddy” as if he were present in her life.  Ms. G at this point told the Social Worker that Mr. A was also the new baby’s father, but that it had just been a one-night stand.    As a result, a decision was made to initiate Public Law Pre-Official 7 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     proceedings.  This is preparatory action taken by the Local Authority prior to seeking a Court Order, during which time the parent has an opportunity to demonstrate they are able to care for their children safely.  2.3.3.    The Child Protection Plan stated that Parenting Assessments of both Ms. G and Mr. A should be undertaken as well as a Family Group Conference to consider how other family members could support the children to stay within the family.     The Parenting Assessment in relation to the mother was undertaken by a Local Authority Family Centre Social Worker.  No Parenting Assessment was undertaken in relation to Mr. A although efforts were made to meet with him, he was spoken to by phone as part of the Mother’s Parenting Assessment.   The Assessment concluded that although the evidence was unclear, it was possible that Mr. A was still present within the family’s life.  It further concluded that whilst Ms. G demonstrated a good theoretical understanding of domestic abuse, including the impact on children, there were concerns about her ability to “practically apply this to her own life”.  Overall, it concluded that Ms. G demonstrated a great deal of potential which, with support, could mean that she was able to meet their needs.  2.3.4.   Grace was provided a place at a Nursery in the Autumn of 2016 having been referred by the Health Visitor under the scheme for free places for 2-year olds. Ms. G undertook a SEAL Course (Social and Emotional Aspects of Learning) at the nursery.   The nursery was a member of the Team around the Child (TAC) Meetings as part of the Child Protection Plan and routinely kept the Social Worker informed of any concerns.    Over the next few months there were continuing incidences of   Grace referring to “daddy”,  saying that ‘mummy kicked daddy’, ‘daddy hurt mummy’, that Daddy had been with them at Christmas, that mummy had slapped her and, on another occasion, said “the cat needs to be slapped”. These concerns were regularly discussed including at Child Protection Review Conferences, but Ms. G provided explanations for her daughter’s comments and denied that Mr. A was in contact.   The Social Worker undertook a number of unannounced visits and also arranged for theOfficial 8 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      Social Work Out of Hours Team to visit but could not find evidence of Mr. A  being present.   2.3.5.    A Family Group Conference took place in which one of Ms. G’s sisters, Aunt G, and her husband Uncle G, were identified as key family members who would provide support. Ms. G had been given a tenancy of a flat next door to her sister and brother-in-law in December 2016. Ms. G had spoken about being worried that she was not going to bond with unborn Georgina.   As a result, in January 2017 unborn Georgina was also made subject to a Child Protection Plan.  2.3.6.   Ms. G had been referred by her GP to the peri-natal mental health service at the hospital3  in relation to anxiety and poor sleep. She was seen by specialist Registrars on 5 occasions during 2017, the last in October and on each occasion, it was concluded there was no evidence of an identifiable mental disorder. She was discharged back to the care of her GP and continued to be treated with medication for depression.  2.4      Spring 2017: Georgina Born  2.4.1.    Georgina was born in March 2017.  Grace said that daddy had been looking after her while her mother was in hospital and she had been sleeping next to him.   There was also evidence that he had been seen at the hospital.   A decision was made that  the mother and children would stay with Aunt G and Uncle G on discharge from hospital until Children’s Social Care could be confident that Mr. A was not visiting or living with them The Police Child Abuse Investigation team visited the house but could find no evidence of him.  Both the Health Visitor and Midwife agreed to undertake earlier and more frequent visits.  2.4.2.   As a result of the concerns about Mr. A’s presence, a PLO (Public Law Outline) review meeting took place to consider again whether Care Proceedings should be initiated. The mother committed to undertaking a further Domestic   3 St George’s hospital as referred to here is located within the South West London and St George’s Mental Health Trust.Official 9 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     Abuse programme and a Triple P Parenting Programme.  Her sister and brother-in-law agreed that they would be subject to an assessment with a view to putting themselves forwards as possible alternative carers. Ms. G had gone back to the voluntary organisation shortly after Georgina was born asking for support and attended there frequently over the following months.  2.4.3.    The children and mother subsequently returned to their own home, with the Social Worker continuing to arrange unannounced visits and weekend visits. Aunt G and Uncle G also assured the Social Worker that they would be vigilant and would report anything of concern.  Separately, the staff at the voluntary organisation    recorded concerns about the way Ms. G was bonding with Georgina and also noted that she had said she did not think Mr. A was Georgina’s father.  In June 2017 she told the Social Worker that she believed that Georgina’s father was not Mr. A but a man of Palestian origin, Mr. B.  Ms. G said she did not have any contact details for Mr. B, but that he did not want to have any involvement with Georgina, nor did he want to be contacted by Children’s Social Care.  2.4.4.    During the summer of 2017 the mother attended the Triple P Parenting programme, a Women’s Group Domestic Violence Programme and the SEAL course.   Reports from each of these was positive regarding the mother’s insight into the impact of domestic violence and the needs of children.  Grace had stopped referring to ‘daddy’ and the unannounced home visits had not found any evidence that he was present.   The assessment of Aunt G and Uncle G as potential alternative carers was positive.      All the agencies described the mother as ‘consistently engaging’ and said they had no further concerns about the children.    As a result, in September 2017 the children were stepped down from Child Protection to a Child in Need Plan.  2.4.5.    The Child in Need plan was in place until the end of 2017.  During this plan the Social Worker continued to undertake home visits and to visit Grace at nursery.   Nursery staff also recorded concerns about the mother’s care of Georgina, although it does not appear that these were shared with the social worker.  The nursery shared some concerns about the mother’s attachmentOfficial 10 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     to Georgina.  In November Georgina was taken to see the GP with bruises to her forehead, her mother explaining this as a result of falling from her bed. She was examined and the mother advised to attend A&E if there were further symptoms.  2.4.6.    At the Review Meeting in December 2017, agencies all agreed it was appropriate to close the case.  There had been no further evidence of Mr. A being involved with the family, Grace had told the Social Worker she had not seen daddy and did not know where he was, also that mummy no longer shouted at her or hit her.  The peri-natal mental health service had concluded their involvement with the mother.   A decision was therefore made to close the case.  2.4.7.    In January 2018 Ms. G told staff at the nursery that she had begun seeing Grace’s father.  This information does not appear to have been shared with other professionals.   Ms. G agreed to attend a Mellow Parenting course to help with play and bonding with her child. There was also reference to Grace’s ‘behaviour’.  Later that month the mother did not attend at nursery as Grace was said to have Chicken Pox and a couple of weeks later that Georgina also had Chicken Pox.   At the same time the nursery identified concerns about Grace’s attendance deteriorating and suggested organising a further multi- agency meeting, but it is unclear what action was then taken.  2.4.8.  At the beginning of February 2018 Ms. G went to nursery with Grace and asked staff members what might cause blood behind Georgina’s eyes.  Staff saw there was blood in Georgina’s eye and advised the mother to take Georgina to her GP. The mother did not want to do so as she was worried that Children’s Social Care might accuse her of hurting Georgina.  She agreed to attend the local hospital but returned saying that the hospital would not see Georgina because she was under 2 years old.   Later that afternoon she attended the GP, who noted Georgina had bloodshot eyes with a history of Bronchiolitis, he reassured the mother and gave her advice.Official 11 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      2.4.9.     A week later Georgina was presented at the South London hospital with suspected infected Chicken Pox and Sepsis.    As a result of the medical examination she was identified as having fractures to her ribs and arms that were likely to be at least 7 days old but could have been longer. An immediate referral was made to Children’s Social Care Child and effective actions taken to protect both children. Georgina was taken into Police Protection and placed into foster care the following day.  Grace remained in hospital for further treatment and was placed with her sister in foster care on discharge.  3         The Children   3.1.       It has not been possible for the author of this review to meet with the children, or to speak to their parents or other family members about them given their current circumstances.      However, information provided by professionals allowed the Review to develop some sense of Grace, but a very limited picture of Georgina.  3.2.      Grace is identified as white British; she was understood to have had some speech and language delay and there were a number of references to her ‘clumsiness’.      Georgina is of dual heritage, White British/Palestian, the possible significance of which is considered in the analysis section.  She is not known to have any physical health concerns.  3.3.       Grace was described by the Family Centre Social Worker as a bubbly, fun- loving child who interacted easily with both adults and children.   She very much enjoyed arts and crafts, especially anything that involved glitter. Her favourite colour was pink. Whilst she lived with her mother, she had daily contact with her aunt, her aunt’s husband, her maternal grandmother and other family members and would as a result have had a sense of her wider maternal family. Her relationship with her father was evidently more disrupted and the only member of his wider family she is known to have a relationship with was her paternal grandmother.Official 12 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      3.4.       The school described Grace as a confident “endearing” child, who settled well in school and enjoyed playing out, although they noted that she had some clumsiness and speech and language immaturity.  The Review has however also been provided with information about the very positive progress both children have made since being taken into foster care, improvements in their general health and wellbeing, and in Grace’s “clumsiness”, and speech and language.   4         APPRAISAL OF PRACTICE AND ANALYSIS  4.1     Introduction   4.1.1.   This Section will appraise the key aspects of multi-agency practice as identified by this Review. It will consider what multi-agency learning there may be for future practice in respect of the Terms of Reference outlined by the Safeguarding Board and any other learning that might have emerged, structured within the following five headings:  • Understanding and working with carers who have complex histories •  Communicating with and responding to the children  •  Responding to physical abuse in infants  •  Management of risks after stepping down from child protection  •  Consideration of multiple forms of abuse.   4.1.2.   Whilst a criminal investigation took place during the course of this Review, no charges were ultimately brought as it was not possible to conclude to a criminal standard of evidence who had been responsible for the injuries to Georgina. However, within the Care Proceedings a Finding of Fact concluded that:  •  All the injuries to Georgina were non-accidental  • Three family members, the mother, maternal grandfather and Aunt G, were described as in the ‘pool of perpetrators’ who caused the injuries. •  The mother had physically abused GraceOfficial 13 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official       4.1.3.    Issues of Ethnicity, Gender and Culture are considered within the analysis, rather than as a separate section. The overall approach to this analysis will be to use examples in order to identify and reflect on the key areas of learning for the multi-agency safeguarding partnership. Individual agencies have identified specific learning for their organisation in the course of this Review and this will be referenced as relevant within this review.  4.1.4.    From the outset, it should be acknowledged that much of the professional practice in relation to this family met the standards required; much of the decision making was reasonable given what information was available and there was a good level of professional response and support of the family. Decisions regarding the need for assessments and Child Protection Procedures were largely timely and appropriate, as was planning for possible Care Proceedings.   The network of professionals appeared to be well co- ordinated, there was evidence of regular Team Around the Child meetings and significant contact with the children.   4.1.5.    There were however occasions when professional practice fell short of some agencies’ own required standards.   This was particularly significant for the decision to close the children’s case in December 2017. Despite these identified areas of weakness, much of the most significant learning emerging from this Review relates to the more complex, challenging features of child protection practice.    4.2     Understanding and working with adults with complex histories   4.2.1.   It has become clear during this Review that the way in which the children’s carers presented to professionals, and were understood by them, played a critical role in shaping the agencies’ responses.   Ms. G and her two children had involvement with a number of statutory and specialist services for significant periods.  Police and Children’s Social Care had been involved with Ms. G’s birth family on several occasions as a result of domestic abuse.    The mother had been involved with CAMHS from the age of 5 with a diagnosis ofOfficial 14 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     ADHD and the family were identified by more than one service as well known to them.  4.2.2.  What was known to all the key agencies to at least some extent was that Ms.  G had a significant number of damaging experiences as a child and young person. She had witnessed and experienced domestic abuse, to such a degree that she herself referred to seeing it as a ‘normal’ part of family life. It was also apparent that there were complex dynamics within her birth family and difficulties in the  relationship  between  the maternal grandmother and  her children.      Whilst this history was known, it does not appear that the assessments were able to fully uncover the full extent to which it may have impacted on the mother’s own adult relationships, her approach to parenting or her relationship with statutory services.  4.2.3.   There was considerably less information known to agencies about the men involved in the mother and children’s lives. Mr. A was referred to almost entirely in terms of being a perpetrator of domestic abuse. Almost all that appeared to be known about Mr. B, is that he was of Palestian origin and a Muslim.  Ms. G had told Children’s Services that Mr. B had no wish to be involved with his daughter and that she did not have any contact details for him. When Grace was 9 months old the Mother had taken out civil orders to prevent contact with Mr. A and maintained from that point that she had ended the relationship and he was not part of their family life. There was however important information to suggest this was not true.  4.2.4.    Domestic  abuse  and  the  professionals’  response:  The  information available suggests that the statutory agencies responded to the mother’s experience of Domestic Abuse in line with expected standards.   There is evidence of Police attendance; of referral to, and response from Children’s Social Care; of good liaison between Children’s Social Care and the IDVA (Independent Domestic Violence Advisor) and of a MARAC regarding the mother’s ex-partner.  Throughout the period under Review there is evidence of Ms. G being supported by both statutory and other agencies. This included being referred to the specialist midwifery anti-natal service for vulnerableOfficial 15 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     adults; safety plans being developed and referral to programmes for victims of domestic abuse.  4.2.5.  However, what proved to be more difficult was in fully understanding the nature of the mother’s relationship with Mr. A and therefore what the risks to the children were and how they could be managed.   This did not reflect a lack of focus on the children or the potential risks to them of living in a household where there was domestic abuse.  In fact, considerable time and energy was involved in attempting to ensure that the children were being kept safe, this itself being one of the reasons for the children being on a Child Protection Plan.  It was also apparent that Children’s Services were very concerned at times that Ms. G was not able to keep the agreement that there should be no contact with Mr. A.   What was more difficult to assess was exactly how the risks of domestic abuse were understood and how this impacted on the wider assessment of both parents and children.  4.2.6.    Mr. A was explicitly identified as posing a significant risk to the children and this was taken seriously by professionals. This was undoubtedly a reasonable starting point. However, what was not available was a comprehensive assessment of Mr. A, either in relation to risk or parenting capacity.   In any event, whatever the actual level of risk posed by Mr. A, the professional focus was significantly centred on him and his presence in the family, at times almost overshadowing concerns relating to the mother. This is particularly noticeable in the pre-birth Child Protection Plan for Georgina in January 2017, when three quarters of the actions related to keeping the children away from the father and only a quarter related to the mother’s parenting.  4.2.7.   Whilst he was in attendance at the Child Protection Conference in February  2014, it is not apparent how thoroughly Mr. A was assessed when Grace was first made subject to a Child Protection Plan.   However, during the second Child Protection Plan it is evident that several attempts were made to contact and involve him both by the children’s Social Worker and by the Social Worker who prepared the Parenting Assessment, but with limited success.  On one occasion the Parenting Assessment Social Worker spoke to him on the phoneOfficial 16 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      and he agreed to meet her and also to contact the children’s Social Worker but did not then do so. As a result, the professionals were significantly reliant on information provided by the mother and her family about Mr. A.  Some of this information, such as the statement by the mother that Mr. A had attempted to snatch Grace, could not be verified. Therefore, proper weight could not be given to such statements in determining where the most significant risks to these children might be.  4.2.8.    Professionals are required to manage a careful and difficult balancing act in these circumstances: that of taking seriously what a victim/survivor of Domestic Abuse tells them about potential risks, whilst also retaining an open mind in the absence of full information. It is crucial to recognise that where someone is experiencing domestic abuse there can be multiple barriers4 that may lead to the individual remaining in, or returning to, an abusive relationship. These range from fear of serious injury or death, through to issues such as lack of self-confidence, family pressure, financial pressure and isolation.  At the same time, when child protection processes are taking place, victims of abuse can feel under pressure to assure Social Workers and others that they have separated from their abuser, for fear of their children being taken into care.  4.2.9.   In this case, there appeared at times to be too ready an acceptance by some professionals of the Mother’s apparent intention, or her ability, to separate from Mr. A. Given her childhood history and experience of domestic abuse as a ‘normal’ aspect of family life, combined with what is known about how difficult it can be for victims to separate from their abusers it is likely that what lay behind her responses was highly complex.   There were clearly significant doubts, not least from the Social Worker, as to whether Mr. A was indeed a part of the family, as well as understandable concerns that Mother might feel under pressure to allow him to have contact with the children.  However, it is difficult to see to what degree professionals entirely understood what the adult     4 See for example: https://www.refuge.org.uk/our-work/forms-of-violence-and-abuse/domestic- violence/barriers-to-leaving/Official 17 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      relationship meant to the mother, what might drive her to conceal that relationship and what priority she gave to the children in the context of this relationship.  4.2.10. A  widely  recognised  challenge  in  child  protection,  where  a  mother  has experienced domestic abuse, is how to ensure that children are protected, without holding the mother solely responsible for managing an abusive man’s behaviour.   In this case, the mother maintained that neither father was involved in the family and may have actively obstructed professional access to them. Whilst this could have been an attempt to protect herself and the children from abusive behaviour by Mr. A consideration also could have been given to the possibility that she wanted to distract professionals from raising concerns about her own parenting ability.   4.2.11. When Mr. A became subject to a Community Sentence in early 2016 for breach of the Restraining Order this presented an opportunity to better understand his role in the family and what risks he might pose.      At this time, he was understood to be living in South Wales and his order was supervised by the Wales Community Rehabilitation Company5  (Working Links). The National Probation Service6, had contacted Wandsworth Children’s Services during the preparation of the Pre-Sentence Report and been informed that the case was closed. The Pre-Sentence Report was forwarded to the CRC who also had access to the CPS file and as such will have been aware of a pattern of violent and abusive behaviour.   4.2.12. Unfortunately,  the  supervision  of  Mr.  A  by  the  Community  Rehabilitation Company fell significantly below the expected standards.   There were long periods without any contact with his Offender Manager  with no resulting enforcement of the order; significant gaps in the records; no evidence of any direct work with Mr. A about the nature of his offending; no risk assessment   5 Community Rehabilitation Company (CRC); Private sector companies contracted by the government to low and medium risk offenders in the community. 6 The National Probation Service is the statutory criminal justice service which supervises high risk offenders in the community and provides Pre-sentence reports to the courts.Official 18 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      when Mr. A committed a further alcohol related offence or in the context of Mr. A having a new partner who was pregnant; and no liaison with other agencies. An initial OASYS7 assessment was undertaken and assessed him as low risk to children and a medium risk to his current or previous partner.   However, there is no evidence from the record of how that risk was being managed.   4.2.13. The Wales CRC’s expectation was that the Offender Manager should have liaised with Children’s Services in relation to the new partner and her unborn baby, as well as checking any information about Mr. A’s ongoing contact with Grace.   In the absence of a discussion with the Offender Manager, who no longer works for the CRC, we can only achieve a partial understanding of the reasons  for  this  poor practice.    However,  there  are  some  factors,  often reflecting nationally identified problems, which we can reasonably surmise may have played a part.   There have been widespread concerns about the impact of high caseloads on staff in CRCs; newly appointed staff at this time in Wales were not provided with any mandatory safeguarding training; the supervision model was reliant on the staff member themselves identifying cases for discussion and there   was little if any evidence of management oversight having been provided.  4.2.14. It is important not to make a simplistic judgement about the practice of one member of staff without a proper understanding of the working context for that individual and the role of the CRC in supporting and overseeing practice. Nationally, recent inspections of CRCs have raised significant questions about the quality of work both in relation to Domestic Abuse and more widely across England and Wales.     The HMIP’s Thematic Report regarding Domestic Abuse,  completed  in September  2018,  found  that  ‘overall  the work  was characterised by a lack of awareness and applied expertise”.  Importantly, the same report also concluded that unmanageable caseloads, lack of experienced staff with poor training and management oversight resulted in an insufficient focus on domestic abuse.  The Inspection Report clearly identifies    7 OASYS. The offender assessment system used by ProbationOfficial 19 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      the lack of a strategic approach for CRCs at a national level in relation to Domestic Abuse and concluded that “practitioners were not empowered to deliver a good-quality service”.8   4.2.15. The HMIP report offers some insights into CRC’s practice relating to domestic abuse and as such offer’s challenges to all of them.  However, it should be noted that this national report was based on an overview of practice in England and Wales from sampling across 21 Community Rehabilitation Companies, companies with multiple parent organisations and differing operating models. Some caution is therefore required before extrapolating how this may reflect practice generally in the Wales CRC during this time.  4.2.16. The Wales CRC has informed the Review that there have been a number of significant changes since the events outlined here.   These include targeted auditing as to whether Safeguarding checks have taken place and compulsory E-Learning safeguarding training for all practitioners whatever their length of service. At the time of writing the Wales CRC (now Wales Probation Services, part of Kent Surrey and Sussex CRC) was undergoing an inspection by HM Inspectorate of Probation (HMIP), which is likely to shed further light on these and other aspects of practice.   4.2.17. In February of this year, Working Links, the Company responsible for the CRC in Wales went into administration.  The contract for delivery of probation services to low and medium risk offenders in Wales was then transferred temporarily to Kent, Surrey and Sussex Community Rehabilitation Company, operated by Seetec.   It is proposed that National Probation Service in Wales will assume responsibility of all offenders in Wales at the end of 2019. Irrespective of the specific parent organisation, given the level of concerns in this case, concerns which also appear to reflect wider national problems, the following recommendation is being made by this Review:      8 HMIP (2018) p8Official 20 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      Recommendation 1:   That Wandsworth SCB share this Review with the Cwm Taf Morgannwg Safeguarding Children Board in order for any relevant actions to be considered.   4.2.18. The Mother’s engagement with professionals:  The unresolved questions about the significance of domestic abuse in these children’s lives was not the only indicator that their main carer’s response may not have been as straightforward as it seemed.  To a large extent the professionals viewed the Mother in positive terms as a young mother trying to improve her situation. She was frequently described as polite and friendly and always keen to get involved with events and listen to advice.   Some professionals, particularly those who were not actively involved in the Child in Need or Child Protection processes, saw her as less vulnerable than others and felt she was doing well with the children. However, with the advantage of the full information it is possible to identify a more complex picture.  4.2.19. The Mother undertook several courses and attended groups, relating predominantly to domestic abuse and parenting, something which was viewed as a positive indicator of commitment.   She was described by one of the professionals as always being the first in the queue for new activities and events. The Health Visitor was struck by the mother specifically asking to be allowed to do an activity individually after missing the group session, but with hindsight she also noted how keen the mother was that the Social Worker would be informed.   What is possible to see now is that there was a gap between the participation in activities and evidence of tangible changes in behaviour which might improve children’s experience.   Ms. G was viewed as having a good understanding of Domestic Abuse, yet, as the Social Worker who undertook the Parenting Assessment concluded, there remained a question about the possible difference between her theoretical understanding and her ability, to translate that understanding into practice.   4.2.20. Whilst attendance by the mother was often recorded or reported back in positive terms, frequently it was not as good as it seemed. Feedback from theOfficial 21 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     Triple P Parenting Course was positive, yet the mother attended only 5 of the  9 sessions. The mother’s engagement with the Health Visitor is revealing of how her apparent co-operation could be effective in creating a barrier against professional curiosity.    The Health Visitor viewed it as a positive that when the mother had to cancel appointments, she always immediately rearranged them. Subsequently the Health Visitor realised that this meant she had almost never undertaken a home visit, as rearranged appointments always took place at the clinic.        Similarly, the Social Worker who undertook the Parenting Assessment recognised that although the mother cancelled appointments quite frequently but did always rearrange them, she had also seen this as a positive.   4.2.21. Ms. G often talked positively to professionals about her contact with other agencies.  She told the Health Visitor that she was seeing the specialist peri- natal (mental health) team and ‘felt the benefits.  Yet in fact she had missed or rearranged a significant number of appointments. The Social Worker also identified that the mother had been dishonest with her about her engagement with the peri-natal team.  Conference minutes and other records refer to Ms. G not always being honest with professionals.   However, in the absence of very robust systemic recording by all agencies, for example by the use of chronologies, the pattern of non-attendance was not fully identified at the time. It is not uncommon and, in many ways, understandable that parents whose children are subject to Child Protection Plans will not always be entirely truthful about what is happening in their lives and whether they have followed agreements.   Getting to the bottom of why people might be dishonest with professionals in this way is an important part of the overall assessment. Ultimately however, the prime focus must always remain on whether required improvements in the children’s care or safety are being achieved.  4.2.22. On other occasions it appears that the mother may have been consciously attempting to influence one professional against another.    This came for example in the form of presenting as stressed and anxious to the Health Visitor when Grace’s disclosures made comments about “Daddy” as she said sheOfficial 22 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     was worried that the Social Worker would believe Grace. On another occasion she became very angry with a nursery worker who had passed on some information which then was shared with the Social Worker.    The nursery worker accepted the criticism, agreeing with the Mother that this hadn’t been fair, when undoubtedly this was legitimate information sharing.  At the Child Protection Review Conference in September 2017 the mother alleged that one of the staff at school had caused a scratch to Grace’s face.  This was looked into and no evidence found, but the potential for this to be a distraction from the real concerns for the children remained.  4.2.23. The Mother’s bonding with GEORGINA:  Several of the professionals identified concerns about bonding or attachment between the mother and Georgina, something which the mother herself spoke about openly and quite frequently. From very early in her pregnancy the mother said she was worried that she would not bond with this baby.   The resulting professional response to the mother was almost entirely a behavioural one of trying to teach her how to respond to Georgina’s needs.  Different professionals clearly identified that the Mother was often not very responsive to Georgina’s needs, that she was slow to help Georgina manage any distress and not always available to her. The latter showing itself very literally through her habit of leaving Georgina outside the nursery in her pushchair despite repeatedly being told not to do so by staff.  4.2.24. The Family Support Worker at the nursery, whose role it was to support the parents with their children was one of the professionals who recognised the mother’s behaviour in terms of attachment.  She would encourage the mother to respond to Georgina and suggest different ways that she could behave in order to improve the bond, such as holding the baby whilst feeding.   She observed that the mother was often distracted by her own needs.    For example, describing the mother as very excitable, rushing in to meet with her friends in the centre and needing to be reminded to focus on her child.Official 23 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      4.2.25.  The role of this worker was specifically to support parents with attachment and to develop play with their children. Whilst this was positive, it is difficult to see how it was linked with the work being undertaken with the mother in the ‘therapeutic group’.  The family support and nursery workers had no involvement with the therapeutic work and there appeared to be no real structured opportunity for staff to reflect together about individual families. Families would be discussed in team meetings, but this was often crisis management with the discussions not looking back further back than the previous week.  Consequently, there was no opportunity to think beyond managing the behavioural symptoms of poor parent-child attachment nor to consider what might be at the root of the problem. This worker’s experience is confirmed in the voluntary organisations report to this Review, which itself identified a lack of any formal approach to review and reassessment with the families attending the centre  4.2.26. The mother’s specific reference to not bonding with Georgina in the way that she had with Grace needed to be explored further. What was it about this new baby that made her feel this way?   It is not uncommon for women to be concerned about bonding with their babies. Research by NCT9  identified that around 30% of new mothers’ experience difficulties in bonding with their babies.  However, given that Georgina was subject to a pre-birth assessment and a subsequent Child Protection Plan, and that there was evidence of poor responsiveness by her mother, further exploration was warranted.  4.2.27. One additional area that justified further consideration in this context was the mother’s lack of transparency as to Georgina’s parentage. Initially the mother named Mr. A.    However, when Georgina was just a few months old, she identified Mr. B as the real father because Georgina did not look like Mr. A. We do not know if this change in disclosing the real father was a genuine mistake on the mother’s part, or whether there was something about this new baby that particularly impacted on how she felt about her.   Whether that was something Ms. G felt personally or something she felt she needed to conceal   9 https://www.nct.org.uk/about-us/news-and-views/news/difficulties-baby-bonding-affect-third-uk-mumsOfficial 10 NSPCC (2014:4) 24 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     from Mr. A, her family or Children’s Services, understanding this would have helped form the assessment as to whether there were significant risks to this child.   4.2.28.  What is known is that both Ms. G and her family identified Mr. B’s religion or ethnicity or culture as the reason he did not want to be involved with his child. This Review is not in a position to conclude that ethnicity or religion was a factor in the mother’s references to not bonding but notes that this was a discussion that should have been had with the mother.  Without speaking to the Social Worker, the Review has no evidence that this was the case. If Georgina’s dual heritage was viewed negatively by the mother, for whatever reason, this needed to be identified and understood in the context not only of risk, but also of Georgina’s wider needs being met.  4.2.29. How was the mother’s response understood? Despite the Social Worker’s evident concerns about the possible presence of Mr. A in the family and the contradictions in relation to the mother’s engagement with agencies, the picture from many of the professionals was that the mother worked well with agencies.  The information that has now emerged suggests that this was not an entirely accurate picture.  4.2.30. “Disguised compliance” is a familiar concept within child protection and a familiar theme within Serious Case Reviews.  It is defined by the NSPCC as being : “when parents/carers appear to cooperate with child welfare agencies but have little intention of changing their behaviour permanently”.10      The concept is not without its difficulties, not least because it can become an unhelpful label for parents who are perceived as problematic, when a more nuanced assessment is required if the working relationship is to be effective. The concept of Disguised compliance encompasses a range of behaviour from aggression through to avoidance.      As such, underneath the familiar shorthand of ‘disguised compliance’ will be a complex range of parental motivations and behaviour and of responses to that parent by professionals,Official 11 C-Change. Platt and Riches 2016, referenced in Howarth and Platt, p241 25 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     responses which can either help overcome unhelpful resistance or increase that resistance.   4.2.31. What is required of parents where there are child protection concerns will always involve    some level of behaviour change.     Helping an individual to make changes, or assessing their capacity to change, is reliant on a good understanding of the complexities of that individual.   A fundamental starting point therefore is establishing a thorough assessment of parenting capacity and a clarity about what needs in order to change to improve the outcomes or decrease the risk to children.  This will need to include an identification of all the aspects of an individual that impact on behaviour, and therefore on any required change to behaviour, including11:   • Priority and relevance for the individual (regarding the required change). •  Knowledge and skills  •  Motivation and intentions  •  Habits and automatic reactions  •  Contextual factors   4.2.32. As part of the Child Protection Plan and the Public Law Pre-proceedings, a full parenting assessment was commissioned and produced by a specialist team within Children’s Services in February 2017. This was a detailed assessment, based on a significant number of meetings with Ms. G, other family members, key professionals and observations of Grace.     The assessment clearly recognises there is a risk that Ms. G might not be able to sustain the changes required of her, particularly in relation to the Father and appropriately questions some of the information the mother provided.  Nevertheless, these concerns are predominantly understood in relation to Ms. G’s own vulnerability, and whilst it was right to be aware of this, a greater focus on any risks she herself might pose would have provided a more balanced picture.  ItOfficial 26 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      is important however that this does not lead us to a simplistic criticism of this or other assessments undertaken in this case.   The reality of working with parents who are not transparent about their lives, is that this can be extremely difficult to uncover at the time.      “Parental resistance is not necessarily indicative of a lack of skilled social work”12  4.2.33. Ultimately, no    assessment    regarding    human    behaviour, however comprehensive and proficient, can be guaranteed to provide a perfect, complete picture of a person’s internal motivators. It is therefore crucial to maintain the focus of any subsequent plan, not just on any identified actions but whether those actions lead to change in outcomes for the children and whether there is evidence of sustained improvements over time.  The single most pressing concern for the multi-agency partnership here was whether Mr. A was having contact with the children. In the face of the mother’s denial, this proved particularly difficult to evidence and will be considered further in the following section.   4.2.34. Conclusion:   Whilst this Review has identified that the way in which the mother was viewed was a very significant aspect of the agencies’ responses, this is not to suggest that the key professionals, not least the children’s Social Worker were unconcerned about the mother’s ability to keep the children safe. Actions were taken when concerns increased, including: undertaking PLO reviews in relation to possible Care proceedings; multiple visits to the home and to see   Grace in nursery; identifying Aunt G and Uncle G as possible alternative carers; and requiring the mother and children to stay with them after Grace’s birth.               12 Ward et al (2014:12)Official 27 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      4.2.35 Two important aspects of working with families in Child Protection are highlighted here.   Firstly, the complexity of fully understanding and working with families who may be very effective in presenting themselves as trying to make the changes required for their children’s safety, but in fact are not achieving the changes required. Secondly that action plans and requirements on parents, if completed, might be reasonably expected to lead to an improvement in their parenting, and the children’s experience.    Given the extent and limits of current knowledge about what is most effective in working with carers where there are known risks to children, this requires a whole system approach to identifying, supporting and reviewing best practice, providing access to specialist resources and ensuring front line professionals have the best available practice knowledge when working with complex families.  This Review notes in particular that the Pan London  Safeguarding Children Board Child Protection Procedures which provide the principle practice guidance to staff regarding working with resistant families13  is very significantly focused on hostility and aggression, with much lesser focus on responding to parents presenting in the way that Grace and Georgina’s mother did. Recommendation 2:  The WSCB to consider the most effective means of promoting and supporting professionals’ practice skills and knowledge across the multi-agency partnership  when working  with parents whose capacity or willingness to make changes for their children is under question, or who appear to be resistant to change. This should include ensuring that practice remains child and outcome focused.    4.3.      Understanding and communicating with the children   4.3.1.   Georgina was only 10 months old when she received the injuries that triggered this Review, but there were nevertheless opportunities to begin to understand her experience of life in her family. That a child is not yet speaking, does not mean that it is not possible to communicate.    All children, but particularly   13 http://www.londoncp.co.uk/chapters/manag_fam_obst_resist.htmlOfficial 28 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     younger children communicate with us by ‘showing’ as well as ‘telling’. Observations of young children’s behaviour are a rich source of information and crucial to understanding their experience.   4.3.2.    One way this was evidenced was when the Family Support Worker at the nursery identified Georgina as being physically stiff and tense, but when she massaged her limbs Georgina relaxed. Georgina responded to safe, gentle physical care from an adult and as such was communicating her reaction to the physical contact she was receiving. The Family Support Worker suggested that Georgina and her mother went to a course of ‘baby massage’ at the nursery with one of their Family Workers. While initially enthusiastic Georgina’s mother then became more reluctant and did not complete all the sessions. She told the family worker that Georgina did not like baby massage. The Family Worker believed it was the mother who did not like the massage, rather than Georgina and she had to encourage her to respond when her child cried.  4.3.3.   Of the agencies, it was the nursery and the Health Visiting Service which had the most routine contact with Georgina.   It was clear from speaking to the Family Support Worker at the nursery that she was very focused on the children.  However, much of the recorded information from the nursery about Georgina relates to her mother’s response to her basic care needs, but without an explicit recognition of what this might signify in terms of Georgina’s daily life.  What was recorded nevertheless provides us with a picture of a child not always well cared for.  She would often have urgent need of a clean nappy, appeared unwashed and in need of feeding and nurturing.  Whilst the mother would respond to these needs when reminded by staff, the fact that she did frequently need to be reminded suggests that Georgina often had to wait for her needs to be met.   4.3.4.    The Health Visitor described Georgina as a sociable baby, with no health or developmental concerns.      However, the Health Visitor’s attention also appeared to begin with Ms. G more than with the child.  This was apparentOfficial 29 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     both from the documentation and in her description of her role as being to  ‘support the parent’. Whilst supporting the parent is clearly very important and can be a crucial means to improve the child’s experience, it should be seen as a means to achieve this, not an end in itself.  Information provided by the Central London Community Healthcare NHS Trust (CLCH) was that this was not the approach that they expected their health visitors to take and have made a number of recommendations for   their own practice to support their expectations that children, not adults, remain the priority for the Health Visiting Service.   4.3.5.    It is not that professionals were unaware of the weaknesses in the mother’s care for Grace or that they did not attempt to help her to improve that care. However, the largely behavioural approach tended to respond too often with the mother’s perspective at the forefront – how could she be helped to do things differently? – with a less obvious focus on the perspective of the child – how might Georgina be experiencing her daily care?   This should not be interpreted as having led to the injuries that she received, an interpretation which this Review would not support.  Rather it is a reminder of the need to look with care at how the child may be experiencing adult behaviour, as a means to better understand the risks that child may be facing.  4.3.6.  Grace’s age and her willingness to speak to professionals, at least in the earlier months, meant that communication with her was more direct.    It will be immediately apparent from the summary of events that Grace made a number of concerning statements about her father hurting her mother, her mother hurting her and her father being in the home.  How this was understood and responded to was therefore a significant issue for this Review to consider.  4.3.7.   Grace is described in positive terms by professionals:  chatty, confident, making good relationships with staff at the nursery.  She was a big child for her age and considered to be a little clumsy and was a little behind with speech and language for which she was referred to the Pediatric Occupational Therapist. The mother attended the Initial Assessment with the OccupationalOfficial 30 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     Therapist who referred Grace on to the Pediatric team in relation to possible developmental delay.      However, Ms. G failed to take Grace to the appointments with the pediatrician, resulting in these concerns not being properly assessed or understood at the time.   4.3.8.     Most significantly Grace began telling professionals from quite a young age about problems in her family and describing her father as being present.  The nursery was generally where Grace made these comments and they were passed on to the Social Worker and at multi-agency meetings. What is very clear is that the Social Worker undertook a lot of direct work with Grace, visiting her in nursery as well as at home and responding every time she made a disclosure about her mother or father.  It is equally clear that Grace’s voice was heard, and she was taken seriously by the Social Worker.   The Social Worker’s manager described her as “bringing the children alive’ when she talked about them in supervision.  4.3.9.   The Social Worker who prepared the Parenting Assessment also undertook a number of observations of Grace, which enabled her to witness directly that Grace spoke about her father quite naturally as someone as part of the family. She clearly took what Grace said seriously, challenged some of the mother’s explanations and was unwilling to accept the adult view that Grace was telling lies.    She was clear that a child of this age would not be able to lie in the detailed and consistent way in which Grace was said to be doing.  4.3.10. What is apparent here  is not that the  key professionals were unable or unwilling to communicate with Grace, but that in the absence of other supportive evidence they were not then able to use the information she gave them to help protect her and her sibling effectively.    Grace’s words were accepted and believed by the Social Worker, who took action to attempt to uncover further evidence to demonstrate that what she was saying was likely to be true.  However, given the fact that Ms. G continued to deny the father’s presence, that there was no further evidence of physical harm to Grace andOfficial 31 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      there was no separate evidence of the father being in the home, Grace’s voice alone was not enough to lead to a change in these circumstances.   4.3.11.  In the absence of any direct evidence of harm to a child it would be difficult to demonstrate that the thresholds for taking legal action in such circumstances would be met. Instead the options available to the multi-agency network were to continue to record and review concerns and to use that network to review the family situation, including considering the possibility of accessing multi- agency supervision.  Routine multi-agency meetings that do not involve the parents are not justifiable.    However, judicious use of properly managed meetings for professionals in order to meet without the parents, can provide an important opportunity to air difficulties, and any differences, in the way in which the professionals work together.  Such a meeting might have created an opportunity for those involved with this family to further reflect on what information they collectively had, whether there were patterns that they had not been otherwise able to recognise and what might be getting in the way of their work with this family.  4.4.      Identification and response to Physical abuse in infants   4.4.1. It  has  long  been  recognised  that  infants  under  one  year  old  are  highly vulnerable to abuse and are disproportionately subject to serious physical injury or death.14     The recent report from the Children’s Commissioner15 has estimated that there is a very significant number of babies in the population who are highly vulnerable to neglect and abuse with an average of 100 such babies being known to Local Authorities. There was certainly a clear awareness by Children’s Social Care and in the multi-agency team that the children were at risk of physical abuse.  In    2016 a Section 17 assessment had been undertaken following an anonymous referral about neglect and an allegation that the mother had hurt Grace.  This was followed by information that mother was pregnant with Mr. A’s baby, resulting in Child Protection Plans under the category of physical abuse.  There was however other information  14 Ofsted (2011); Ward et al (2012:2) 15 OCC (2018)Official 32 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      about injury or possible injury to the children that did not reach the multi- agency partnership.   4.4.2. Head injuries to infants and young children should always raise particular concerns.  The head is the most frequent site of bruising in child abuse and bruising to the face in a non-mobile infant is of particular concern (RCPCH16). There were three occasions when one of the children had a possible injury to the face or head:   • July 2016, Anonymous referral that Grace said her mummy had hurt her eye.  Information provided to Children’s Services • November 2017.  Georgina seen by GP with bruises to the forehead following an ‘accidental fall’ •       February 2018. Georgina seen by GP with blood spots to the eye    4.4.3. Children’s Social Care was not aware of the two consultations with the GP until after Georgina’s presentation at hospital with suspected Chicken Pox. That neither of these was referred to CSC, particularly the November 2017 incident, is of concern.   The mother brought Georgina to see the GP in November after what she described as an accidental fall from her bed. The GP assessed the mother as sensible and genuinely worried, and he did not feel there was any cause for concern.  He had only had one previous contact with Georgina for a childhood complaint when he had felt the mother had acted properly by bringing her in to be seen and this contributed to his sense of a mother acting responsibly. The GP also reflected that he was working to build rapport with the mother and wanted to support and encourage her for coming into the Surgery. He assessed Georgina as looking well and showing no signs of distress but did not conduct a full examination of her.   4.4.4. In fact, at this point Georgina was still identified as a Child in Need and two months previously had been subject to a Child Protection Plan as a result of    16 RCPCH (2017:7)Official 33 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     risk of physical abuse. The GP was aware that there had been previous safeguarding concerns and that there was a flag on the Database identifying this, but he did not view it as a current issue. It is highly unusual for a child under 1 year old to be made subject of a Plan on the basis of Physical Abuse, which should in itself have raised concern.   With hindsight the GP has fully accepted that he that he should have revisited the information flagged on the computer system, which included the Child Protection Plan, and sought further advice or made a referral to Children’s Services.   4.4.5. The second visit to the Surgery at the beginning of February 2018 was a further point at which consultation in relation to safeguarding could have been sought. Whilst the GP’s conclusion was not medically unreasonable, again, given the history, alternative explanations to the blood spots being caused by coughing should have been considered. This presentation could also have been caused by shaking or physical injury.   4.4.6. Any head injury to a non-mobile child in the absence of clear evidence as to how it was caused should lead to a fuller examination and a consideration of the possibility of abuse. That the child concerned was also on a Child in Need plan and was known to services, should have been an additional trigger to seek a consultation with CSC, or with a Safeguarding lead or colleague. Whilst it cannot be presumed in retrospect that either of these presentations did in fact arise out of physical abuse or that reference to Children’s Services would have prevented the ultimate injuries  from taking place, given the current knowledge about risks to infants, particular caution given Grace’s age and family history was needed. In the event, examination of Grace in hospital at the end of February did not identify any evidence of head injuries.   4.4.7.  The GP in this case has received individual training in relation to physical abuse; the link with domestic abuse; the use of flags and codes on the GP system; and liaison with health visitors.  Georgina’s experience has also led directly to a number of wider actions for GPs including:Official 34 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      • Refreshing GP training, with particular reference to vulnerability of infants and increased risk relating to domestic abuse as well as the role of fathers. • Better use of flags on computer systems to make them more immediately useful and accessible to GPs during consultations •       New contracting arrangements to include regular meetings between  Health Visitors and GP leads in Child Safeguarding at every practice.  •       Specialist training for GPs on bruising in babies    4.4.8. What emerges from Georgina’s experience, from research and from previous Serious Case Reviews conducted in Wandsworth is that active recognition of the risks of physical injury to infants remains an area of vulnerability for the child protection system, not just locally, but also nationally.  Recommendation 3: The Board to consider developing a programme to raise awareness and to refresh understanding of the risks to infants of physical abuse for children at all levels of intervention.    4.5     Managing risk when Stepping down from Child Protection   4.5.1. The decision to step down from Child Protection: Given the information that was available at the time it is the conclusion of this Review that it was reasonable for the decision to be made for the children’s cases to be stepped down from Child Protection Plans to Child in Need in September 2017 and the case then closed in December 2017.   •       The children had been subject to Child Protection for over a year  •       Grace had stopped mentioning her father being in the home;  •       Mr. A was not found to be present in the home during unannounced visits;  • Ms. G was reported to have been consistently engaging with most of the professionals and there were no continuing concerns regarding the children’s, wellbeing and safety or the mother’s parenting •       Parenting assessments were largely positive about her capacity to parent.Official 35 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     • Legal advice was that the children’s case would not meet the threshold for care proceedings.   As identified by one of the team managers:  “it is hard to justify keeping children on a child protection plan when everyone has agreed the plan has been complied with and everyone has done a lot of work to get the children off the plan.” However, there was information held by one of the agencies, that if it had been transparently and clearly shared, might have led to a different conclusion.   4.5.2. Ms. G had a considerable level of contact with the nursery and as required, the voluntary organisation produced an Individual Agency Learning Report for this Review reviewing the nursery’s practice. That report identified clearly and transparently that there had been very significant failings in the work of the project and urgent action was taken to rectify these failings throughout the time of this Review.    These failings were analysed in detail by the Voluntary organisation, the most significant of which are as follows:   •       No comprehensive assessment of Mother or child’s needs undertaken  • Significant absence of detailed case recordings, including no clear plan of work or response to the identified risks • Positive description to other professionals of the Mother’s engagement at odds with the evidence. •       Lengthy periods of drift before planned activities actually took place.  •       Incidents of alleged Domestic Abuse not reported to Children’s Social  Care.  •       Information about the mother’s poor attendance not passed to the  Social Worker  • Unilaterally informing the Mother prior to the CPC in September 2017, that the meeting was just routine, and the case would be closed in a matter of weeks.Official 36 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     • Lack of clarity about the purpose of the service, which had become by default a ‘drop in’ rather than a project offering clear programmes of work.   4.5.3.  From the voluntary organisation’s analysis it is apparent that the nursery’s relationship with the mother and their very adult focus set the scene both for their direct work with her and for the way in which they engaged with the multi- agency partnership.    Nursery staff attending the final Child Protection Plan said that the mother had made progress with them and agreed that the children should be stepped down.   However, this did not reflect the reality, indeed the project manager subsequently said that the Mother had “made no progress with her parenting and had not changed in anyway” during her time she was involved with the nursery.   4.5.4.  In  the final two months before the  Child  in Need  plans were  closed  in December 2017, the nursery made at least 8 recordings of concern about the Mother’s behaviour, ranging from bringing Georgina to the project in sodden nappies, to ‘having a meltdown’ in the playroom.  There is no evidence that these concerns were shared with the Social Worker or at the Review Child Protection Conference in December 2017 at which the case was stepped down. Inevitably the lack of this information would have played an important part in the decision to step the children down from firstly Child Protection and secondly Child in Need.   4.5.5. The voluntary organisation has reached the conclusion that during this timeframe the service lacked any system for reflection, review or quality assurance and identified too much with the parents as opposed to the children. They also concluded that there had been a drift away from the purpose of the project by staff and that staff skills and knowledge in relation to safeguarding children “required significant improvement”.     There appeared to be no understanding that the project had statutory responsibilities or familiarity with basic safeguarding practice and regulation, including Working Together, the statutory guidance.  It has been identified both by the voluntary organisationOfficial 37 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     and by the Local Authority Commissioners, that a significant factor in this was the increase in service users with higher level mental health problems, something that the service struggled to adapt to.  4.5.6.   Managing the risks: The step-down agreement from Child in Need, included that the nursery would continue to work with the family, in the belief that this was a strong support and would mean that some safeguards were in place. However, not long into after the children were stepped down from their Child in Need Plan, there were indications that the mother’s engagement with agencies was deteriorating but no re-referral took place.    In January the nursery noted that there was a decline in Grace’s attendance and an internal note suggested another Team around the Child Meeting, but no information as to whether this was pursued has been identified.  Also, during this period Grace was not taken to pediatric appointments.  Just a month after the case was closed to Children’s Social Care, the nursery recorded that the mother had started to see Georgina’s father, that there were issues with Grace’s behaviour and that the mother was going to attend a Parenting course to help with  play and bonding.    It would appear that certainly in relation to the nursery’s involvement with the mother there was no fundamental change.  4.5.7.    It is not uncommon for cases to be stepped down, even though there may continue to be some reservations, but because all identified actions have been met and there is inadequate reason to keep the case open.  Within CSC there is a commitment to a minimum a period of 3 months under Child in Need. If a re-referral is received within 3 months after case is closed it would be managed by the original team within Children’s Services.    Additionally, there is a requirement of a clear final assessment specifically identifying what would constitute a future risk and what action may be needed.  This latter point has been acknowledged as being of variable consistency and requires further work.  4.5.8.    Events immediately prior to the hospital admission:  Staff at the nursery had been told by the mother in January that Grace was off school with chicken pox, and that Georgina had bronchitis, so they had not seen the childrenOfficial 38 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     during that period. Ms. G came into the nursery on 1st  February 2018 and asked staff what would cause blood behind the eyes, referring to Georgina. Georgina was left with the Play/Family Support staff while the Mother went into the therapeutic group. The staff noticed that Georgina had bloodshot eyes and her hair was stuck to a scab behind her ear, Ms. G commented that she might be getting chicken pox.  The Family Support Worker made a point of checking Georgina for spots while changing her nappy and was concerned both about the bloodshot eye and that Georgina was quite cold.  4.5.9.   Despite encouragement by staff, the mother demonstrated an evident reluctance to seek medical assessment for Georgina.  Later that day Ms. G phoned the nursery and told them she had seen her doctor, which was in fact the case, but which was not checked by staff at the nursery.   The Family Support Worker told the Review that at that time she did not think she had the authority to check with the Doctor and regretted that they had not done so. What is more concerning is that project staff in management roles did not take action. As both the individuals concerned are currently on sick leave it has not been possible to seek their views directly.   However, two underlying issues appear to be relevant. Firstly, a culture of focusing on the adults needs rather the child, possibly linked to a lack of experience of working with children or familiarity with the safeguarding responsibilities in relation to children.   As described by a member of staff “there was a lot of responding to what’s going on for the adult”. Secondly that the complexity of the service users, particularly the increasing numbers with child protection concerns was not envisaged at the outset of the project.  As a result, the project appeared to have struggled to keep up with the changing nature of their work, including the need to develop their understanding of child protection and had not informed the organisation nationally of this change.  4.5.10. Voluntary organisations’ Response to the learning from this Review: The voluntary organisation has put together a detailed plan of Action, effectively ensuring a complete review of the nature and structure of the Project, putting in place experienced Social Work registered managers toOfficial 39 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      implement fundamental changes, developing an immediate training and supervision programme for staff and creating a system of independent audit for a minimum of 12 months.     The voluntary organisation has openly recognised that weaknesses in its wider organisation in turn allowed the weaknesses in this project’s practice to continue unchecked for too long. Action has also been taken in relation to capacity issues regarding individual staff members.   4.5.11. There is evidence that this comprehensive review and plan of work is having an impact in the service. All their projects nationally are being reviewed and the voluntary organisation has invested in a new National Quality Assurance team led by a Senior Manager with extensive experience of children’s safeguarding.  The role of this team is to be actively responsive to changes in thresholds, demographics, poverty and other factors which impact directly on the knowledge and skills required within their projects. At a local level, the Family Support Worker who spoke to the Review was able to describe her own experience of significant practice changes in the project, for example regarding Risk Assessment  4.5.12. The concerns about the nursery were raised immediately with the WSCB and the commissioners and assurance required as to what action was being taken. Those responsible for commissioning have recognised the increased pressure on a number of services, including the nursery, with a more complex user group developing than had originally been intended.  Given that both the voluntary organisation and the commissioners have taken immediate action; the significant investment and constructive response from the voluntary organisation   and the focus on ensuring quality oversight from the WSCB /Partners it would not be proportionate for this Review to make a further recommendation.  4.6.   Co-existence of other forms of abuse   4.6.1.   The final item in the Terms of Reference asked this Review whether there was learning about the multi-agency’s capacity to identify the co-existence ofOfficial 40 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      different forms of abuse.      We know from research that children who experience one form of abuse, are at increased risk of experiencing other forms of abuse or neglect. Evidence from Serious Case Reviews nationally has identified that both neglect and sexual abuse are more likely to take place where there is physical abuse of children but that this can be underestimated when the focus remains to too great a degree on the primary category of harm identified. Based on this research there was evidence of, for example, sexual abuse also being a factor in a third of cases of non-fatal abuse17.  Alongside this   there is evidence of an increased risk of child abuse of all kinds in households where there is domestic abuse taking place.18 What is pertinent in terms of the learning for this Review is not whether these children were experiencing other forms of abuse, but to what degree this was considered as a possibility.   4.6.2.    For these children, it was also the case that a number of members of the extended family were involved in their care and that this was not always clear or transparent.    At times the children were cared for by adults who had previously been identified as of potential concern and assurances had been given by the mother that they would not be left in their care.  Also, because the mother was recognised as vulnerable and in need of support her sister and brother-in-law were presented as alternative carers and as individuals who could support her and help protect the children.   4.6.3.    The assessment for Aunt G and Uncle G concluded that they could be considered as Special Guardians and they were very much seen by the network as a positive protector for the children.      However, there were indicators both in the report and in their response to professionals that suggested some concerns.   These included:   • The couple’s strongly expressed views that Grace must be lying about the presence of her father within the family   17 Sidebotham et al (2016:63) 18Official 41 SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official     • Questions about their own birth families and how their early experiences may have impacted on them •  The Aunt and Uncle’s failure to share important information with the Social  Worker  • Reference by maternal grandmother to her daughters’ mental health problems. • The lack of information about the father of Aunt G’s daughter and his significance in her life.   What is of interest is not that professionals were untroubled by these concerns relating or concerns about the wider extended family, but that this did not result in more explicit consideration of the potential risk of harm to children by other carers in their extended family network.  4.6.4.    Reference has been made earlier in this analysis to the different potential safeguarding risks to these children at the outset of the second period of child protection in 2016, including both neglect and physical abuse. Two linked aspects of practice are highlighted in this Review as a result.   Firstly that irrespective of what presents as the most worrying risk to a child, whether that is physical abuse, neglect, emotional  or sexual abuse, professionals across the multi-agency partnership need to be conscious of maintaining focus on the whole of a child’s experience including the possibility of a child being subject to more than one form of abuse.  This has not always been clearly evidenced in relation to this family  4.6.5.   Secondly, the decision to change the category of abuse identified for the Child Protection Plan from Physical Abuse to Emotional Abuse requires further consideration. The use of the category of Emotional Abuse as the prime category for children, where the underlying concern is in fact that of Domestic Abuse, may prove to be actively unhelpful.   This in particular relates to the impact it may have on professionals’ understanding of the nature of risks to those children. Unusually in comparison to other Local Authorities, Emotional Abuse is the category used for a large proportion of children subject to a ChildOfficial 42 SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      Protection plans in Wandsworth, including a third of children for whom the underlying concern relates to the risks from Domestic Abuse.  When working in particular with young children, this have may have the effect of distracting professionals from the risk of direct physical injury to children in the context of Domestic Abuse or other parental problems.      Further, depending on professionals’ experience and knowledge, the category of Emotional Abuse may seem unclear, or suggest a lesser degree of harm, or an actual absence of physical abuse, neglect or sexual abuse.  4.6.6.   Two recommendations are made as a result:  Recommendation 4:   That the Board consider the degree to which the reality that children can be harmed in different ways and by more than one perpetrator is understood within the multi-agency partnership and what actions can be taken to develop best practice.   Recommendation 5:  That the Board review the way that the category of  Emotional Abuse is used for children subject to Child Protection Plans.       5         CONCLUDING COMMENTS    5.1.       The purpose of a Serious Case Review is to learn from the case in order that improvements to practice can be put in place to help families in the future. Georgina received serious injuries, a finding of fact has concluded that Grace was physically abused by her mother and that she may also have experienced harm from other family members.  That this was the case despite the children having had been subject to Child Protection for a significant period of their lives merited serious reflection.   5.2.        What is evident in looking back at the events culminating in the injuries to Grace, is that much of the practice of the agencies met required standards and practice expectations, including quick and appropriate responses toOfficial SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official      referrals, good levels of contact with the children and defensible decisions based on what was understood at the time.    The response on Grace’s admission to hospital in identifying the injuries and ensuring a quick multi- agency management of the situation was positive. That there were exceptions and some examples of poor practice has been accepted by the relevant agencies and action taken as a result.   5.3.       The most significant learning for the multi- agency partnership in this Review relates not to basic practice standards, but to the less tangible, more complex issues of Child Protection work which require constant vigilance, curiosity and care. Working with parents who have complex backgrounds, who themselves have adverse childhood experiences and who may therefore have developed ways of responding to services that can frustrate best efforts to help them achieve change, can be extremely difficult.   That we can learn from these children’s experience with the benefit of time and hindsight, does not in itself evidence that professionals were not working to expectations or committed to the children’s best interests.  The recommendations arising out of this review are intended therefore to contribute to constant improvement of practice, rather than as a remedy to poor practice.     6         RECOMMENDATIONS FOR THE BOARD    Recommendation 1: That Wandsworth SCB(Partners) share this Review with the Cwm Taf Morgannwg Safeguarding Children Board in order for any relevant actions to be considered.   Recommendation:   The Board to consider the most effective means of promoting and supporting professionals’ practice skills and knowledge across the multi-agency partnership when working with parents whose capacity or willingness to make changes for their children is under question, or who appear to be resistant to change. This should include ensuring that practice remains child and outcome focused.   43Official SERIOUS CASE REVIEW Grace and Georgina – May 2019    Official       Recommendation 3: The Board to consider developing a programme to raise awareness and to refresh understanding of the risks to infants of physical abuse for children at all levels of intervention.   Recommendation 4:  That the Board consider the degree to which the reality that children can be harmed in different ways and by more than one perpetrator is understood within the multi-agency partnership and what actions can be taken to develop best practice.   Recommendation 5:  That the Board review the way that the category of Emotional Abuse is used for children subject to Child Protection Plans.Official SERIOUS CASE REVIEW Grace and Georgina – May 2019   Official     APPENDIX A: BIBLIOGRAPHY      Burton, V and Revell, L. (2017). Professional Curiosity in Child Protection: Thinking the Unthinkable in a Neo-Liberal World.  British Journal of Social Work .  Children’s Commissioner for England (2018). A Crying Shame: A report by the Office   of the Children ’s C o m m i s s i o n e r  into vulnerable babies in England    HMIP (Her Majesty’s Inspectorate of Probation). Domestic Abuse: The work  undertaken by Community Rehabilitation Companies.  Sept 2018   Marchant and Turner (2017) n Focus Volume 19 No 6 October 2017:  Opening Doors: Best Practice when a young person might be sharing or telling you that they are at risk.  NSPCC (2014). Fact Sheet: Assessing Parental Capacity to Change   OFSTED (2011):  Ages of concern: learning lessons from serious case reviews   RCPCH - Royal College of Paediatrics and Child Health (2017):  Child Protection  Evidence. Systematic review on Bruising.   Sidebotham et al (2016). Pathways to harm, pathways to protection: a triennial  analysis of serious case reviews 2011 to 2014   DfE    Ward, H et al (2011): Safeguarding Babies and Very Young Children    Ward, H et al, (2014).   Assessing parental capacity to change when children are on the edge of Care. DfE. 