Death of a girl, Bethany, aged 19 months on 11 April 2015. Cause of death was inconclusive after an open verdict at the inquest. Both parents had learning difficulties and troubled childhoods. Concerns were expressed by professionals from pre-birth onwards as to the parenting capacity of both parents. Bethany had been the subject of a Child Protection Plan for Neglect from October 2013. The parents received Early Support in parenting Bethany, and later a Care Order was put in place for Bethany to remain in her mother's care with the support of professionals and extended family when the father moved out. After key family members withdrew their support, the Care plan was in breach and the process to take Bethany into care was started. Bethany died before steps towards removal could be completed. Findings include: the assessment of parental capacity is essential; vulnerability of the parents should not override the needs of the child; over-reliance on extended family support in planning; there were issues of professional bias. Recommendations include: the LSCB should examine parental assessment processes; be able to identify and respond to neglect; ensure multi-agency challenge processes are in place for child protection plans lasting longer than 9 months.
      
 Title:  Serious case review: Bethany: overview report. LSCB: Central Bedfordshire Safeguarding Children Board Author: Amy Weir Date of publication: 2016  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.                           Central BedfordshireSafeguardingChildren BoardSerious Case ReviewConducted underWorking Together to Safeguard Children 2015BethanyOverview ReportLead ReviewerAmy Weir MA MBA CQSWFebruary 25th 2016Updated October 18th 20162 | P a g eFinal draft 25/2/2016 updated 18.10.2016SCR BethanyDate of birth: September 2013Date of death: April 2015Ethnic origin: White UKLIST OF CONTENTS1. Introduction and Background to the Review32. The Review Process43. The Family as Known to Agencies and Brief History64. Bethany’s Experience and Family Involvement in the Review195. Findings – Themes and Areas of Significant PracticeASP1. Timely and prompt response to the pregnancy but the assessmentcompleted was not comprehensive.ASP 2 Prompt response made to concerns after Bethany’s birth and a ChildProtection Plan was made.ASP 3 There was a drift in the case and delay in completion of the CognitiveAssessments and PAMs and there were several changes of social worker.ASP 4. An appropriate response was made once the specialist assessmentwas received.ASP 5. The plan made at Court faltered but the Court was not informedimmediately as the Judge had requested216. Conclusions and Summary297. Recommendations for The LSCB338.Next Steps – Progress Report and Learning379. Next steps - Progress Report / Learning38AppendicesAppendix A - Family and Significant others and GenogramAppendix B - Scope and Full Terms of Reference of the ReviewAppendix C. - List of References3 | P a g eFinal draft 25/2/2016 updated 18.10.20161.Introduction and background to the review1.1This Serious Case Review (SCR) was commissioned following the death of a youngchild, aged nineteen months. It considers the circumstances in which she died andwhether the services, which were received by the family from a range ofprofessionals, provided the best response required to address her needs and to keepher safe.1.2All the names in this review have been anonymised. The child is known as Bethanywithin this report. Bethany was born in September 2013. When she was nineteenmonths old, her mother found her lifeless in her bed. The cause of death wasinconclusive but there was evidence of vomit in her lungs and of swelling of the brain.A police investigation was initiated as the conditions in which Bethany were foundappeared to suggest that she had been neglected prior to her death and, that thispoor care, may have resulted in her death. Her mother was arrested and charged withcausing neglect to a child. However, this charge is no longer being pursued.1.3As stated above, there were parallel proceedings in relation to the death of Bethany.Her mother was subject to criminal proceedings for the neglect of Bethany. This casehas now been discontinued due to lack of evidence. The author has been providedwith relevant information from the criminal investigation to inform the serious casereview.1.4An Inquest was held from 13th to 14th September 2016. This concluded with an openverdict. The Coroner described the care of Bethany as “chaotic”. Her mother told thecourt that she thought her parenting was “alright” and that she was “doing a goodjob.” The Coroner described mother as being “fabricating and being unreliable”.1.5The circumstances of Bethany’s death led to the decision in April 2015 by the Chair ofthe Central Bedfordshire Safeguarding Children Board (CBSCB) to undertake a serious4 | P a g eFinal draft 25/2/2016 updated 18.10.2016case review. The Working Together 2015 criteria for commissioning a SCR were met asfollows:Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functionsof LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases inspecified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation toserious case reviews, namely:5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partnerson lessons to be learned.(2) For the purposes of paragraph (1) (e) a serious case is one where:(a) abuse or neglect of a child is known or suspected; and(b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is causefor concern as to the way in which the authority, their Board partners or other relevant personshave worked together to safeguard the child.2.The Review Process2.1This review has been conducted with due regard to the principles of fairness,impartiality, thoroughness, accountability, transparency and above all with a focuson the experience of the child, Bethany. The consideration of her interests andexperience has been the central focus of the review. The circumstances in whichBethany died have affected all those involved in the review. her family members,and all of those staff who worked closely with the family.2.2The time period covered within this Serious Case Review is from 1st March 2013 upto and including 11th April 2015 the day of Bethany’s death. This time period hasbeen chosen to cover the date when Olivia’s pregnancy was known to agencies up toand including the date of Bethany’s death. Any additional historical informationrelevant to the review going back before these dates (e.g. within the parents’ ownchildhoods) has also been fully considered in the review.5 | P a g eFinal draft 25/2/2016 updated 18.10.20162.3Amy Weir, who is an experienced independent safeguarding expert, was appointedas the independent reviewer. A Panel of senior managers was formed to support theprocess. Amy Weir wrote this report with the support of the SCR Panel.2.4.1The full terms of reference for the review are appended to this report. Critical pointsin the case were considered in the SCR. Possible reasons for actions taken at thetime and learning and improvements needed have been identified – including thesignificance of these insights for current practice. Where there was evidence of goodpractice in the case, this has also been noted. These findings will inform the CBSCB’sLearning and Development Plan and the responses to them will be embedded inlocal practice through that plan.2.5The investigation has examined key documents and spoken to staff and practitionersdirectly and indirectly through the involvement from each agency of experiencedsenior managers, who have had no direct involvement in this case. Local practitionershave been brought together to consider, discuss and comment on the findings of thereview. The root cause analysis “fishbone” approach to identifying key contributoryfactors has been used. The aim of this has been to gain an understanding of how theinteraction between the various factors influenced the way practitioners respondedto, and provided services to, Bethany and her family.2.6Bethany’s mother and father were contacted to inform them that this review wasbeing undertaken. They were asked whether they would like to contribute to thereview. Both parents expressed a wish to contribute to the review. Father was seen on18th August 2015 and mother was seen on 24th September 2015. Father’s mother andstepfather were also seen on 24th September 2015. These views provide importantinsights into what happened to Bethany and to the events during Bethany’s lifetime.2.7Mother’s extended family members, including her mother and her brother, werecontacted and spoken to about the review. However, they did not agree to contribute6 | P a g eFinal draft 25/2/2016 updated 18.10.2016to the review.2.8As Bethany’s case was subject to care proceedings brought by the Local Authority atthe time of her death, the author has been given access to the transcript of thehearing held shortly before Bethany’s death. The Judge involved in the case and thesolicitor for the child have also been interviewed as part of the review process to elicittheir views on what can be learnt from the case.2.9The critical points and issues in the history were identified and the areas to considerwere set out in the terms of reference which are appended to this report.2.10 The review report sets out the findings – including the possible reasons for actionstaken or not taken at the time were considered:What factors contributed to practice decisions at the time?What could have been improved?What good practice occurred?2.11The significance of these insights for current practice is also explored.If the same event occurred now – what factors would influence the response?What learning and improvements have already been implemented?What is working well now and what still needs to be improved?3.The Family as known to Agencies and a brief history3.1Bethany and her family were known to Central Bedfordshire Council (CBC)Children’s Services prior to her birth, and throughout her life; Bethany had beensubject to a Child Protection Plan under the category of Neglect from October2013 to the date of her death in April 2015.3.2At the time of her death Bethany, aged nineteen months, was living with hermother, Olivia Fisher. Bethany’s father, David Lamb, had moved out of the familyhome at the beginning of March 2015, after a Family Court hearing. Central7 | P a g eFinal draft 25/2/2016 updated 18.10.2016Bedfordshire Council had applied for an Interim Care Order in relation to Bethany.The court agreed, pending a full hearing of all the evidence, that Bethany shouldremain in her mother’s care on the basis that members of the extended familyagreed and gave undertakings to provide additional support to Olivia to help hercare for Bethany. The local authority also continued to visit and support thefamily.3.3Bethany died three weeks after the court hearing. Her mother found herunresponsive in her bed in the early afternoon. Olivia called her own mother whocame. An ambulance was called and paramedics came speedily to the home but,within ten minutes, Bethany was pronounced dead. Bethany was reported to havebeen found in her room in an open cot bed with a nappy on; the nappy was laterfound to weigh one pound which was estimated to be two full bladders of urine. Theambulance staff who attended advised that Bethany had been dead for some time.The room was hot, there was vomit on the bed and Bethany was found at the bottomof the bed with her head hanging over the end of it.3.4Over the next few days, Olivia provided several slightly different accounts of whathad happened to Bethany. The postmortem subsequently carried out wasinconclusive about the cause of death although it is known that there were signs ofbrain swelling and vomit in her lungs.3.5Bethany’s mother has another child, Bethany’s older half-brother Scott - now agedseven years - Olivia cared for him until 2012 but at the end of that year, it was clear thatshe was struggling to care for him and he moved to his father’s care. He remains in hisfather’s care subject to a Residence Order in another local authority. Scott had regularcontact with his mother about four times a month and sometimes stayed the night.After Bethany’s death this contact ceased when Central Bedfordshire Councilinformed the other local authority of Bethany’s death.3.6Olivia, Bethany’s mother has learning difficulties. She is twenty-eight years old. Itappears that she was in care and then adopted as a young child. She attended a8 | P a g eFinal draft 25/2/2016 updated 18.10.2016school for children with special needs as a child. She was described at school asbehaving badly, having poor concentration and being inattentive.3.7David, Bethany’s father, has learning difficulties. He is thirty-three years old. Heattended the same special needs school as Olivia and this is how they knew eachother. As a young child, he was said to have poor listening and attention skills whichhave limited his development and cognitive ability. His parents separated whenDavid was two years old. His father took David from his mother on two occasionswhen David was two years old and he had to be recovered by Police with a briefperiod of being in care. After that he was brought up by his mother with whom hehas a good relationship.3.7.1The family moved three times during Bethany’s lifetime. This included one veryshort move to temporary accommodation prior to the family receiving permanenthousing. This meant that several different professionals were involved with thefamily during the nineteen-month period of Bethany’s life.3.8 Prior to Bethany’s Birth – March to September 20133.9.1In March 2013, when Olivia was about three to four months pregnant with Bethany,she was referred to Central Bedfordshire Council Children’s Services by the midwife.The midwife was concerned from Olivia’s presentation about whether Olivia wouldbe able to cope with the demands of caring for a newborn baby. These concernsalso arose because of the information the midwife had that Scott was not beingcared for by her and that Olivia had known difficulties in parenting Scott.Information that both Olivia and her new partner David - father of the unborn child -had learning difficulties raised further concerns about whether they could look afterthe baby safely. The midwife made further contact with Children’s Services at thebeginning of May 2013 about her concerns. This referral resulted in an InitialAssessment being undertaken.9 | P a g eFinal draft 25/2/2016 updated 18.10.20163.9.2The records show that the family was known to Central Bedfordshire Council aswell as to the other local authority’s Children’s Services, where Scott’s father lives,because of the decision by Scott’s father to become his carer rather than Olivia. Inthese private law proceedings during 2012, a Central Bedfordshire Council socialworker completed a Section 7 report and Scott was placed with his father. Thedifficulties which Olivia had experienced in parenting her first child, Scott, weretherefore known.3.9.3During her pregnancy with Bethany, Olivia was reluctant to be involved withChildren’s Services. However, she did cooperate with the completion of a coreassessment which was completed by a social worker. The family was referred to asupportive pre-birth parenting service, Mellow Bumps, in early May 2013. A Childin Need meeting to review progress was convened at the family home at the endof June 2013 just as the core assessment was completed; the assessmentrecommended that the case be closed in Children’s Social Care and that an EarlyHelp package of support should be delivered through Mellow Bumps and Babies,and children’s centre support. A referral for this Early Help was made at thebeginning of July 2013 and the case was closed to Children’s Social Care a few dayslater. Olivia attended Mellow Bumps a pre-birth parenting course. She attendedfive out of six sessions and the staff providing the course did not raise anyparticular concerns.3.10After Bethany’s birth – Bethany 0-3 months - September 2013 to December 20133.10.1 Bethany was born in early September 2013. It was a normal delivery andBethany weighed 8lb 8oz. There were no particular concerns raised at thehospital before the baby went home. The midwives who visited the family athome after this did not raise any immediate concerns.3.10.2 A children’s centre worker contacted Children’s Social Care in early October2013 after David, Bethany’s father, had called to say he was worried about10 | P a g eFinal draft 25/2/2016 updated 18.10.2016how Olivia was coping with caring for Bethany. David also stated that he wasconcerned that Olivia was saying she might harm the baby. The children’scentre worker also said that she had wider general concerns about Olivia’sand David’s parenting of their young baby. The relationship between Oliviaand David was not always positive and it was reported that there were fightsbetween them and David had been bruised. There was also the concern thatOlivia had said she felt depressed and was worried she may harm Bethany.However, this was clarified later by Olivia who said she had been feeling soexhausted and down that she was concerned she may not care properly forBethany rather than pose a risk of deliberately harming her.3.10.3 The next day, a Strategy Meeting was held involving Police, Health andChildren’s Social Care. It was reported that David had committed someoffences though the details were not clearly recorded. Olivia was found tohave previously been in charge of a child, her son Scott, whilst intoxicated. Itwas reported at this meeting that Olivia’s IQ was between 50 and 70 – wellbelow the average of 100. It was stated that she was struggling to cope withBethany’s feeding and reflux problems. The GP reported that he did not feelOlivia was depressed but rather that she was struggling to cope with thevaried needs and demands of a newborn child. A visiting matrix for each ofthe professionals involved was agreed and the Early Help worker referred thefamily to the Early Intervention Outreach Worker for adults with LearningDifficulties. The aim was to raise the level of family support being provided tosupport the parenting of David and Olivia. It was realised that there wasmissing information about the parents’ backgrounds and it was agreed toseek that information from other Local Authorities who had known them.3.10.4 Following the section 47 investigation, an Initial Child Protection CaseConference (ICPC) was convened a week later. From the referral made in May2013 to October 2013 when the Initial Child Protection Conference was held,Central Bedfordshire Council Children Services and Health staff workedtogether to ensure a high degree of support was provided. The family were11 | P a g eFinal draft 25/2/2016 updated 18.10.2016visited several times a week in order to support the basic care of Bethany -feeding, home hygiene, parenting skills. Family members also visited thefamily to support them.3.10.5 At the ICPC in mid-October 2013, it was agreed that the risk of significantharm to Bethany was high and that that Bethany should become subject to aChild Protection Plan under the category of Neglect. There was discussion atthe conference about the parents’ ability to care for Bethany and theirapparent lack of confidence to parent; it was suggested that Olivia and Davidmay not always understand the support and guidance being offered giventheir learning difficulties. The view was that, given their presumed lack ofconfidence, a high level of support and monitoring was required to keep hersafe and well cared for. The Chair of the conference suggested that acognitive and specialist parenting assessment related to their learningdifficulties should be undertaken; a PAMs assessment was therefore to becommissioned. Adults Social Care was also requested to assess the parents’cognitive functioning and a visit was undertaken shortly afterwards.3.10.6 After November 2013 further concerns emerged. The maternal extendedfamily were helping the parents but in November 2013, Olivia’s brother andpartner reported they were stepping back in terms of the support they wereto offer Olivia and David in caring for Bethany. In December 2013 two markswere noted to Bethany’s head. A Strategy Meeting took place and a ChildProtection medical was immediately undertaken. The conclusions were thatno injuries were specifically noted during the medical and parents were notthought to have caused physical harm. However, there was still much concernabout their overall ability to care for, and parent, Bethany. There were alsofrom time to time issues raised about Olivia’s older child, Scott, and the factthat Olivia and David were struggling to cope and manage his behaviour whenhe visited for contact most weeks.12 | P a g eFinal draft 25/2/2016 updated 18.10.20163.10.7 There was a significant amount of interaction and service involvement – bothfrom a variety of Central Bedfordshire Council Children’s Services and Healthprofessionals - with the family throughout Bethany’s life and pre-birth.Children’s Social Care (CSC) was involved with the family for most ofBethany’s life - March to July 2013 (pre-birth) and October 2013 to her deathin April 2015. There were five different social workers (as well as one socialwork assistant), and in the local area Family Support Team there were threechanges of social worker over six months. There were three different linemanagers.3.10.8 As well as the Children’s Social Care involvement with a social workerallocated to the family, there was extensive Early Help support. The FamilyIntervention Support Service (FISS) was involved throughout October 2013 toApril 2015 and FISS workers were consistently involved. There were 145 visitsin total to the family home – though the family was not always at home.Intensive support was offered to the parents on these visits and there wasalso further contact including telephone conversations with family members,extended family, and attendance at professional meetings (Child ProtectionCase Conferences, Core Groups) by FISS staff. Central Bedfordshire CouncilEarly Intervention Outreach Service (EIO) was also involved from August toNovember 2014.3.10.9 From the early days following Bethany’s birth, the relationship between Davidand Olivia was strained. Both the parents and Olivia’s family reported thatthey felt too many professionals were involved. David expressed concernsabout how Olivia cared for the baby and her son Scott when he came forcontact. Olivia complained that David sought to control her and her familysupported her in this view.3.11Bethany aged 3 months to 1 year 3months – January to December 20143.11.1 There was a delay in identifying who should undertake the PAMs assessment and in thefunding for it being agreed. A Central Bedfordshire Council resource panel had to agree13 | P a g eFinal draft 25/2/2016 updated 18.10.2016the funding and in January 2014 this was refused because it was believed that aninternal member of staff could do the assessment. The resource panel asked for theEarly Intervention Outreach Worker (EIO) for learning disability and the Adult LearningDisability Team to contribute to the social worker’s assessment and the PAMs fundingwas refused on that basis. However, it was subsequently discovered that the EIO wasnot qualified to complete a PAMs assessment. The EIO only worked with the family fromOctober to November 2014 following a request from the Early Help social worker butdid not do the assessment. The Core Group decided to end the EIO involvement aboutsix weeks later because it was felt that there were too many professionals involved.3.12.2 The view of the social worker involved at that time was thought to beoptimistic. It is clear that this social worker, who was only allocated the casefor a short period, did not hold the same level of concerns in respect of Oliviaand David’s capacity to parent Bethany as some other professionals involveddid. The records show that when the case was reallocated in May 2014, moreprogress was made and a more appropriate view was taken of the parents’parenting difficulties.3.12.3The funding for PAMs was refused initially in January 2014, it was notrequested again until July 2014 – a six-month delay. It is unclear what thereason for the delay was. It is not clear that there was any further discussionabout whether PAMs was the most appropriate assessment, given the delayand frustration of the original child protection conference recommendation inOctober 2013 that a cognitive assessment and a PAMs should be completed.The PAMs was commissioned to be undertaken by an independent socialworker in September 2014. There was delay with the independent socialworker having difficulty in seeing Bethany who was frequently in bed whenvisits were made. It was not completed till December 2014 and it was actedupon by Central Bedfordshire Council in January 2014.3.12.4 The need for a cognitive assessment to test the parents’ functional capacity14 | P a g eFinal draft 25/2/2016 updated 18.10.2016had been identified at an early stage. Although an adults’ social workercarried out an assessment through a home visit with the social worker, thiswas not a full cognitive assessment. Attempts to commission a fuller cognitiveassessment of both parents were frustrated. The local NHS provider oflearning disability services did not agree to undertake this assessment. Theservice was not commissioned to provide parenting assessments, and on thatbasis the referral was declined. It was clarified that the referral was in fact fora cognitive assessment, which is a routine referral, however it was suggestedthat this may not have been in the parents’ best interests and the referralremained declined.3.12.5 The concerns continued to be acknowledged and the information wascollated by the most recent social worker. There continued to be a high levelof visits to the home, shared between the social worker and FISS workers.There were occasions during this period where it was felt by the social workerthat other professionals were being too sensitive to the needs of the adultsand not recognising the needs of Bethany and this was addressed by her at aCore Group meeting in November 2014 when the meeting was informed thatfurther legal advice was being sought.3.12.6 The family moved twice during this period of involvement and, when intemporary housing, it was felt they coped better because they had access toon-hand support from the warden at the temporary accommodation. Thefamily then chose to accept housing in a relatively isolated village which wascloser to their family.3.12.7 There were indications from mid-2014 that the concerns about Bethany’swelfare and safety were not shared proactively by all the professionalsinvolved or some were not voicing the concerns they held about the family.Focusing on the welfare of Bethany was sometimes lost in the light of thesignificant support needs and increasingly strained relationship between15 | P a g eFinal draft 25/2/2016 updated 18.10.2016Olivia and David. The social worker challenged the lack of full consideration ofthe concerns by some professionals.3.12.8 As a result of these shared concerns, a legal planning meeting was held inOctober 2014. The concerns were domestic abuse between the parents, theparents’ lack of understanding of what may pose a danger to Bethany andtheir neglect of her basic care. There were concerns about the impact onBethany of David’s alcohol use, the parents mixing with unknown peopleparticularly those met on the internet and those persons being brought intothe home whilst Bethany was present. Olivia admitted to meeting this man onthe internet. The couple acquired a dog and professionals were concerned atthe parents’ lack of understanding of the risks it may pose to Bethany. ThePublic Law Outline process was started and parents were informed of this at ameeting with them and their legal representatives in November 2014. It wasnoted that the PAMs assessment had been started with an expectedcompletion date of mid December 2014.3.12.9 Olivia alleged in this meeting that David was drinking heavily and was verballyabusive to her. David had previously been bruised by Olivia but both of themsaid there was no violence between them. David agreed to the alcohol servicehe was attending providing information about his drinking and he also agreedto find suitable alternative accommodation. A review meeting was to be heldat the end of February 2015.3.13Bethany – aged 1 year 3 months to 1 year 5 months - Care Proceedings -January to April 20153.13.1 Throughout the Early Help / family support services maintained a high levelof visits to the family whilst they were awaiting the PAMs assessment.When the PAMs report was finally submitted to the local authority inJanuary 2015 it raised serious concerns about Olivia and David’s capacity toparent. It was shared with the Legal Department of Central BedfordshireCouncil and as a result, Care Proceedings were instigated in February 2015.The assessment had concluded that Bethany’s parents were not able to16 | P a g eFinal draft 25/2/2016 updated 18.10.2016meet her needs.3.13.2 Although the PAMs report was dated mid-December 2014, it was notreceived by the social worker until January. It was then decided thatproceedings should be commenced. Towards the end of January, theassessment was shared with the parents and their solicitors. At a reviewPublic Law Outline meeting at the beginning of February 2015, the parentswere informed that it was the intention of the local authority to commencecare proceedings. All the papers for court were sent in early March 2015.3.13.3 There were two court hearings held a week apart in mid-March 2015 to consider thelocal authority’s application for an interim care order. The local authority appliedfor an Interim Care Order, with a care plan for Bethany’s removal from her parents’care. It was thought the Guardian would support this. However, an adjournmentwas proposed by mother’s solicitor. The application to adjourn was on the basisthat support could be offered by the extended family and this needed to beexplored to enable the court to have all reasonable options before it. There hadalready been three family group conferences held to identify what support thefamily could provide. It is not clear whether the Judge was aware of this. Davidinformed the court that he would move out. The application to adjourn wasopposed by the local authority but the court granted an adjournment and the orderstated:“The court being of the view that such a step is necessary to ensure that the right toa fair hearing and family life is complied with.”3.13.4 The court reconvened just over a week later. There were oral submissions by thelegal representatives of the parties. The local authority’s application for an InterimCare Order was opposed by Olivia, David and the Guardian. Within her judgment, theJudge expressed serious concerns for Bethany’s welfare, agreed that she hadsuffered emotional harm but did not sanction removal. Instead, she decided thatBethany should not be removed into care on the basis of the support plan put beforethe court by the family with some parts included by the local authority as they wereobliged to do. The family members were spoken to by the Judge to ensure they17 | P a g eFinal draft 25/2/2016 updated 18.10.2016understood the commitment they were giving to support Olivia to care for Bethany.3.13.5 Following the direction of the court, the agreement was for the FISS worker tovisit twice a week and for the social worker to visit once a week – the otherdays were to be covered by family members.3.13.6 Central Bedfordshire Council had formed the view that David was no longer apositive influence particularly since major arguments were occurring betweenDavid and Olivia. David was therefore asked at court to agree to leave thehome which he did. Some of the maternal extended family members had notbeen as involved with the family for a significant period of time but they gavean undertaking to the Judge that they would offer support in providing a highfrequency of visits along with an increased level of visits by the FISS team.3.13.7 This was all on the basis of further assessments to be undertaken in respectof Olivia and David’s cognitive functioning and within a timetable to concludethe case within 26 weeks. A cognitive assessment of both parents wasrequested by the court.3.13.8 At the end of March 2015, Olivia told professionals that she had gone to apub with a man she hardly knew and taken Bethany with her; she alsoadmitted smoking cannabis in the garden with him. The social workerinformed the LA’s solicitor and told Olivia that this was unacceptable. A fewdays later on 31st March 2015, Olivia said that she was worried about herfeelings for Bethany. She said her family was suggesting that Bethany wouldbe better off with someone else. Over the next few days, despite repeatedefforts the professionals could not get access to the home and Bethany wasnot seen by any professional. On 2nd April 2015the FISS worker and a socialwork assistant sought advice from a manager as they had still not managed tosee Bethany. The GP was contacted who said he had seen Bethany and hadno concerns.18 | P a g eFinal draft 25/2/2016 updated 18.10.20163.13.9 On 4th April 2015, the FISS worker could not get in but she could hear thebaby crying inside; she alerted the social worker. The worker called andtexted mother but she did not respond to either. The FISS worker visitedagain an hour later. The worker sent a further text message to mother to askher to make contact within one hour or the Emergency Duty Team and thePolice would be contacted. The FISS worker telephoned MaternalGrandmother who confirmed that she was with mother and child at thetime of the call.3.13.10 The gap in professional contact between 4th to 7th - Saturday to Tuesday- was only on the Sunday and Monday. This was because of thefamily plan as set out in court which expected family members to carry outvisits.3.13.11 On 7th April 2015, access was gained by the FISS worker but Bethany was notseen as she was with her father’s family. The house was dirty and untidy withthe bed stained and an old baby milk bottle and a dirty nappy on the floor.3.13.12 The next day David contacted the Police stating that he thought Olivia wasusing drugs and drinking; Police visited on 8th April 2015and could find nosigns of this and, as a result, formed the view that the call had been malicious.Children’s Social Care was informed of the referral but there does not appearto have been any direct liaison between the agencies; it is likely thereforethat the police officers attending were not aware that Bethany was subject toa child protection plan. The police referral to children’s services after the visitdid not indicate any cause for concern; mother did not appear to be underthe influence of any substances and the police officer found no evidence ofany alcohol/drug use or any other persons present. Bethany was upstairs inbed. Mother did admit that she had smoked some cannabis a few weekspreviously but she denied being a regular drug user.19 | P a g eFinal draft 25/2/2016 updated 18.10.20163.13.13 On 9th April 2015, the social worker visited the home. Mother, maternalgrandmother and Bethany were present. The concerns about Olivia’sinappropriate use of Facebook were discussed. It was felt Olivia wasrealising that even with immense family support she was struggling to carefor Bethany.That same day the paternal aunt and uncle, Katie Lamb andElliot Green stated that they no longer wished to be assessed to care forBethany and had pulled out of being part of the support plan. The socialworker who spoke to a duty solicitor said that the Judge had been clear thatif there were any issues with the plan the matter was to be returned tocourt. By the following week there would be gaps in the support plan so thiswas discussed. The social worker said that she would speak to the maternalgrandmother to see if she could help pending this matter returning to court.The duty solicitor advised the social worker that to return the matter backto Court would need an updating short statement and care plan as removalwas being sought and the statement needed to update the court on thebreakdown I support from the paternal family due to ‘personal reasons’. Thecourt was not informed directly of this change in circumstances as the socialworker was to prepare a statement and next steps were going to beconsidered at a meeting to be held early the next week.3.13.14 The local authority solicitor wrote to the social worker confirming what hadbeen agreed as a temporary solution. She also informed mother’s, father’sand the Guardian’s respective solicitors about what had happened andconfirmed that the local authority would be seeking to return this matter tocourt. There was no response to these emails within the records.3.13.15 On 10th April 2015, Olivia was with her mother and was seen by the FISSworker. Olivia told the worker that she had agreed for Bethany to be adopted.She said she had agreed because the family could not maintain supporting herto such a high degree. The FISS worker sent an alert to the social worker thatday. The next day, Bethany was found dead. The local authority intended to20 | P a g eFinal draft 25/2/2016 updated 18.10.2016return to court the next week and the social worker had drafted a statementabout the new concerns.4.Bethany’s Experience and Family Involvement in the Review4.1Olivia and David appeared to be happy about the pregnancy and made preparationsfor the baby and attended pre-birth sessions to support them. There were noimmediate concerns after her birth and she went home with her parents.4.2For the first few weeks of her life, Olivia seemed to manage caring for Bethany. Shebreastfed Bethany for the first two weeks but did not sustain it beyond that briefperiod. There were no immediate concerns about the quality of care.4.3However, within a few weeks, the Health Visitor and others started to be concernedabout how difficult the parents found it to retain information and to follow advice.Both parents needed a great deal of prompting to meet Bethany’s basic care needs.There were many professionals visiting the home throughout Bethany’s life. Visitswere carried out up to six times a week. Bethany therefore had several differentadults to interact with and to provide her with care. When these other adults werenot present, the level of care dipped and Bethany appears to have been neglected.Above all, some professionals realised the real problem was that Olivia could notempathise with Bethany nor appreciate and foresee her basic needs.4.4The parents took Bethany to the children’s centre and she would have benefitedfrom these trips. However, particularly as she became older and more demanding, itappears that she spent more time in her room. When the PAMs assessment socialworker visited, she was said to be asleep and in her room on many occasions.4.5Bethany is likely to have experienced a considerable amount of conflict in the home.By September 2014, Olivia and David’s relationship, which had been poor for a longtime, seemed to be over though they still lived together. It is clear that Bethanywould be adversely affected by their arguments and their own preoccupations whichdistracted them from caring for her. It seems he was drinking heavily and she wasspending a great deal of time on Facebook and other social websites.21 | P a g eFinal draft 25/2/2016 updated 18.10.20164.6The Guardian visited the home just before the first Court hearing and saw Bethanyjust weeks before her death. It was her observation that Bethany had very littlespeech and seemed scared and watchful when her mother raised her voice. Bethanywent to her parents but she was much more interested in the FISS Worker when shearrived.4.7Bethany’s parents had wanted to care for her but it appears that she was neglectedand not consistently provided with the basic care and comfort she needed. On theday of her death, there was evidence that she had been left alone in her room for anextended period without being changed or attended to.4.8Father, David has clearly been very distressed by the death of his daughter. He wasinterviewed and said he felt that he did most things for Bethany after the first fewweeks when Olivia cared for her. After that Olivia felt low and said she thought shemight hurt the baby. He did the cooking, housework and made the bottles up forBethany4.9He said that Olivia spent a great deal of time on her mobile and on the internet andafter May 2014 she provided very little care to Bethany. They started arguing. Forexample, Olivia bought a dog and David was unhappy about this – the dog growled atBethany and left hairs everywhere. In September 2014, he came home to find asemi-naked man in the house. Olivia carried on using web-based dating sites andDavid looked after the baby.4.10David said that during the PAMs assessment, Olivia kept Bethany upstairs out of theway. The situation deteriorated after Christmas 2014. Olivia accused him of drinkingand he was. The relationship seemed to be over and the plan was not working – thehouse was dirty and untidy. David agreed to leave but he was worried about whetherOlivia would look after Bethany.4.11Mother, Olivia was seen as part of the review process. David was also in the homewhen we visited. She has also been very distressed by Bethany’s death. She is stillconcerned that the cause of Bethany’s death is not clear.22 | P a g eFinal draft 25/2/2016 updated 18.10.20164.12Olivia felt that some of the support they were given was useful but there wereproblems. It is her view that she did not need help in caring for the baby; it wasDavid who needed the help. There were many different workers and they werealways in and out. Her brother and his wife originally helped but they dropped outand she was not happy about that.4.13Olivia said that in Bethany’s last week in April 2015, her brother had spoken to herand had advised her to have Bethany adopted as they both had been. She said thatshe had decided that was the right thing to do and had told the social worker whoadvised that there would need to be a Court hearing. The day after this Bethanydied.4.14David’s mother and step-father were seen at their request. Paternal grandmotherused to look after Bethany twice a week. They have found Bethany’s death difficultto bear.4.15Paternal grandmother said that it had been very difficult having so many differentsocial workers involved – she said there were five or six. As soon as they were usedto one social worker they would go and they would have to start again. This was alsodifficult for Olivia and David. The FISS workers were by contrast able to providecontinuity.4.16In her view, it was taking David and Olivia a long time to understand what wasrequired of them and they were not getting it fast enough. Olivia thought she wascoping better than she was; paternal grandmother felt this was not really challengedin core group meetings and most often professionals said how well Olivia was doing.4.17The maternal extended family – particularly Olivia’s mother and her brother havedeclined to be seen for the review.5.Areas of Significant Practice (ASP)5.1ASP1. Timely and prompt response but the assessment completed was notcomprehensive. (Pre-birth).23 | P a g eFinal draft 25/2/2016 updated 18.10.20165.1.1The midwife correctly and appropriately referred the family to CSC when she knewabout mother’s background and she perceived that both parents had learningdifficulties. Her initial view that they would need additional support was right. CSCpicked up the case and initial and core assessments were completed. At the sametime pre-birth services were provided to the family and they cooperated well withthis.5.1.2This pre-birth assessment recommended that Early Help and family support servicesshould be provided through a CAF. The case would be closed in CSC and steppeddown to Early Help and Health. From July to September 2013, the parents werecooperating and when Bethany was born there were no additional concerns. Thepre-birth Core Assessment did not draw fully on contributions from other agenciesand it lacked detail about the parents’ history including the level and nature of theirown parenting and learning difficulties. Olivia’s inability to care for Scott without ahigh level of support from her own mother was not fully explained. It did not statethat they lived with her mother when he was a baby and it was grandmother wholooked after him. Scott had only recently been transferred to his father’s care andthis was also a strong indicator that Olivia was likely to struggle to parent Bethany.This was also a missed opportunity to specify the need for specialist assessment ofthe parents’ functioning or perhaps even a residential family assessment which couldhave been indicated given the history. The decision to close the case in CSC wastherefore premature but a well organised range of Early Help services were planned,offered and taken up. As a result of this safety net the early difficulties were pickedup promptly and child protection processes put in place.5.2ASP 2 Prompt response made to concerns after Bethany’s birth and a ChildProtection Plan was made. (Bethany 0-3 months - September 2013 to December2013).5.2.1In the first few weeks, a high level of support was provided. Despite this someconcerns about whether Olivia and David could care for Bethany emerged from anearly stage which suggests that the pre-birth Core Assessment was over optimisticabout the level of support which would be needed and had not taken sufficientaccount of the parental history. The midwife continued to visit beyond the usual 1024 | P a g eFinal draft 25/2/2016 updated 18.10.2016days and up to the 28th day after birth. The Health Visitor also was seeing the familyfrequently and suggesting to David that he needed to be at home to support Olivia incaring for Bethany. Things were not going well within the first few weeks. Olivia wastired, saying she might harm Bethany. David said Olivia was hitting him. Davidadmitted that he was drinking heavily. Bethany was having feeding problems withreflux and suffered from recurrent oral thrush.5.2.2Appropriately, CSC called a strategy meeting. At this early stage, the strategymeeting rightly identified the need for a further core assessment as well as aspecialist assessment of the parents’ intellectual and cognitive capacity. A referralwas made for Adult Learning Team assessment of parents. An initial assessment wascompleted promptly by an Adults’ social worker However, when it was identifiedthat a full cognitive assessment of the parents was required, the NHS providerservice refused to provide this. That service did not see itself as responsible forcontributing to the assessment of parenting in that way. The service also suggestedthat it would not be in the parents’ interests for this assessment to be completed.This was worryingly un-child focused approach.5.2.3Problems continued to emerge during October 2013. David stated that he could notleave Bethany with Olivia. The house was untidier. In mid-October 2013 David andOlivia were complaining about the level of support being provided saying it wascausing stress. A family group conference was planned. The ICPC was held on 30thOctober 2013 and there was a clear view that Bethany was at risk of significant harmthrough neglect and should be subject to a Child Protection Plan. At this point, theplan to continue the intensive level of support was maintained with the Chairrecommending that a cognitive and PAMs parenting assessment should becompleted. Four family members including the parents were present and the Chairmet them prior to the conference.It was identified that due to a lack of self-confidence the parents do not alwaysactually understand guidance that is given about Bethany's care and untilprofessionals are satisfied that both parents fully understand and can apply safe25 | P a g eFinal draft 25/2/2016 updated 18.10.2016parenting skills a high level of support and monitoring was required. Minutes ofICPC 30/10/135.3ASP 3 There was a drift in the case and delay in completion of the CognitiveAssessments and PAMs and there were several changes of social worker. (Bethanyaged 3 months to 1 year 3months – January to December 2014).5.3.1 There were many different professionals involved with Bethany during her lifetime.There were five social workers though the most recent one has been involved sinceJuly 2014. There were four different health visitors reflecting the family’s threemoves. Undoubtedly, having so many changes of staff in such a short period of lessthan two years, must have led to difficulty in providing continuity of planning andmonitoring and a tendency to “start again” when a new professional becameinvolved. However, it was positive that many of the family support workers wereinvolved consistently throughout.5.3.2Coordination of the plan was carried out through the child protection meetingswhich were held regularly. The parents and often family members were alwayspresent and this is likely to have inhibited full disclosure of worries and concerns.Professionals had no opportunity to share or voice concerns together outside thatcontext which may have led to some earlier and more realistic appraisal and need tochange the plan given the continuing problems they were having in getting theparents to heed advice and guidance and to learn how to care for Bethany as shewas developing and growing. In separate supervision sessions, there is evidence thatthe social worker and the health visitor were able to voice these concerns. Followinga group supervision session for health visitors in November 2013, the health visitortold the social worker that it was clear that mother’s capacity to parent was notgoing to change however much intervention was in place given her inability toempathise with Bethany. There is evidence in the records but also from thediscussion with practitioners that during the first half of 2014 there was a lack ofsharing of true perspectives on the seriousness of the problems.5.3.3Child protection meetings were held regularly but additional independent reviewwas lacking. The professionals involved attended the child protection meetings and26 | P a g eFinal draft 25/2/2016 updated 18.10.2016consistently supported the family with a range of different services. The childprotection conferences were able to provide some monitoring of progress but thosemeetings could not be the only source of critical challenge. It was encouraging andperhaps over reassuring that the parents and family members attended the childprotection meetings but robust challenge may have been difficult with them presentthroughout. It is clear from the minutes that both the parents and other familymembers would argue away the concerns which were being raised and dispute thefacts. It is of note that the PAMs assessment – an independent assessment – wasawaited and hung over proceedings. There was a high professional focus on theneeds and issues of the parents. The extensive, intensive family support providedcompensated for their lack of basic parenting skill and meant that their parentingcould not be fully tested.5.3.4By November 2014, professionals were clear that Olivia and David were notmanaging to parent Bethany appropriately and it was likely that they would never beable to do so. A Family Group Review Meeting was held at the end of November2014 attended by Olivia, David, her mother and his mother. The continuing concernsof professionals were shared. The need to identify alternative carers for Bethanywas discussed if it was found that the parents were not capable. The view agreedwas that Olivia would be better able to cope with single parenting with additionalsupport than David would. This seemed to be at variance with the evidence from thepast year that David had provided most of the hands on care to Bethany.5.3.5The last child protection conference was held but the PAMS was still awaited. Thechild protection conference held in mid-December was attended by the author ofthe PAMs assessment though he did not share the details of it. The Chair’s view wasthat the parents had engaged with the plan and worked with professionals but notedthis had only really been since the commencement of the pre-proceedings process.As in previous meetings, Bethany was said to be developing well and reachingmilestones despite two falls, David was said to be providing most of the care.Concerns about David’s drinking and the parents’ ever deteriorating relationshipwere also discussed. It is not clear why the PAMs report was not made immediately27 | P a g eFinal draft 25/2/2016 updated 18.10.2016available at that point because, if it had been, it is clear that the court proceedingswould have been started in December; instead a rather uneasy conference occurredin the face of uncertainty and a lack of clarity about the next steps. Olivia said shewas going to work in a pub over Christmas which she duly did leaving Bethany withDavid as well as Scott for a period. A review PLO meeting date was set for 26thFebruary 2015 which seemed to be a long gap given the high levels of concerns andthe local authority’s intention to remove Bethany from her parents’ care.5.4ASP 4. An appropriate response was made once the specialist assessment wasreceived. PAMS received - Care Proceedings initiated. Full range of placementoptions needed to be presented. (January to March 2015)5.4.1It was not until the end of January that the PAMs report was received and sharedwith parents. During January core group and family group meetings were held. Davidand Olivia were still living together in the house. There were signs of deterioratingcare of Bethany with dirty milk bottles left out and Bethany being left alone in herroom for extended periods. Bethany was heard growling when she wantedsomething rather than seeking to speak which is likely to have indicated that she wasdistressed. On another occasion, Bethany was purple with cold and mother had to beprompted to put clothes on her. David was depressed, on medication and drinking.There was conflict between the parents. The situation was not improving and thereceipt of the PAMS report led to the decision to go to court.5.4.2Planning for the court proceedings and the evidence required seems to have beenlimited by the delay in receipt of the PAMs. The case was presented on the basis ofthe PAMs assessment and the social worker’s statement. Despite discussions inNovember 2014 about the need to investigate alternative family carers this waspartially but not fully completed - no viability assessments had been completedthough some discussions had occurred. Given that the local authority was seeking anInterim Care Order and for Bethany to be removed from her parents’ care this wasan omission. It led to the Judge making an adjournment and contributed to theJudge’s decision not to remove Bethany on 20th March 2015 even though sheacknowledged that there was evidence that she was suffering harm.28 | P a g eFinal draft 25/2/2016 updated 18.10.20165.4.3There had been active engagement by the local authority with the extended familyand four family group conferences had been held but it is not clear that this wasbrought to the Judge’s attention. In the search for alternative carers, on the 9thDecember 2015, father informed the social worker that paternal grandmother wasunwell with leukaemia. Maternal grandmother offered to have Bethany on a shortterm basis but could not do so long term because her husband had Parkinson’sdisease. Mother had not spoken with her brother and his partner for nearly a yearand when they were put forward as potential carers, on the 4th March 2015 theydeclined to be assessed because they said they had their own children to care forand had a poor relationship with Bethany’s mother. However, they then appeared atcourt with her on the 11th March 2015 and signed the written agreement saying theywould initially visit her every day for two hours. Despite these approaches to theextended family, the outcomes of these approaches and formal viability assessmentswere not written up or presented to the court. Options for placing Bethany withfamily members were therefore not fully explored, though there had beendiscussions with family members, and the court was only presented with the optionof removal from mothers’ care with no familial option as a result.5.4.4It may be that the Judge had only limited time to read and acquaint herself with allthe papers prior to the hearing but it may also be that the local authority did notpresent strongly enough at court how much communication there had been withfamily members about providing alternative care for Bethany. The Guardian alsoidentified that there was no cognitive capacity assessment of the parents but onlythe PAMS parenting assessment. These issues resulted in further delay and interimdecision-making in relation to Bethany. The court was provided with a positivedevelopmental assessment, drawn from a developmental checklist, by the healthvisitor which did not identify any concerns about Bethany’s development and thiswas out of kilter with the local authority’s opinion and the Guardian’s observationsof Bethany when she visited the family.5.4.5The Guardian visited Bethany at home and was very concerned about her lack ofspeech, and her positive interaction with a professional in contrast to her response29 | P a g eFinal draft 25/2/2016 updated 18.10.2016to her parents; the home was cold and untidy. When her mother shouted, Bethanywas said to have been very frightened.5.4.6 The first Court hearing before Lay Judges on 11th March 2015 was adjourned. TheGuardian supported the application for an ICO because she was concerned aboutmother’s interaction with Bethany. The maternal family proposed providing moresupport and the Guardian having spoken with the Child’s solicitor changed her mind.The Guardian was a new and inexperienced Guardian and the Child’s solicitor wasvery experienced and highly regarded by the court. Bethany was to stay with Oliviawhilst the family put together support with the local authority and David was tomove out.5.4.7No witness evidence was taken by the court. During the period between the first andsecond hearing on 20th March 2015 – 9 days in total - various concerns about thequality of care were noted. Bethany was cold, Olivia had to be prompted to feed her,the baby was left alone in room with a large television and mother did not respondwhen Bethany hurt herself. Comments were made by the Health Visitor that thewider family were minimising the impact of the couples’ cognitive deficits in relationto the parents’ functioning on a day to day basis. The court did not agree Bethany’sremoval into care and a support package was agreed with the extended family.5.4.8 It was appropriate for the Guardian to take account of the advice given but she alsoneeded to consult with her manager when it was clear that her professional view ofwhat she had seen at the home and of Bethany did not accord with the solicitor’sadvice. It is always more difficult to justify removing a child in cases of neglect butthere was in this case such a long history here of no progress by parents, of emergingbehavioural problems in the child and the Guardian’s own initial analysis of thechild’s lived experience.5.5ASP 5. The plan made at Court faltered but the Court was not informedimmediately as the Judge had requested. (March to April 2015)5.5.1Some high risk behaviours by mother were recorded but there was no immediatereturn to Court. These behaviours showing that she continued to find it impossible to30 | P a g eFinal draft 25/2/2016 updated 18.10.2016prioritise Bethany’s needs, were noted after the court hearing. These have been setout earlier in this report. In particular, on 31st March 2015, Olivia said that she wasworried about her feelings for Bethany. Legal advice was sought by the social workerand it was agreed that the social worker should prepare a fresh statement to updatethe Court.5.5.2On 9th April 2015, two days before Bethany’s death, the extended family memberswho had told the court they would support the plan decided to withdraw from thesupport plan. The social worker who spoke to a duty solicitor said that the Judge hadbeen clear that if there were any issues with this plan the matter was to be returnedto Court. Although the solicitor informed the other parties about what had happenedand confirmed the local authority would be seeking to return this matter to court,there was no response to these emails. It does not appear that the court wasinformed of the failure of the plan; it is not clear why this did not happen but theemphasis which the Judge placed on her being informed if the plan failed as soon aspossible may not have been fully appreciated. On 10th April 2015 the day beforeBethany died, Olivia told the family support worker that she had agreed for Bethanyto be adopted. Given this and other continuing concerns, children’s servicesintended to return to court the following week. Her death over the weekend couldnot have been predicted.6.FindingsFourteen findings or underlying patterns, in the management of the case have beenidentified. These have helped the panel and the reviewer to understand why some practiceshappened in the way they did. Each of the findings is explained with a rationale, anindication of its impact on the wider systems in Central Bedfordshire and a series ofrecommendations follow to enable the Board to strengthen safeguarding by addressing theroot causes underpinning the finding.There was much positive effort and good practice in this case to provide support to theparents and to keep Bethany safe. There are also some areas for further consideration anddevelopment.31 | P a g eFinal draft 25/2/2016 updated 18.10.2016The findings fall into different typologies of systems issues, with a clear link betweeneach of the findings and each of the typologies. This is not unusual, as it would be expectedto find links between findings when adopting a whole systems approach. There are fourteenfindings for the Board to consider, these are:Patterns of Management of Systems1. The concerns about whether Olivia and David would be able to care were identified atan early stage. Early help was provided soon after she saw the midwife and later afterthe birth when problems arose, child protection processes and additional supportwere used to keep Bethany safe.1.1 The ante-natal midwife identified the vulnerability of both parents and referred herconcerns on. An assessment was completed and a detailed plan was put in place toprovide support to the parents prior to birth.1.2 Pre-birth early help and ante-natal support tailored to their needs was provided tothe family. Mother was able to attend a parenting group. Both parents were in touchwith the children’s centre. The need for specialist assessments of parenting capacityand cognitive functioning was identified at an early stage.1.3 Midwives and the health visitor provided advice and support and additional visitingwhen the baby was born. Additional visits were made and every effort was made toensure that the parents understood and followed the advice given.1.4 When the parenting difficulties were identified, there was a very high level ofprofessional engagement. High levels of support were provided, the child protectionprocesses were followed with regular case conferences and core groups being held.2. The assessment of parental capacity and motivation is an essential requirement tokeep children safe. When parents have learning difficulties or other particularneeds, it is important to use specialist tools to assess their cognitive and practicalparenting skills. In this case, there appears to have been a lack of a clear system forsuch specialist assessments. This resulted in a cognitive assessment not beingcompleted and delay in achieving a clear assessment of the parents using the PAMstool.32 | P a g eFinal draft 25/2/2016 updated 18.10.20162.1 Although it was realised that additional expertise and assessment were required,there was a lack of a clear system and arrangements for these to be delivered in atimely manner. There was no clear interagency pathway for a specialist parentingassessment geared to addressing the needs of parents with learning difficulties. As aresult, there was delay in commissioning and undertaking of specialist parentingassessment and access to learning difficulty expertise.2.2 The system for joint working between adults’ services – in the LA and in Health - andchildren’s services in relation to parents with a learning difficulty was not clearlydefined. Expectations were not clear and there is evidence that the overridingrequirements of child protection should be the primary focus for all.3. The management of cases of neglect and measuring its impact is challenging. In thiscase, child-centred timescales were not set or imposed for parental improvement.3.1 There is no evidence throughout the life of the case that either parent was able toretain and put into practice this advice in any real or sustained way.3.2 Professionals compensated for the parental shortcomings and carried on trying to dotheir best for the child. There was a lack of testing at some points of how wellparents were really coping.3.3 The family were dependent on the professional support which acted as a safety netand as a buffer seeking to ensure Bethany’s needs were being met.4. There was a discrepancy between the view of the Court and that of the LocalAuthority about the urgency to bring Bethany into care. The Guardian initiallysupported the local authority position but probably, through her inexperience as aGuardian, changed her mind after conversation with the child’s solicitor; followingher visit to the family home on 10.3.2015, the Guardian spoke to child’s solicitorabout her observations and concerns. The Guardian later stated that the child’ssolicitor had said “…there was not enough information to remove Bethany, he saidwhat I had seen was a short snapshot of a day and the parents would argue this wasnot reflective of their general care of Bethany.” The child’s solicitor held to his viewand the Guardian acquiesced. In her report, the Guardian did not reflect acompelling analysis of her opposition to the local authority plan probably because33 | P a g eFinal draft 25/2/2016 updated 18.10.2016she was conflicted about supporting the plan for the child to remain with mother.The child’s solicitor is very experienced and was of the view that there wasinsufficient evidence for the child to be removed at this stage of the proceedings.The court system as well as time constraints for the Court did not require or enabledirect evidence to be heard from the local authority or the Guardian even thoughthere was no consensus amongst the parties about the action required.Patterns of Professional-Family interaction5. The vulnerability and needs of the parents were considerable. Professionals tendedto be parent–focused and at times they were distracted by parental excuses andexplanations about why they were not following the advice given to them. Thismeant that the impact of the parental behaviours on Bethany was not alwaysobserved or responded to.6. The parents and members of the extended family were involved in child protectionmeetings and in family group conferences and every effort was made to engagethem. Father was explicitly involved by professionals; he was visible and generallycooperative. He was very actively involved in caring for Bethany and professionalsperceived this and supported him. Considerable efforts were made to engage with,and involve, the extended family through Core Groups and Family Groupconferences.7. The contribution of the extended family involvement was not fully tested andseems to have been over-relied on in planning.8. Professionals engaged very positively with Bethany and sought to provide her withpositive stimulation. They did this by modelling good parenting to the parents butunfortunately the advice was not followed when Bethany was solely in the care ofher parents.Patterns of Professional Bias9. The professionals in each agency who were involved with the family lacked thespecialist knowledge and expertise to work with adults who had learning difficulties.34 | P a g eFinal draft 25/2/2016 updated 18.10.201610. Given that Bethany was such a young child and that there was almost dailyinvolvement with her, it appears that it was not easy for professionals to identifythat her development was being impaired. The developmental summary providedto the Court by the health visitor suggested that she was developing within normallimits; when the Guardian visited the family at home with a fresh pair of eyes shewas immediately concerned about Bethany’s development, lack of speech and heranxious response to her mother. In fact, the professionals who were in frequentcontact were concerned and frustrated that intervention did not occur sooner.11. There is also an indication that agencies were not always sufficiently challenging ofeach other over several months of concerns about the care of Bethany, the lack ofimprovement in her care and the parental shortcomings. The presence of thesevulnerable parents and other family members may have impacted on how preparedprofessionals were to discuss concerns. There were also several changes of socialworker and this is likely to have hampered planning, monitoring and consistentconsideration.12. When the assessment of the parents’ capacity was being considered by an adults’service, there is evidence that a focus on equalities considerations in relation to thelearning disability and difficulties of the parents’ needs and rights of parents mayhave taken precedence over the needs of Bethany. For the most part this was notthe case but there was at that point a focus was on Parents’ Rights rather than theirParental Responsibilities. A cognitive assessment requested from one agency wasnot provided because there was no agreement that this should be provided by thatagency and because it was seen as “detrimental to parents”.Patterns in Multi-Agency work13. Agencies worked together through the child protection process to try and ensurethat she was kept safe and that her welfare was being promoted. Child protectionprocesses and plans were in place and regular reviews and monitoring of progresswere carried out.35 | P a g eFinal draft 25/2/2016 updated 18.10.201614. When the child protection plan was not keeping Bethany safe, legal advice andaction was taken. Legal advice was regularly sought and prompt responses wereprovided. When the plan was faltering in April 2015, the social worker contactedLegal straightaway and there were plans made to have a new working plan inpreparation for Court.7.Conclusions and Summary7.1Bethany was a very vulnerable young child who was totally dependent on herparents for her care and safety.“Babies are almost entirely dependent on their immediate caregivers. A parent’scapacity to respond appropriately to the motions and needs of their babies has aprofound impact. Becoming a new parent is a major transition; there are times whenevery parent feels under pressure and may struggle to cope with the stresses andresponsibilities of their role. But, for very young parents, or parents facing additionalchallenges in their lives such as mental illness and domestic abuse, this can be aparticularly difficult time.”NSPCC 2011 All Babies Count7.2 Both Bethany’s parents had experienced troubled childhoods. Both her parents havelearning difficulties and appeared to find it very difficult to put Bethany’s needs firstconsistently. There were concerns about both parents’ stated learning difficultiesand the impact of this on their capacity to parent Bethany, to keep her safe and topromote a thriving and happy childhood for her. There were reports of violence inthe relationship and issues with alcohol for both parents, but in particular David.7.3 It seems that the stress of parenting led to difficulties for them in caring safely forBethany. Unfortunately, in many respects and, for some time, they presented asappropriately committed to caring and cooperated well with a wide range ofinterventions designed to develop and improve their parenting capacity. Theintensive support provided by services as well as the support of extended familymasked the real difficulties they were experiencing and the impact this was having36 | P a g eFinal draft 25/2/2016 updated 18.10.2016on Bethany. In reality, they were not coping with caring consistently for Bethany andas her needs for stimulation grew, they struggled even more.7.4 There was much positive practice in this case. The midwife rightly identified thepotential vulnerability of Bethany’s parents before she was born. She providedadvice to them and informed other health professionals of the possible need foradditional support when the baby was born.7.5 A whole raft of support was provided through the FISS service with a considerablecommitment from all those staff who were involved. It was clear at the practitioners’event how much effort had gone into trying to do the best for Bethany.7.6 It is clear that the difficulties which Bethany’s parents experienced in caringconsistently and safely for her were predicted. Significant levels of support wereprovided to them but their capacity and willingness to respond were not alwayssufficient. When it became increasingly clear that they could not parent Bethanyeffectively, the LA sought to remove her.Summary view:7.7 Every effort was made by all the agencies involved to keep Bethany safe, it is unlikelythat her death could have been prevented. It was also not predictable to anyone as itwas believed that she was not at immediate risk and that the wide range of serviceinvolved could protect her.7.8 It is very clear that all the professionals who were involved with Bethany and herfamily did their utmost to help her parents to care for her and to keep her safe.There was a strong commitment from staff and evidence of exceptional efforts beingmade to support the family.7.9 The demanding behaviour of the parents, their learning difficulties and othervulnerabilities led on some occasions to there being an over-focus on their needsrather than Bethany’s. Again, professionals wanted to give David and Olivia every37 | P a g eFinal draft 25/2/2016 updated 18.10.2016opportunity to succeed. The Chair of the child protection conferences has said thatstaff were: -“so keen not to penalise them both for their learning difficulties, and to ensure theirright to family life, that we may have at times lost sight of Bethany’s needs andrights” (IRO1).7.10 This happened despite a clear awareness and intention to be child-centred.Professionals and the Court at times lost sight of the fact that every parent has aparental responsibility towards their child. There are rights as adults - including theparticular rights of an adult with a disability - and the right to enjoy a family life.However, children also have rights which in law are paramount and the parents holdparental responsibility for the child. In Court the risks and harm to Bethany were notregarded as immediate and there was a concern that her family should have everyopportunity to care for her. The right to family life principle was an important factorin the Judge seeking to involve the extended family and in not agreeing to removeBethany.7.11 Bethany’s needs and experience tended to be “lost” in the focus on her parents’needs and issues and the life of the family. An enormous amount of time, resourcesand effort were expended to support the parents and to involve the extendedfamily. The high level of need of the parents distracted the professionals. Theoutcome was that professionals tend to compensate for the parental neglect ofBethany and they were making the best of what was not very good.7.12 Meanwhile both parents – but particularly mother - tended to fall in line when shehad to and feign compliance with the advice given. There is no doubt that motherhas learning difficulties and she did struggle to retain information but an elementof her just not wanting to bother was observed by professionals. It seems that shehad little capacity to tune into Bethany’s needs or to empathise with her. Thesituation was that Olivia had some potential to care for Bethany but she found ithard to do so consistently and it seems that she had her own preoccupations andwas easily distracted from caring for Bethany. Olivia was not able consistently toprioritise caring for Bethany over considering her own needs and preoccupations.38 | P a g eFinal draft 25/2/2016 updated 18.10.2016The history of her inability to care for Scott had previously demonstrated that shedid not have the capacity to live independently and care for a child.7.13 Although David provided a significant amount of care to Bethany, he did struggle,frequently questioned his ability to care and is unlikely to have been able to carealone and without significant prompting and guidance. He was willing and helpfuland loving and caring but just was not able to manage care of Bethany due to hislearning difficulties.7.14 It seems that Bethany’s needs were never wholly met by Olivia and David. Oliviamanaged for two or three weeks when Bethany’s needs were more straightforwardto meet. As Bethany developed the amount of information, guidance and supporther parents required in order to meet her emotional needs and need forstimulation grew exponentially and both Olivia and David struggled. Theprofessionals became increasingly frustrated about the lack of progress andapparent effort made. In addition, David and Olivia’s relationship becameincreasingly strained, Olivia bought a large dog and David became more stressedthrough hearing of his father’s serious illness and Olivia’s behaviour towards him.7.15 The neglect Bethany suffered was an insidious threat to her which she hadexperienced in varying degrees throughout her life. It was known that her parents’care was neglectful and it was also known that this was affecting aspects of herbehaviour and development. The extended family knew that Olivia and David hadsignificant difficulties in caring though it seems they underestimated how risky thesituation was for Bethany. The extended family sought to help Olivia and Davidattending child protection meetings, calling in occasionally and finally, reassuringthe Court that they could manage to keep Bethany safe. However, in reality thecouple needed more help than they could provide and within a week or so, theextended family withdrew much of what they had agreed to provide.7.16 After such long and intensive involvement and support to the family, it was right forthe local authority to seek to remove Bethany from her parents’ care in March2015. The indications were that they would never cope either singly or togetherwith Bethany’s increasing needs. Once the plan agreed at Court had faltered, the39 | P a g eFinal draft 25/2/2016 updated 18.10.2016local authority needed to inform the Court and return the matter to court as soonas possible. The social worker was preparing a statement for this to occur. Theimmediacy of the risk could not be foreseen. Unfortunately, such is the insidiousand unseen impact of neglect that it can result in long term serious affects as wellas immediate suffering and even death. The impact of this immediate suffering isnot always fully appreciated. The death of Baby Paul, aged 15 months, in Islingtonin 1994 which was the subject of an independent investigation, clearly evidencedthat severe neglect of a very young child may be fatal.8.Recommendations for LSCB to consider and action8.1Each of the agencies involved with the family has identified a number ofrecommendations. The implementation and impact of these actions will bemonitored by the Central Bedfordshire Safeguarding Children Board.8.2In addition, the following recommendations are made to the LSCB. They reflect thekey learning from this review. The Central Bedfordshire Safeguarding Children Boardshould: Ensure that the following are in place and monitoring the effectiveness ofthe arrangements for: -8.3Parental assessment processes (single and multi-agency) including consideration ofparticular circumstances such as parental learning difficulty, domestic violenceshould be reviewed and updated.8.4Identifying and responding to neglectful care – both physical and emotional neglect.8.4 a. Develop and implement the neglect strategy. The role of the Police and theprocess for the collation and presentation of multi-agency evidence particularly inrelation to cases of neglect should be included in the strategy.8.4 b. Ensure staff are trained together across agencies to implement the GradedCare profile system and to make sense of all the information available whilstmaintaining a focus on the needs of the child.8.4 c. Promote the use of professionals’ only meetings to measure and reviewconfidentially progress or lack of it in relation to individual cases of neglect.40 | P a g eFinal draft 25/2/2016 updated 18.10.20168.4.d. The significant and possible fatal impact of severe neglect and absence of carefor a very young child should be kept in mind within the interagency management ofcases of neglect.8.5Develop working links with the Family Justice Board so that the LSCB canunderstand, influence and support the Court’s work with children in public andprivate law proceedings.8.5.a This should include sharing of the local approach to neglect using the GradedCare Profile tool with the local Family Justice Board.8.5.b The expectations of both the Judiciary and of the local authority and otherpartner agencies in relation to the presentation of evidence and of making the casefor legal intervention and action should be shared.8.6There is a need to clarify standards and expectations for joint working arrangementsbetween children’s and adults’ services along a continuum from support /advice todirect joint working but above all to ensure that the paramountcy of the child’sneeds is the guiding principle.8.7Oversight of Child protection cases. Ensure that additional multi-agency challengeprocesses are established for all children subject to a child protection plan for morethan 9 months.9.Next steps - Progress Report / Learning9.1Since this review was established a number of measures have been put in place torespond to the learning from the case.There are now new threshold documents and a robust pre-birthassessment template and process in place.A new strategy for managing cases of neglected has been implemented.9.2A further LSCB response is attached to this report outlining further progress whichhas been made.42 | P a g eFinal draft 25/2/2016 updated 18.10.2016Appendix A - Family and Significant others and GenogramAppendix B - Scope and Full Terms of ReferenceTerms of ReferenceSERIOUS CASE REVIEW CHILD – BETHANY FISHERIntroduction:Bethany Fisher was an open case to Central Bedfordshire Council, Children’s Services andhad been subject to a Child Protection Plan since October 2013 for concerns about neglect,domestic violence and parental capacity to care for her. Both Bethany’s parents are believedto have a learning difficulty. Following concerns about domestic abuse within the parents’relationship Bethany’s father was asked to leave the family home.A legal planning meeting was held in October and Care Proceedings issued in February 2015following an independent assessment which concluded that Bethany’s parents were notable to meet her needs. Although application was made to remove Bethany from herparents’ care this was not agreed. The case was adjourned on the 11th of March 2015 foralternative placement options within her family to be considered. An intensive supportpackage has been in place which included daily support visits from her family andunannounced visits by the social worker and Family Intervention Worker.Bethany was found to have died on 11 April 2015 while at home in the care of her mother.Bethany was reported to be found in her room in an open cot bed with a nappy on. Thenappy was later found to weigh one pound which was estimated to be two full bladders ofurine. On her mother finding Bethany dead at approximately 1.45pm Bethany’sgrandmother called the ambulance. The ambulance staff who attended advised thatBethany had been dead for some time, the room was hot, there was vomit on the bed andBethany was found at the bottom of the bed with her head hanging over the end of the bed.At post mortem the cause of Bethany's death was given as inconclusive although it is knownthat there were signs of brain swelling and vomit in her lungs.Decision for Serious Case ReviewBethany’s case was referred by Central Bedfordshire Council, Children’s Services on 13 April2015 as she had died in her mother’s care and neglect was known to be a factor within hercase history. Her case was considered by the CBSCB Case Review Group on 15 April 2015and it was agreed that the criteria for a Serious Case Review were met under Regulation44 | P a g eFinal Draft 18/10/20165(2)a and b(i). Alan Caton, Independent Chair, agreed a Serious Case Review must always becarried out in these circumstances. Agencies have been formally notified that a Serious CaseReview is in progress as well as Ofsted, Department for Education and the National Panel.Principles and ApproachThis review has been commissioned in accordance with the new statutory Working Together2015 which came into effect on 26 March 2015. It is therefore being conducted under theguidance at Chapter 4, Section 18 of Working Together (2015)The purpose of a Serious Case Review is to:establish what lessons are to be learned from the case about the way in which localprofessionals and organisations work individually and together to safeguard andpromote the welfare of childrenidentify clearly what those lessons are both within and between agencies, how andwithin what timescales they will be acted on, and what is expected to change as aresult; andrecognise good practice and improve intra and inter-agency working and bettersafeguard and promote the welfare of children.Serious Case Reviews should be conducted in a way which:recognises the complex circumstances in which professionals work together tosafeguard children;seeks to understand precisely who did what and the underlying reasons that ledindividuals and organisations to act as they did;seeks to understand practice from the viewpoint of the individuals andorganisations involved at the time rather than using hindsight;is transparent about the way data is collected and analysed; andmakes use of relevant research and case evidence to inform the findings.LSCBs may use any learning model which is consistent with the principles within workingTogether (2015), including the systems methodology recommended by Professor Munro.For this review it has been agreed to conduct a systems methodology with a Lead Reviewer.The Lead Reviewer will also chair the Serious Case Review Panel. Following a commissioningprocess, the Lead Reviewer has been confirmed as Amy Weir (MA MBA CQSW).The agencies involved in a Serious Case Review should draw up Single Agency LearningReview Reports. These should be based on a comprehensive chronology of involvement by45 | P a g eFinal Draft 18/10/2016the organisation and/or professional(s) in contact with the children and family over theperiod of time set out in the review’s terms of reference.This chronology should clearly set out when the children were seen and, where ageappropriate, whether the wishes and feelings of individual children were sought. Theyshould briefly summarise decisions reached, the services offered and/or provided to thechildren) and family, and other action taken.The Individual Management Review should consider the events that occurred, the decisionsmade, and the actions taken or not taken. Where judgements were made, or actions takenindicate that practice or management could be improved. This information will be utilisedand considered at a practitioner learning event to get an understanding not only of whathappened but why something did or did not happen. The nature of supervision acrossagencies should be addressed alongside frontline practice.The historical information and the actions or inactions of agencies should be consideredalongside the findings, recommendations and actions taken in response to other relevantlearning reviews conducted by CBSCB. New recommendations should only be made wherethere are significant differences in the findings from this review. This should be made clearin the overview report.The commissioning and production of Single Agency Learning Review Reports must followthe CBSCB guidance with particular attention being given to SMARTER recommendationsand a comprehensive action plan. The Serious Case Review will identify good practice bothin the Single Agency Learning Review Reports and in the Overview Report.The Single Agency Learning Review Reports and Overview Report will be anonymised byauthors according to the anonymisation grid issued.Key lines of enquiryThe review will consider whether there was information which was known to agencies, orshould have been known, that should have identified that Bethany was at risk of harm. Allagencies should consider the historical information they hold and if there is significantlearning from this it should be appropriately referenced and brought into the review. Thefollowing key lines of enquiry have been identified by the Case Review Group as the focusfor the review:What relevant historical information prior to Bethany’s birth was known to theagencies about the background and experiences of Olivia and David? Was thisinformation effectively shared to ensure that appropriate decisions could be madeto ensure Bethany was protected from any known risks?What was the quality of the multi-agency information sharing, assessment, riskanalysis and decision-making in the reported injuries to Bethany in December 2013?46 | P a g eFinal Draft 18/10/2016Is there evidence that the procedures for injuries to pre- mobile babies werefollowed and was sufficient weight and consideration given to the possible risks toBethany remaining in her parent’s care?Did the professionals working with Bethany and her family have the requiredknowledge, skills and experience regarding the identification of and requiredresponse to possible child neglect, alcohol and substance misuse and domesticabuse? Were there any gaps in practice that may have impacted upon theoutcomes for Bethany?Was there sufficient focus and assessment of the likely impact of the parent’sreported substance and alcohol misuse on their capacity to parent Bethanyeffectively?Was the PAMS assessment commissioned by Central Bedfordshire Council,Children’s Service sufficiently thorough, did it consider all the risk issues and did itresult in appropriate recommendations?Is there evidence of robust assessment and analysis of parenting capacity; apparentlearning difficulties and ability to change that is based on known history as well as thecurrent case presentation?What was the quality and robustness of the multi-agency pre-birth assessment? Didthe decision to close the case accord with the risks identified?Did the assessment of parenting capacity consider sufficiently whether David couldassume the role of main carer for Bethany given his reported stronger emotionalattachment and ability to identify risks for Bethany?Was there professional over-optimism in her parents’ ability to parent Bethany andmeet all her daily living needs and to keep her safe?Was sufficient focus placed on the neglect that Bethany experienced and was thereany consideration of whether it met the threshold for a criminal investigation?How robust was the Child Protection Plan and what evidence is there of how well theagencies involved engaged with the Child Protection Plan? Did agencies believe theplan would keep Bethany safe? If not, is there any evidence of any agency providingeffective challenge and was the escalation procedure implemented appropriately?How effective was the core group in ensuring that the Child Protection plan, processand procedures were adhered to and that the plan provided clarity of expectation andthe timescales for action?Consider how the extended family’s view of family functioning was used in theassessments and risk analysis undertaken.47 | P a g eFinal Draft 18/10/2016Was practice sensitive to the racial, cultural, linguistic and religious identity and anyissues of disability of the child and family, and were they explored and recorded? (Thisshould address any broader aspects of "culture", i.e. housing, benefits, potentialpoverty, and the social and economic environment in which this family lived).Was there sufficient management accountability for decision making?Is there sufficient evidence of robust challenge where there was professionaldisagreement about the best course of action to ensure Bethany was safeguarded?Were all necessary actions taken in this regard? (This should specifically includecomment on the interface between Central Bedfordshire Council Legal Services,CAFCASS and the court in reference to the decision of the judge not to removeBethany from her parent’s care)Were the workers within agencies sufficiently alert to the potential for parents to‘disguise compliance’?Did the needs of Bethany remain paramount throughout the period?With hindsight what, if anything, could have been done differently and what impact, ifany, such action may or may not have had on the outcomes for Bethany?Time period over which events should be reviewedThe scope of this Serious Case Review is from 1st March 2013 to 11th April 2015.Agencies will need to consider the period from 1st March 2013 up to and including 11thApril 2015 the day of Bethany’s death. This time period has been chosen in consideration ofthe date when Olivia’s pregnancy was known to agencies up to an including the date ofBethany’s death.Single Agency Learning Review Reports should cover this time period as a minimum. Wherethere is additional involvement going back beyond these dates (e.g. within Olivia andDavid’s own childhoods) that is relevant to the review agencies should provide a summaryof their previous involvement within the Individual Management Review.Involvement of Family MembersBethany was living with her mother at their family home at the time of her death. BothOlivia and David’s extended family had significant contact with Bethany during her lifetime.At the current time CBSCB is awaiting further information regarding the family members’involvement in any police investigation and whether they can be approached.Should there be information and/or learning to be gained from the involvement orcontribution of Bethany’s family members this will be agreed between Alan Caton as theIndependent Chair and Amy Weir as the Independent Overview Author.48 | P a g eFinal Draft 18/10/2016Amy will facilitate the family contribution liaising with agencies as necessary. Anyrequirement to involve family members will be communicated to Individual ManagementReview authors as necessary who will agree a named lead to take responsibility forcoordinating the contacts with the family. The SCR Panel will keep this under review throughthe process and identify appropriate resources to facilitate the process.Bethany’s parents will be written to by Alan Caton as the Independent Chair to advise themof the Serious Case Review being commissioned and to request consent for access to theirrecords. Should their direct involvement not be appropriate due to parallel proceedingsthey will be contacted again and asked if they wish to contribute their views directly to theIndependent Overview Author or in some other way at an appropriate point in the review?Arrangements will be made to offer them feedback at the end of the Serious Case Reviewprocess. As described above, consideration will also be given to making contact with anyother significant members of the family such as Olivia and David’s extended family.Organisations to be involved in this SCRThe following organisations/services in Central Bedfordshire will be asked to submit SingleAgency Learning Review Reports and will be members of the Serious Case Review panel.Bedfordshire PoliceBedfordshire Clinical Commissioning GroupCAFCASSCentral Bedfordshire Council - Access and Inclusion ServiceCentral Bedfordshire Council - Adult Social CareCentral Bedfordshire Council - Children Social CareCentral Bedfordshire Council - Legal ServicesEast London Foundation TrustNHS EnglandSouth East Partnership University TrustA statement of information will be sought from:Bedford Hospital Foundation TrustCourts and Tribunals Judiciary - Family Court DivisionEast of England Ambulance Service49 | P a g eFinal Draft 18/10/2016Lister HospitalAt this stage it is not known whether there are any relevant interests outside the mainstatutory organisations such as voluntary or independent organisations. If the chronologyidentifies the involvement of such organisations the CBSCB Business Manager will link withinthem as necessary.It is anticipated that agencies will cooperate and fully engage in the process. In the unlikelyevent of a failure to cooperate with the review, this will be initially addressed by the CBSCBBusiness Manager and escalated to CBSCB Independent Chair with the relevant Boardmember or Chief Officer of the agency where necessary.Involvement of organisations in other LSCB areasThere is no known involvement of agencies in other LSCB areas at this stage. Where this isidentified it is the responsibility of the CBSCB Business Manager to bring this to theattention of the Serious Case Review Panel and Independent Chair.Legal AdviceThe use of legal advice will be kept under constant consideration throughout the process ofthe Review.Commissioning of an Independent Author and Panel ChairAn Independent Overview Author and Panel Chair have been appointed who has noprevious connection to the CBSCB, Case Review Group or any organisation that potentiallyshould have been involved in the case. Amy Weir is self-employed and has considerableexperience of working within the safeguarding arena, specifically with LSCBs and conductingSerious Case Reviews. She will draw together all the elements from the Single AgencyLearning Review Reports, offer engagement with the family members and analyseprofessional practice into the Overview Report and Recommendations to the CBSCB. Shewill also provide guidance to the Case Review Group, IMR authors and commissioners onquality assurance of the IMR’s.The Overview Author should follow the guidance within the CBSCB SCR Toolkit using thestandard CBSCB template. Should the Board regard the report to be of poor quality or fail toratify the final report there will be an agreed independent mediation process to resolve theissues. This will ensure that the final report meets the standards required by the CBSCB andalso addresses the pertinent learning.Expert OpinionDue to the issue of adult learning difficulties the use of expert opinion in a consultativecapacity around this issue will be considered throughout the process of the Review.50 | P a g eFinal Draft 18/10/2016Other Parallel ReviewsParallel reviews are as follows:CDOPThe case will be reviewed by the CBSCB Child Death Overview Panel in accordance withChapter 5 of Working Together 2015.Coroner's InquiriesPolice are currently liaising with the Coroner’s Office in relation to their inquiry and at thisstage there are no other known investigations. The timescales for the Coroner’s inquiry arenot yet known but any implications arising from the inquiry will be communicated to theCBSCB Business Office by Central Bedfordshire Police’s nominated representative who willliaise with the Coroner’s office to ensure that relevant information can be shared withoutincurring significant delay in the review process. Where delay is likely the Coroner will beasked for advice on how to address this within the Serious Case Review process.Criminal InvestigationsBedfordshire Police are conducting an investigation into the circumstances of Bethany’sdeath and this is being handled by the Major Crimes Unit. Olivia was recently charged withthe neglect of Bethany and is currently held on remand. The Head of Public Protection willkeep the CBSCB Business Manager informed of any developments and any possible conflictsof interests in relation to this Serious Case Review. The Serious Case Review Panel will havedue regard to the national guidance “Liaison and information exchange when criminalproceedings coincide with Chapter Four Serious Case Reviews or Welsh Child PracticeReviews - A Guide for the Police, Crown Prosecution Service and Local Safeguarding ChildrenBoards”Media coverage/enquiriesThere has been some media interest in this case and statements have been issued byBedfordshire Police. This will be kept under review to ensure that any public, family andmedia interest is appropriately managed before, during and after the review. It has beenagreed within the communications plan that Bethany and other family members will not beidentified. The Serious Case Review Panel is also to give consideration into how Olivia andDavid and other family members will be informed of the findings of the SCR. This will be inliaison with the Chair of the LSCB and Core Business and Improvement Group who willdevelop and implement a media strategy.SCR Timescales51 | P a g eFinal Draft 18/10/2016A timetable has been scheduled according to the attached timeline with dates for thesubmission of the Single Agency Learning Review Reports, Panel meetings, the presentationof the Overview Report to the CBSCB; and the submission of papers to Ofsted is targeted for15 October 2015.Liaison with Ofsted, Department of Education and the National Panel will be by the CBSCBBusiness Manager who will update them on progress with the SCR and liaise where thereare any requests for extensions required (e.g. due to criminal proceedings).52 | P a g eFinal Draft 18/10/2016Appendix C - List of ReferencesBrandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, JaneDodsworth and Jane Black - Analysing child deaths and serious injury through abuse andneglect: what can we learn? A biennial analysis of serious case reviews 2003-2005Brandon M, Sue Bailey and Pippa Belderson - Building on the learning from serious casereviews: A two-year analysis of child protection database notifications 2007-2009; DFE 2010Brandon M, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis &Matthew Megson - University of East Anglia & University of Warwick – July 12: New learningfrom serious case reviews: a two year report for 2009-2011Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children – 2013Department for Education - Safeguarding Children in whom illness is fabricated or induced -2008DH 2011 Health Visitor Implementation Plan: A Call to ActionDH Healthy Child Programme 2009Islington Area Child Protection Committee (1995) – Independent review by The Bridge of thedeath of Baby PaulNSPCC 2011 - All Babies CountOfsted 2014 – In the child’s time: Professional responses to neglectOfsted 2015 CIN assessments thematicPAMS Parenting Assessment Manual Software Sue McGaw – need a footnote for this.Revised Ed 2014 first published 1998. Assesses parenting basic skills.Can Parents with LD parent? 1. Purposeful abuse infrequent by parents (Booths, 2005;Whitman 1994)2. Neglect -omission not commission (Booths, 2005; Tymchuk& Andron,1990)3. Parental Risk Factors: Cognitive functioning & ability to learn(Tymchuk, 1992;Feldman, 1997)