Life-threatening injuries to a 4-year-old girl who was struck by a road vehicle in June 2021. Police commenced an investigation into possible neglect following reports of mother being intoxicated at the time. Learning includes: disproportionate/issues of professional optimism in the context of substance abuse addiction and domestic abuse; the voice of the child and the child's journey was not understood by all professionals; engagement and communication with the family was not always/could have been more robust and concerns raised by relatives were not given/could have been given adequate weight; the family's history, including an older sibling being subject to a Special Guardianship Order, should have been considered more when assessing parenting capacity; engagement and service delivery were impacted by Covid-19. Recommendations include: ensure families are systematically used to inform decision-making, information sharing and managing risk, with extended families able to contribute to the plan for a child; ensure a full understanding of a family's history is collated and this is considered in all assessments; children placed on Special Guardianship Orders with family members must be comprehensively included in assessments and planning; police should ensure that incidents of domestic abuse are linked to the same family network so that the cumulative impact is understood and risks can be assessed; partner agencies working with adults must share information with relevant children's professionals where there are concerns which could impact on parenting capacity.
      
    Serious Case Review No: 2022/C9525  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   1           Local Child Safeguarding Practice Review   Subject: Daisy                                       2   Daisy – Local Child Safeguarding Practice Review    1  Introduction  This Review was commissioned in July 2021 to examine the circumstances of the incident and consider lessons to be learnt across the partnership.   Daisy Subject of the Review M1 Mother F1 Father OS1 Older sibling OS2 Eldest sibling MGM Maternal Grandmother F1P Father’s partner MA Maternal Aunt   Daisy is a 4-year-old, white British girl and at the time she and her sister lived with their mother (M1). M1 was in a relationship with the girls’ father (F1) until sometime in 2020.  Both M1 and F1 have children from previous relationships, but of note in this review is M1’s 12-year-old daughter (OS2) who resides with her maternal grandmother (MGM) under a Special Guardianship Order (SGO).   On an evening in June 2021 M1 travelled to F1’s home with Daisy and OS1 and there was a domestic disturbance and conflict between M1, F1 and F1’s new partner. M1 was described by witnesses as being heavily intoxicated at that time. M1 called a taxi around 10.00pm to take herself, OS1 and Daisy home a couple of miles away. On getting back home, M1 was in dispute with the taxi driver as she did not appear to have means to pay the fare and in this time Daisy and OS1 exited the car. Very shortly after this Daisy wandered into the road and was struck by a passing vehicle.     Daisy sustained life-threatening injuries including several fractures to her legs, ribs and arms, alongside internal injuries, and a head injury.  She was placed under sedation at a Children’s Hospital and underwent various surgeries. The sedation was lifted over the weeks following the incident. Daisy remained in hospital for a significant period, and although she is making a recovery in respect of most of the injuries there are fears that she may have acquired brain injuries which will result in lifelong disabilities.   Due to the reports of M1 being intoxicated at the time of the incident and queries around her lack of supervision of Daisy at the time, Police commenced an investigation into a possible crime of neglect.    2  Terms of Reference  The Panel of professionals, including practitioners agreed the following terms of reference:  a. Was professional engagement, communication, and involvement with the family (including extended family) robust prior to this incident?  b. Was there a full understanding of the family history in the context of capacity to parent to support decision making?   During the course of the rapid review and the first panel meeting, it was agreed that there were some key lines of enquiry already in scope from historical reviews and those recommendations had already formed actions for agencies.   These were posed as questions to the review: 3   • Was there disproportionate professional optimism about the safety of the children and progress sustained by M1?   • Did poor quoracy, attendance or delay in execution of strategy and core group meetings impact on information sharing and planning? Would this have impacted on the ability to exchange information, assess risk, and ensure effective planning?  • Was the voice of the child and child’s journey really understood by all professionals?   • Was there consistent application of safeguarding thresholds throughout the child’s journey?  • Did drift and delay in professional response impact on the outcomes for Daisy?  The above elements were explored while undertaking this Review, but the Authors are aware that any recommendations that would follow this are in scope within other reviews. In order to avoid duplication of learning these areas were explored but not included in recommendations  The partnership is tracking learning through system change to address:  • Professional optimism • Poor quoracy and attendance (including delays) in key meetings • The voice of the child and the child’s journey • Consistent application of thresholds  Although these recommendations are not being reiterated in detail here they will be raised as areas of ongoing challenge to inform practice implications across the partnership.    3  Review Process  In June 2021 a Rapid Review was held to consider the facts of the case and consider the potential for identifying improvements to safeguarding. The Rapid Review agreed that a concise Local Safeguarding Children Practice Review (LCSPR) was needed to highlight improvements, reoccurring themes and where agencies could work together more effectively to safeguard children.   Agencies submitted their involvement with the family including an analysis of practice identifying any potential learning. A Panel was formed of key professionals, including the practitioners involved in the case. A root cause analysis exercise was used to extract the learning as a Panel, focusing on the pathways to decision making (see appendix 1)  The report is based on agency submissions and the Panel meetings held with key agencies and practitioners. We also had participation from Maternal Aunt, although other family members were asked to participate.    4  Agencies involved in the review  Business Manager    Safeguarding Children Partnership   Detective Sergeant    SCR Unit, Police Interim Virtual School Head   Children’s Services Safeguarding Lead    National Probation Service Head of Service    Innovate CYPS – Children’s Social Care (CSC) Community Domestic Abuse Worker  DIAS   Director     Innovate CYPS - CSC Senior Lettings Officer   ASC and Health Homes  Named Nurse Safeguarding Children Manchester NHSFT Specialist Nurse Safeguarding Children WWL NHSFT  Named Nurse Safeguarding Children MH NHST (Mental Health) Manager      Nursery Quality Assurance Manager   Children’s Social Care Practice Manager    Start Well Service Operations Manager    We Are With You Safeguarding Lead    Early Years Service Manager    Inclusion Service Service Lead     Children’s Safeguarding   4  Findings  The following section seeks to explore the questions identified in the Terms of     Reference. This analysis is drawn from the written submissions from individual agency discussions with the panel and practitioners who took part in the review process.   5  Information from the Review   5.1  F1 and M1’s relationship has a substantial history of domestic abuse, with the majority being F1 as the perpetrator of violence on M1 and on maternal aunt, MA at other times.  This review looked at the 2 years prior to the incident, however it is notable that M1 has been in at least one previous relationship with a violently abusive partner in 2009.  This had impacted at that time on M1’s older daughter, OS2.  As a result of Children’s Social Care intervention OS2 was placed, eventually on a Special Guardianship Order, with her MGM. F1 has a history of offending behaviour and in early 2020 he was charged and remanded to custody.  After a long period on remand of around a year, he was released on conditional bail in early 2021.    Almost immediately upon his release from custody in March 2021 incidents began to recur between F1 and M1, albeit both state that they were not in a relationship. As mentioned above in this report, F1 then formed a new relationship with another female who he was with on the evening of Daisy’s accident.    Alongside her experiences as a victim of domestic abuse, M1’s use of alcohol, and her mental health issues have been problematic for her since at least 2009, and she has had contact with services around these issues intermittently since 2012. Family members including MA made referrals to services for help and support for F1 and the children. There is a repetitious pattern of her not sustaining contact with services and poor engagement around her alcohol use. This was a woman who was being subjected to domestic abuse, had poor self-esteem and addiction to substance misuse in the form of alcohol misuse. Latterly, in May 2021 around 3 weeks prior to the accident involving Daisy, M1 had said that she had gone 30 days without drinking.  This view was challenged by her sister, MA who felt that there was no way M1 could have done that but reflects what M1 had also told her substance misuse worker at We are With You.     5  Commentary   All the above sets a robust picture that there is long term, chronic indicators of vulnerability and static risk factors – the nature of which should have underpinned all assessments of the children or adults in the family.  Were extended family views listened to and did they form enough ‘weight’ in the assessments? Arguably there was professional optimism about M1’s ability to sustain abstinence and keep the children safe from harm.   5.2  Focusing on the period June 2019 – June 2021 it is evident that M1’s alcohol use, the impact of this on the children and the unhealthy relationship with F1 had not meaningfully changed. On 16th August 2019, MA (MA to Daisy and OS1) contacted Children’s Services in respect of M1’s drinking following an incident attended by police on 26th July where both M1 and F1 had been drinking and the children were resultantly taken care of by neighbours. There was a decision taken to commence a Child and Family Assessment, but this did not occur, and a further contact was made to Children’s Services by MA on 10th September.   It is unclear from the review why the initial assessment did not occur. Resultantly, a S47 investigation was conducted, with the eventual outcome being that OS1 and Daisy were placed on Child Protection Plans on 2.10.19 under the category of emotional abuse.  Further information shared at the panel meeting indicated that it was MA who reported to the police in relation to live domestic incidents. Although minimised by the mother, the third-party report was acknowledged and acted upon as a domestic incident by Police. No further action taken, or referral made to CSC.  Commentary  It was the view of the Rapid Review Panel that placing the children on Child Protection Plan was the correct decision for the children, based on the frequency and impact of M1 and F1’s behaviour. However, delays in statutory intervention in July meant that by September 2019 intervention was required in the form of assessing risk of harm. The needs and risk to Daisy had accelerated due to drift and delay. This was identified as due to missed opportunity to plan and individual agencies focusing on specific pieces of work rather than considering the holistic needs of the family.   5.3 The following period of Child Protection Planning showed two Core Groups taking place, at which there was insufficient representation from some agencies. In mid-January 2020, the second Review Protection Conference was held and the position on the Child Protection plan continued.   Later, on 24th January there was another police attendance to the property where both F1 and M1 were intoxicated and deemed unable to care for OS1 and Daisy. The police then used Powers of Protection to place with their MA.  A strategy meeting was held, albeit delayed by 7 days on the 31.1.20 where there was no further action taken and the Child Protection plan continued. This coincidentally was also the day that F1 was arrested and subsequently remanded to custody.    Commentary  The delay in the strategy meeting meant information couldn’t be shared swiftly and decisive action wasn’t taken to secure the welfare of the children and plan effectively. At the time the delayed strategy meeting was not deemed significant due to the perceived reduction in risk due to F1 being placed in custody.  However, this meeting could have been utilized to plan for F1 eventual release and escalation of risk due to domestic abuse. The risk was temporarily removed due to F1 absence, but this did not reduce risk only delayed it. Whilst timescale is determined by need and level of risk good practice states strategy meetings should be held within 24 hours as per CSC practice standards.   5.4 There was then a period of almost 6 months where the only reported incident was attendance by the police to M1’s address in April where she had been reported to be passed out in front of the children through intoxication, but this was not substantiated by the police, and nothing further happened.  6  Commentary  It is notable in review that F1 was in prison in this period, perhaps suggesting that the risks both to M1 of domestic abuse, and those of her drinking impacting on the children reduced simply due to his absence. This physical removal of a risk however and period of desistence of incidents, appear to have been taken as a positive indicator in M1’s ability to protect the children both from the external risks of the abusive relationship but also as a mitigative factor around her alcohol use.  There is little evidence to support that decisions were made pursuant to robust risk assessment, and this is further evident in the following section. Information shared at the panel meeting included further clarity on this point. At the time of F1 being taken into custody it was predicted he would receive a significant sentence due to the nature of the crime. COVID 19 impacted this due to the high number of cases in the remand centre/prison which resulted in his early release on bail pending court hearing and sentence. Children’s social care state this could not have been foreseen due to the unique impact of COVID 19.   5.5 In June 2020, a Review Child Protection Conference was held, without M1 (or F1 due to his continued period in custody) and the recommendation was made to move the case to Child in Need Planning. There follows a long period through to November 2020 where a CIN plan was in place, but reviewing information shows there was little evidence of work being completed with M1. The case was closed to Children’s Social Care on 23.11.20 with further support through Start Well (early intervention and prevention) recommended predominantly in relation to supporting M1 seek new housing as part of an Early Help Plan.  Start Well’s records show some engagement regarding the housing progress and with her GP but also, pertinently, say that M1’s mother phoned Children’s services on 5.2.21 after finding M1 drunk in the house with OS1 and Daisy, a half bottle of vodka and the gas hob on. There is no record of this contact within Children’s Service’s records.   However, Start Well records show that they had acknowledgement of this referral to CSC.  M1 engaged with support from Start Well services during this period to address her housing needs. This was an opportunity to support via wider engagement of services to address her parenting needs and the safe care of her children. The escalation to CSC meant Start Well closed the case on 10th March 2021.   Start Well closing the case was more understandable than the earlier CP – CIN ‘step down’ move, and subsequent closure to children’s social care, as it was only an Early Help plan and was therefore wholly voluntary, but it is repetitious of decision making without full view of the history of agency involvement or testing the hypothesis of how long M1 would sustain that engagement for.   On 15th March 2021, Children’s Services were contacted again by MA with concerns that her sister M1 had been drinking again and had re-kindled her relationship with F1 who had been bailed from custody. There was no immediate action in response to this. However, on 29th March 2021 there was an incident where a member of the public contacted the police having witnessed M1 so intoxicated that she tipped the pushchair she was steering causing the young child (assumed to be Daisy) out.  The police attended and found an empty vodka bottle under the pram.  M1 became volatile and both Daisy and OS1 were taken to their MGM by police.     Commentary  This delay to the strategy processes, and the eventual decision of it not crossing the threshold for further Child Protection Planning are both concerning. This should have warranted legal advice with a view to initiating proceedings. The social workers view that the family were ‘working well together’ was optimistic.   5.6 Subsequently there were other incidents in April 2021 where M1 reported being assaulted by a male in the community (17th) and being sat on a bridge threatening suicide reporting alcohol problem and suicidal thoughts (20th).  On 27th April almost a month from the incident of 29th March a strategy meeting took place to consider all three recent incidents.  A further S47 investigation commenced, and the outcome was that the CIN plan should continue.   7  Commentary  This delay to the strategy processes, and the eventual decision of it not crossing the threshold for further Child Protection Planning are both concerning. This should have warranted legal advice with a view to initiating proceedings. The social workers view that the family were ‘working well together’ was optimistic.   5.7 The early years setting which Daisy attended described Daisy as a lovely, friendly, happy girl who socialises well with her friends and had settled into the nursery well when she started attending there in March 2021. There had been disclosures to the nursery by Daisy’s MA about M1 not being able to control her alcohol use and explanations that she, and MGM would sometimes cover the care of OS1 and Daisy. There is reference of a Strategy Meeting on 24.5.21 which the nursery attended where positive progress was being made that reflects the reports earlier of M1 being abstinent of alcohol over that month prior possibly since the incident of 20th April. Nursery staff would have regular contact with M1 but within a specific context of bringing Daisy to nursery and potential brief observation of interaction with other families and children. Using a signs of safety practice framework approach to measure the situation on a scale of 1-10 (1 extremely unsafe – 10 being extremely safe) the meeting gave a 7 based on observed progress and communication with M1. This is the last substantive meeting prior to Daisy’s accident on 10th June and potentially points to over optimism on the part of professionals  Commentary  It is notable that the nursery modelled good practice in this case albeit for only a couple of months with Daisy. The nursery attempted to gather transfer information from Daisy’s previous nursery, offered free additional sessions to support the family and clearly fostered a good relationship with both M1 and MA. There was less known about F1 by the nursery that would have been helpful to them, but when they asked M1 whether there were any other agencies involved they were told no.  This point, minor in context, was discussed at the Rapid review. The Panel felt this was perhaps the use of professional ‘jargon’ in saying ‘agencies’ – to that end the Early Years team and the Nursery have adapted the proforma used to capture initial information to make it more informal / accessible. Notably, the nursery felt that the fact that all contacts with M1 and F1 were subject to both the family and staff wearing face coverings due to Covid and may have impacted on communication as some of the ‘enablers’ for communication (smiles etc.) cannot be communicated and perhaps make it harder to achieve a rapport with a family.   The patterned behaviour around M1’s long history of alcohol use, domestic abuse, amounted to high-risk behaviours that were evident even in the last couple of months, a score of 7 was giving undue credit to M1’s recent abstinence and represents over-optimism. Significantly at various points the family have stepped in as clearly M1 has been unable to care for the children, yet CSC optimistically didn’t see the same level of concerns throughout Daisy and her sibling’s lives as the family members saw.     6 Family Contribution  Consultations with key family members are a very important aspect of any review and the authors and The Safeguarding Partnership are very grateful that Daisy’s family felt able to contribute. The information they shared is contained in this section in the following paragraphs.   7  Contribution from MA  Maternal aunt was open, honest, and helpful in her comments. She was able to highlight how she and the wider maternal family had experienced services and how a number of key episodes could have been managed better. MA gave the reviewers her reflections on the relationship between M1 and F1 over the period where there was the reported Domestic Abuse.   8  She feels the family were flagging to services constantly about the struggles M1 had with her own needs and meeting those of her children. She felt not all referrals to the police were then passed onto CSC, or they certainly weren’t always acted upon. The fact that the children witnessed so much of the domestic abuse and the police were routinely seeing this, caused her concern that this didn’t get  escalated quicker or that a cumulative view was taken on it. The family felt that any interventions by services always lay at M1s ‘door’ for accountability not with F1. One example given is she believed the limited intervention with F1 around domestic abuse was asked to be carried out by a CYPF Worker, (who is attached to CSC,) and would not have had expertise in Domestic Abuse. MA stated professionals were always involved but information provided by M1 was always taken on face value. There wasn’t enough professional curiosity. MA felt she and the family weren’t ‘heard’. MA stated she made numerous referrals to health, police, CSC and drug agencies but many times they didn’t result in further action. During a time when F1 was in prison M1 started to make small disclosures about her lived experience living in an abusive relationship. At the same time her alcohol misuse also got worse. MA described the changes in social workers at this point made F1’s situation worse, the ‘start again’ processes overwhelming for M1 and them as a family. Key information was constantly being repeated. On one occasion, injuries to M1 were apparently not pursued to establish how they had occurred. The family found the situation difficult because their own relationship with M1 wasn’t always strong however the paramount interests for Daisy and her siblings were their number one priority. Formal meetings such as CIN planning, CP planning were not always attended by family member nor parents.    8  Summary of Lessons and learning and Implications for wider practice  To note in terms of good practice changes, the Early Years team and the Nursery have adapted the proforma used to capture initial information from families to make it more informal / accessible to share information on services they are working with.   There was disproportionate professional optimism about the safety of the children and on the view that progress could be sustained. Poor quoracy and attendance at strategy meetings and core group meetings would have impacted on not having a consistent working group to exchange information and assess risk, ensuring planning is effective. The voice of the child and child’s journey wasn’t always understood by all professionals, which also resulted in inconsistent application of thresholds throughout. Drift and delay in professional responses at times impacted of the outcomes for Daisy. We know from research that abuse is more likely to escalate after separation and therefore this would have been a risky time for both M1 and the    children in her care. These factors and an over optimism of substance abuse addiction and domestic abuse meant services felt they could reduce intervention.   The professional engagement and communication with the family throughout involvement with services wasn’t always robust, nor were family members concerns given adequate weight. The use of family network meetings and planning alongside the wider family didn’t support an understanding of how best to protect Daisy from harm. The fact that an older sibling had been placed with MGM on a Special Guardianship Order some years previous should have provided a serious ‘marker’ for M1’s ability to parent. The lack of understanding of the family history in the context of parental capacity didn’t always support decision making. Because the ongoing assessments were not considering the circumstances that surrounded the older child being placed with MGM on a special guardianship order, nor the family’s information around M1’s ability to parent it meant that circumstances were being evaluated based on the current here and now rather than looking at the cumulative effect of these key episodes on the child’s life.    During this period services were limited by the implications of covid 19 on service delivery. We heard as part of the review how DIAS for example moved from face to face and drop-in services to telephone contact inhibiting robust engagement and service delivery.      9  9 Recommendations  There will not be any recommendations that are already in progress through previous reviews and will be limited to new learning. This review will feed into the formal processes in place for other existing reviews.  1 The Safeguarding Partnership should seek assurances from partners to ensure that Families are more systematically used to inform information sharing, decision making and managing risk. There should be a strong expectation that extended families contribute to the plan for a child. This is at lead professional and early help level, through to child protection level.  2 CSC to ensure they collate a fuller understanding of the family history, and that this is considered in all assessments. When children are placed on an Special Guardianship Order with family members, these children must be included comprehensively in assessments and planning.  3 The Safeguarding Partnership should assure themselves, through multi-agency audit activity, that, The Safeguarding Partnership practice model signs of safety is producing robust risk management in cases such Daisy  4 Police should ensure all incidents are linked to the same family network, so the cumulative impact of Domestic Abuse is understood, and risk is assessed appropriately.  5 Partner Agencies should assure The Safeguarding Partnership that when they are working with an adult and there is a concern that may impact on their parenting capacity, that this is shared with relevant professionals working with children. Safeguarding children and adults policies and training must direct staff to consider the cumulative harm and impact on the children (including their age and vulnerability) and share key information and escalate concerns accordingly.     Signed ………………………………………….    