Death of a 4-week-old infant boy in May 2020. Learning includes: cases of children who have been the subject of a supervision order, should remain open on a multiagency child in need plan for a minimum of 3 months, to ensure they can be stepped down safely; for children in transition, the next school or nursery should be invited to a child protection conference, even if they have not yet started; all reports submitted to a child protection conference should be formally considered, openly shared, and commented upon during the conferences; issues of non-engagement and self-reporting should be actively addressed during child protection conferences; the summary and outcome of pre-birth assessments should be shared with all agencies that have contributed to the process; escalation procedures should be easy to use; child in need plans are invariably multiagency, and all partners need to be aware of their importance in safeguarding children; extended family or kinship to be included in child in need planning to explore sources of safety and risk when they have been integral to a child protection plan; it is important to ensure practitioners can recognise disguised compliance and are supported to work with resistance; police attending any incident at homes where domestic abuse has been a feature should interview the parties separately; the safeguarding children partnership should review the child protection categories used for children exposed to domestic abuse; the use of neglect as a category can be misleading for professionals. Recommendations form part of the learning.
      
 Title:  Local child safeguarding practice review (West Berkshire): ‘Bobby’. LSCB: Berkshire West Safeguarding Children Partnership Author: Maureen Floyd Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1                    Berkshire West Safeguarding Children Partnership (BWSCP)   Local Child Safeguarding Practice Review (West Berkshire)   ‘Bobby’            Maureen Floyd, Review Author      2   1. Introduction  This Child Safeguarding Practice Review (CSPR) was commissioned by Berkshire West Safeguarding Children Partnership (BWSCP) following the death of 4-week-old Bobby whilst in the care of his parents in May 2020. Bobby lived with his 4-year-old brother Alfie and their parents. Previously, Alfie had been subject to child protection plans and care proceedings in relation to domestic abuse perpetrated by his father. The family’s case had been closed to Children’s Social Care (CSC) for six months when Bobby died.  On 9th June 2020, BWSCP decided that these events met the Working Together 2018 criteria for a local Child Safeguarding Practice Review (CSPR). This decision was agreed by the Child Safeguarding Practice Review Panel.   2. Review Process  2.1 - CSPR Panel A panel was appointed to work with the lead reviewers during the review process. The panel was comprised of the following representatives: • Head of Safeguarding Children, Berkshire West Clinical Commissioning Group (CCG) Chair • Independent Reviewers, Bridget Griffin & Maureen Floyd. • Head of Children and Family Services, West Berkshire Council • Service Manager, Children and Family Services, West Berkshire Council • Emergency Duty Service, Children & Families Service, West Berkshire Council • Detective Chief Inspector, Thames Valley Police • Head of Safeguarding, Berkshire Healthcare NHS Foundation Trust • Deputy Headteacher and Designated Safeguarding Lead, Primary School • Associate Chief Nurse Safeguarding, Mental Health & LD and Designated Professional for Child Death, Royal Berkshire NHS Foundation Trust • Named Midwife, Royal Berkshire NHS Foundation Trust • Partnership Coordinator, Berkshire West Safeguarding Children Partnership  • Strategic Partnership Manager, Berkshire West Safeguarding Children Partnership  2.2 - Independent Reviewers Bridget Griffin has extensive experience as an author of Serious Case Reviews and more latterly, author of CSPRs. Bridget recently undertook a thematic review in Norfolk relating to 6 children who died from or sustained serious, non-accidental injuries. Bridget and Maureen were co-authors of the Croydon Safeguarding Children Board Vulnerable Adolescent Review, a thematic review looking at the lives of 60 Vulnerable Adolescents.   Maureen Floyd has extensive experience of statutory safeguarding work within Children’s Social Care, from Social Worker to Head of Service, with a consistent specialism in child protection. Maureen is an experienced project manager of Serious Case Reviews, Learning Reviews and Safeguarding Practice Reviews and has been the lead author with supervision provided by Bridget.   2.3 - Methodology  A comprehensive Rapid Review meeting provided the CSPR panel with extensive background information and identified initial learning. The agreed methodology for this CSPR was outlined as follows: 3   • Chronologies  Agencies were asked to provide background information of their engagement and knowledge of the family with detailed Chronologies of involvement between September 2019 to May 2020   • Key Lines of Enquiry (KLOE) The Terms of Reference noted the KLOEs as: 1. How do we work together as a multi-agency safeguarding team across threshold models, approaches, procedures, and processes to safeguarding children?  a) Child in Need – How did the CiN Plan get to the point of being closed without a multiagency decision and why was this not challenged.  b) How do we facilitate a culture of respectful challenge? c) Pre-birth assessment  d) Vulnerable Women’s Midwifery Team   2. Decision making and risk assessment in cases of long-term Domestic Abuse. a) Dynamic risk assessment  3. What have we learnt from previous reviews and how has this changed the way we work?  4. How did Covid-19 effect the way that agencies were able to safeguard?  a) Difficulties in safeguarding children virtually  • Emerging Themes The report has also sought to examine the systemic issues, which for the purpose of illustration is shown at Appendix One. Analysis of the information from the composite chronology and agency KLOE documents were used to formulate emerging themes which were shared and agreed by the CSPR panel.  • Engagement with Practitioners The practitioner learning event enabled staff who had worked directly with the children and their family to gain an overview of ‘Bobby and Alfie’s Story’;  to explore the emerging themes and discuss their experience, views, and perspectives.  They were able to contribute to the recommendations and advise of positive changes in practice since.   A range of views and reactions emerged, which are considered within this report.  • Engagement with Family The boys’ father has recently been charged with murder and inflicting grievous bodily harm with intent. The boys’ mother has also been charged with causing or allowing the death of a child, and assault, ill-treatment or neglect. The panel have taken the view that neither parent should be approached for their views whilst the matter is sub-judice.    The BWSCP intend to share the report with relevant family members for comment before publication.   • Overview report A final draft of this report was agreed by CSPR Panel before being finalised and presented to the Berkshire West Case Review Group for approval. Final sign-off was given by the Executive of the Berkshire West Safeguarding Children Partnership.   4  3. Impact of domestic abuse on children  The Panel were aware of the importance within the review of considering the child’s lived experience. It was decided that this would be extremely sensitive, and the preferred approach was to consider the implications for all children exposed to domestic abuse.  The Children Act 1989 Section 311 is the legislation which allows local authorities to ask a court to make a child the subject of a care or supervision order. Such an order can only be made by a court if a child has suffered or is likely to suffer significant harm.   Section 31(9) gives definitions of ‘harm’; this was updated in 2002 by the Adoption and Children Act (section 120) to include what was recognised as the very real impact of domestic abuse on children.  “harm” means ill-treatment or the impairment of health or development, including, for example, impairment suffered from seeing or hearing the ill-treatment of another.   UNICEF in their 2006 Behind Closed Doors report2 note the impact of domestic abuse on children. Their Key Findings include:  • Children who live with and are aware of violence in the home face many challenges and risks that can last throughout their lives. • There is increased risk of children becoming victims of abuse themselves. • There is significant risk of ever-increasing harm to the child’s physical, emotional and social development. • There is a strong likelihood that this will become a continuing cycle of violence for the next generation.  These two examples acknowledge the long-standing awareness and understanding of the significant and detrimental impact of domestic abuse on children.    Barnardo’s 2020 report: Not just Collateral Damage.3 The hidden impact of domestic abuse on children noted:  Domestic abuse can have a severe impact on child development, particularly for very young children who are exposed to violence. Research suggests the impact on neurological development can manifest itself in poor health, poor sleeping habits, excessive screaming, and result in disrupted attachment.    4. Alfie & Bobby’s Story  All family members are White British and have lived predominantly within Berkshire. Father has a long history of juvenile offences, for drug use, violence, criminal damage, and public order offences. He struggled to control his anger and was known for concerns about his mental health, both depression and self-harm.  Concerns were also raised about mother’s depression.  She had twice taken an overdose which required hospitalisation, aged 15 and 17 and had taken medication and used counselling services to seek support with her emotional wellbeing.   1 https://www.legislation.gov.uk/ukpga/1989/41/section/31 2 200154_SVITH_report5.qxd (unicef.org) 3 https://www.barnardos.org.uk/Not just collateral damageReport_0.pdf  5   Mother was 19 when Alfie was born, and father was 22. The first recorded violent incident towards mother, perpetrated by father, was when Alfie was 3 months old.  When Alfie was 6 months, his father was imprisoned for injuring Alfie and his mother. Mother made it clear that she and father were intending to reunite when father was due to be released, so Alfie was made subject to a Child Protection Plan for neglect, from June 2016 to May 2017 and care proceedings were initiated.  Both parents underwent parenting assessments, and it was agreed that father would not be allowed to be a primary care giver to his son. In May 2017, the court made a six-month Supervision Order on the basis that Alfie lived solely with his mother, and as a result the Child Protection Plan ceased.     The multiagency partnership was aware of the danger towards mother and Alfie in this relationship, and that risks escalated when father used alcohol.  The combination of father living apart from them, with contact taking place supervised at paternal grandmother’s home, was the status quo judged to keep Alfie safe.   In November 2017, Children’s Social Care ceased their involvement within days of the Supervision Order expiring.  Case analysis The criteria for a Court to make either a Care or Supervision Order, is the same; the child must have suffered or be likely to suffer significant harm. The granting of a Supervision Order requires the Local Authority to work with the family, ‘to advise, assist and befriend the supervised children’.  Section 35 Children Act 1989  Care proceedings is the highest level of concern that a local authority can demonstrate about the care of a child. Alfie was on a Child Protection Plan, but the local authority regarded that a more serious level of intervention was required.  However, once the Supervision Order expired, the case was closed. It is not clear why this happened.   At the subsequent CP Conference, the Chair questioned why the case had closed when the plan had not been achieved. What had father achieved in addressing his anger management, alcohol, and drug use. What did both parents now know and understand of the impact of domestic abuse on children?   Father had not undertaken the required Building Better Relationships Course via Probation linked to his conviction.  Mother had not attended the associated course for partners. Both cited not liking group work. Alfie’s case had not been presented to either of the borough’s domestic abuse panels, Multiagency Risk Assessment Conference (MARAC) and Domestic Abuse Repeat Incidents Meeting (DARIM). The explanation for this was that it was judged to be a case of medium risk and therefore did not meet the threshold for either of these specialist Domestic Abuse meetings. (See Finding 15)  Finding 1 Cases of children who have been the subject of a Supervision Order, should remain open on a multiagency Child in Need Plan for a minimum of 3 months, to ensure they can be stepped down safely.   2018 In December 2018, Police received a dropped call from mother at the family home. It was understood that father was in bed, intoxicated, and became irate with 3-year-old Alfie who had disturbed him.  Father took mother’s phone, and she fled the home with Alfie. Despite his intoxication, father had already driven away when Police arrived. Mother denied that they were a 6  couple or that father was living at the property. Concerns were immediately raised for Alfie’s safety and child protection enquires initiated. Later in December 2018 Alfie was made subject to a CP Plan for neglect.   The social worker (SW) told the CP conference:  ‘the family had been through the Court process, and it was made clear should they be together, and alcohol was involved, then the risk was massive. They were aware of the risk but still placed themselves in that position.’4  Father and paternal grandmother both advised conference that the parents’ relationship was ‘toxic’, and they were not intending to be together.  Conference heard that Alfie’s behaviour had deteriorated at nursery of late, he had been swearing and had to be kept apart from other children when playing with sand as he was prone to throwing it in their eyes.   The pattern of CP conferences and CP Plans were reinstated; father was not permitted to live at the home and contact with Alfie took place at the paternal grandmother’s home.  The focus of the CP Plan was to educate the parents about the impact of domestic abuse on Alfie, explore their respective mental health issues, father’s drug, and alcohol use, and a requirement that they keep to these specific requirements to ensure that Alfie was safe and well.  Case analysis This was good practice, the response to safeguard Alfie was swift and decisive. Mother’s suggestion that they were not in a relationship was disregarded as father was at her home, in her bed, intoxicated and Alfie was in danger. She had removed Alfie from that danger and attempted to seek Police help. It was good practice that the Police responded to her dropped call and were able to ensure that mother and child were safe.    2019 The review CP conference in March 2019 heard there had not been any reports of domestic abuse or violent incidents.  There was some improvement in Alfie’s behaviour at nursery, and a health visitor developmental review had judged him to be reaching his developmental milestones. Although his score on the social and emotional questionnaire was borderline; it was decided to wait and see how he progressed before making a referral to the child development clinic. The aim being to identify if the behaviours were more environmental than organic.    Mother and father were each offered direct support in relation to Domestic Abuse and Mental Health.  Father acknowledged that he was taking antidepressants, conference heard he had sought support with low mood and a referral had been made to the mental health team which he had not taken up.  Father advised that he had been seeing a private hypnotherapist but could not continue when he lost his job.  The Chair stressed that Alfie was unsafe when the parents were together, and he was better when they were separated. If they resumed their relationship, it should be away from Alfie and the social worker should be notified, as their relationship was harmful to Alfie.   It was noted that father’s alcohol and cannabis use fluctuated. Father said he did not see it as an issue; because he ‘never drank around ‘Alfie’ and just used cannabis as a social thing. ‘However, Alfie was on a CP plan because of his father’s behaviour towards him and his mother in December when he was intoxicated.     4 CSC Initial Child Protection Notes 20 December 2018.   7  Case analysis This was good practice.  The conference recognised all the areas that the parents needed to engage with and did not lose sight of Alfie’s needs. There was acknowledgement that there had been some progress, i.e., that parents were engaging with the CP Plan. Paternal Grandmother was present and was vocal about the ‘toxicity’ of the parent’s relationship and inherent risk to Alfie.     At the end of July father went to a bridge with the intention of jumping off and ending his life. He was stopped by a passer-by and an urgent referral was made to the Mental Health Crisis Recovery Home Treatment Team (CRHTT). Eleven contacts were offered by the team, and he engaged with six including a medical and psychological review, he was discharged in mid-August. Father agreed to a referral to Talking Therapies although he never engaged.  He was taking antidepressants prescribed by his GP.   In early August father told the Domestic Abuse worker of his suicide attempt.  ‘he is generally okay but that things had not been good and as a result of his low mood and wanting this feeling to end, he took himself to a bridge to end his life’.  A few weeks later the review CP conference made no mention of this mental health crisis. Agency reports were submitted to conference although not all the agency representatives were able to attend. The Police report was referred to in that there was no new information.   The GP report on father cited the potential suicide attempt as an issue and a risk: • Talked down from bridge – planning suicide.  • Depression/suicide risk, depressed mood for 3 to 4 weeks, and had failed to attend his appointment in mid-August.   The only reference that was made to the GP report during conference was that it referred to father but did not provide information on Alfie, despite the GP noting the identified risk factors being specifically related to Alfie.  The CRHTT, who provided a crisis mental health response to father following his intended suicide, were neither invited to the CP conference nor asked to provide a report. The SW conference report noted a contact with a CPN (Community Psychiatric Nurse) in early August when father was being seen by CRHTT, but their view or a summary of the information or intervention was not recorded.    The SW report noted: Although father’s mental health has been generally stable, there was an incident on 27/07/2019 when he went to a bridge, according to him and on reflection, more of seeking attention than actually attempting to jump.  A copy of the assessment undertaken by the mental health service was requested  but has not been shared. This matter is addressed later in the report.  A summary has since been provided.   The Pan Berkshire Child Safeguarding procedure states:  It is essential that staff working in adult mental health services and Children's social care work together collaboratively to ensure the safety of the child and management of the adult's mental health.5  5 https://proceduresonline.com/berks/west_berk/p_ch_par_mental_health.html  8   A mental health report was provided to conference which related to the work undertaken with mother, noting mother’s anxiety and issues of self-confidence and self-esteem, particularly in relation to parenting Alfie when he displayed challenging behaviour. Since July, Mother had disengaged and Alfie had not attended Nursery, Alfie had started at school on the day of the conference. Also, it was reported that mother had disengaged from domestic abuse services and her case had been closed.  The health visitor acknowledged there had been little contact since the last conference in March 2019. All planned appointments had been missed by mother. Alfie’s audiology and asthma appointments had not been achieved despite requests and the HV had only seen Alfie in communal areas on two occasions.    Father was closed to Talking Therapies and had attended less than half of the planned meetings with the domestic abuse worker, who advised there was more work to be done. Father said, ‘It was sometimes hard to get up and out of the house’.  Father was supported by a Recovery Worker to address his drug and alcohol use. Although unable to attend conference, their report was submitted, but not referred to during the meeting.   The report advised that father had numerous DNA’s and rearranged appointments. The recovery worker advised that father had not been seen since early August and should he miss his next appointment his file would be closed for non-engagement. The noted risks to Alfie related to father’s risk of relapse and his mental wellbeing.    The report was reliant upon father’s self-reporting; there was no mention of drug or alcohol testing, the recovery worker noted that father said his cannabis, alcohol and cocaine use had all been reduced.  This was the first mention of father using cocaine, as the report was not examined, it passed without comment.   Father told conference that his cannabis use was under control, he had reduced it from daily to monthly because he realised it was making him paranoid. If true, that was a remarkable achievement, but it was not commented upon.   Both parents acknowledged they were drinking and gave conference details of their usual daily or weekly consumption. It is recognised that alcohol use is invariably under-reported, but from their description, each would have been drinking more than the respective weekly UK guidelines. As the Recovery Worker was not present, nor their report scrutinised it is difficult to judge whether there was a contrary view to any of this self-reported information.    Each parent said they wished to gain support but had made only limited use of the support provided.  Father said he needed help with his anxiety, ‘but there was a block in him accessing support.’ This was not explored.   Both parents assured conference they were not in a relationship, did not want to be in one and that they recognised living separately was a protective factor for Alfie. It was noted that again there were no reports of domestic abuse.    9  The CP conference attendees unanimously agreed that a CP plan was no longer required to keep Alfie safe6 and that he could be made subject to a child in need plan (CiN).7 There appeared very genuine understanding from conference members that the parents would cooperate with a CIN plan.   The following were noted by Conference:  What we are worried about: • If parents were to get back together and/or live together • If parents do not follow up support, which they have identified they need.   Case analysis  Finding 2 For children in transition, the next school or nursery should be invited to a child protection conference, even if they have not yet started. A practitioner at the Learning Event advised this had been tried and this had a positive effect.   It is important to gain an understanding of why the conference made the decision it did, when the factual information demonstrated that not only was the parents’ recent engagement and cooperation with agencies much less than at the March conference, but also father had experienced a significant mental health crisis of which there was no formal information or opinion.  This was not referred to by any professionals during the meeting, which was an important omission.   The conference began with an update from the Chair, recounting their meeting with the parents where they listed what had gone well since the last conference on the whiteboard, which was in the room for attendees to see.  The parents identified lots of strengths and acknowledged that they were not, nor should they be in a relationship. This is likely to have influenced the tone of the meeting.   The omission of vital aspects in the information is likely to have had a bearing upon decision making and in the absence of this information, parental positive self-reporting was not challenged against the facts given within the reports.  Reassurance would have also been taken from no reports of domestic abuse.   The conclusion of conference members was that the parents would cooperate with a CIN plan, which would continue to seek to address all the concerns raised. For those reasons attendees would have felt reassured that Alfie was going to continue to be subject to regular oversight and that the steer from all parties was in that supportive direction with the agreement of the parents.   The Annual Review of LCSPRs and rapid reviews8 published in March 2021 found: At child protection conferences an incomplete or inadequate assessment could undermine the plans for subsequent protection and support. In these cases, child protection or child in need plans often continued ineffectually without progress being made or, more worryingly, cases could be closed and ‘stepped down’ specifically because of a lack of progress.    6 September Review CP Conference minutes dated 4 September 2019. 7  Section 17 the Children Act 1989 1) It shall be the general duty of every local authority  (a)to safeguard and promote the welfare of children within their area who are in need; and (b)so far as is consistent with that duty, to promote the upbringing of such children by their families, by providing a range and level of services appropriate to those children’s needs. 8 Annual review of LCSPRs and rapid reviews (publishing.service.gov.uk) 10  The fact that a decision has been made to end a child protection plan does not necessarily mean that all risks to the child have ceased and this may also apply when the case moves out of children’s social care into early help or universal service.   Finding 3:  All reports submitted to a CP conference should be formally considered, openly shared, and commented upon during Child Protection Conferences.   Finding 4:  Issues of non-engagement and self-reporting should be actively addressed during Child Protection Conferences.  CSC did not ask Mental Health services for a report for conference; therefore, Mental Health services cannot be criticised for not supplying it. No evidence has been provided to suggest this was a one-off isolated incident, therefore, it is vitally important that the BWSCP gain an understanding as to whether this is a systemic issue. As per the local guidelines, this is a basic expectation and is compliant with BWSCP procedures for both services to work collaboratively to ensure children’s safety.  Finding 5:  The BWSCP should conduct a review of how Mental Health services are engaged in CP conferences including the requests made, and the provision of mental health reports to CP Case Conferences when the parent and/or carer is known to Mental Health services.   However, the lack of a report to this Safeguarding Practice Review is an unacceptable anomaly for the SPR Panel.  The Safeguarding Children Partnership is comprised of three equal partners, the Local Authority, the CCG, and the Police.  Each have responsibility to ensure children are safeguarded in their area. Full disclosure of the information is a requirement and there are no grounds for noncompliance.  Finding 6:  Attempts to be made by BWSCP to clarify with Mental Health services the evident confusion about the requirement to disclose information to a CSP Review. If the matter remains unresolved, this should be escalated to the Partnership Executive. 9   Practitioners at the Learning Event discussed the challenge of the conference voting system as colleagues may not feel confident to express their views, and how staff were trained or prepared for attending CP case conferences, especially those for whom it was an irregular occurrence.   It was reiterated that it is the responsibility of the chair to ensure all views are heard and shared. Additionally, that agencies support their staff to attend, invariably when they ask for support. Although some staff, may not be aware of quite how daunting a CP conference can seem until they have attended. Multiagency training in mock conferences, shadowing colleagues, being supported by a manager, are some examples of how staff can be prepared. It appeared those opportunities would be welcomed.   9Response from Berkshire Healthcare NHS Foundation Trust: Having taken advice from the Trust information governance lead, Berkshire Healthcare NHS Foundation Trust have a duty of confidence to all of our patients and their records, as well as having legal obligations to the personal information held under the UK General Data Protection Regulation (UKGDPR) and Data Protection Act 2018 (DPA18). In order to share information with others there must be a clear and legitimate necessity for this and the information shared must be relevant to the purpose it is being shared for. It is not standard practice for the Trust to share full patient records of third parties for the purpose of practice reviews. The Trust instead, as it has done in this case, provides a summary of relevant information where we hold it. In this case the Trust could not identify a need to work outside of usual information sharing practice and could not see a legal basis for sharing the full health records of a third party.       This response has been accepted by the local CSPR Panel. 11   Finding 7:  BWSCP should gauge if there is an appetite across the partnership for multiagency case conference training. This could be considered as mandatory training for some agencies.    Ten days after the conference decided to end the CP Plan, mother attended for a 12-week maternity booking as the couple were expecting their second child. As a result of the history, the midwife made referrals to the Vulnerable Women’s Team10, the SHaRON service11 and alerted Children’s Social Care. CSC commenced a pre-birth assessment.  Case analysis This was good practice, the midwife gained good oversight of the circumstances and made appropriate referrals.  The speedy response by CSC to conduct a pre-birth assessment was also good practice.   The information that the parents were expecting their second child completely undermined their assertion they were not in a relationship.   Decision making thereafter should have continued on the basis that they were in a relationship. Reconvening the CP conference was an option that should have been considered.    The Berkshire West Safeguarding Children Partnership Procedures Manual notes review conferences should be brought forward when:  There is a significant change in the circumstances of the child or family not anticipated at the previous conference and with implications for the safety of the child.  Although Alfie was no longer subject to a CP Plan, that did not preclude re-consideration of his circumstances. Conferences had repeatedly referred to the increased risk to him if the parents resumed their relationship. There was a significant change which required formal examination. There was no evidence to suggest the parents were not in a relationship.  Finding 8: The CP Procedures should specify that if there is a significant change within 3 months of the conference that removes a child’s name from a CP plan then a multiagency strategy meeting should be convened, to determine whether a s47 enquiry is necessary to enable the local authority to decide whether it should take any action to safeguard and promote the welfare of the child, for example, a CP conference should be held12.      The first multiagency Child in Need (CIN) meeting was held in October as would be expected, although parents did not attend. Despite all their assertions at the CP conference neither parent had engaged with the CIN plan nor completed any of the required actions and were expecting another child together. The conference had raised these two points, not engaging with support, and resumed relationship as the risk factors for Alfie.   Father had not engaged with the domestic abuse, mental health, or the recovery workers and mother had not engaged with the domestic abuse worker, adult mental health worker or talking  10 A team of midwives who provide maternity care to women identified with complex social factors across Berkshire west with the aim of ensuring these women receive women centred, specialised care that is individually tailored to their needs. 11 SHaRON is a peer support-based e-health system, available via a mobile phone app and associated website. 12  Child Protection Conferences (proceduresonline.com) 12  therapies. Mother did continue to attend the Family Hub to attend the Boost13 course with Alfie being in the crèche.  The SW reported it was difficult to complete visits to see Alfie at home, these were required by the CIN plan and in conducting the pre-birth assessment. Actions for mother to ensure that Alfie had an asthma check, and an audiology appointment remained incomplete. Alfie’s school attendance had reduced to 87.7%.   There was recognition by most agencies that the parents were spending a lot of time together, which was confirmed by paternal grandmother. On one SW home visit, father was present having just had a shower.  Despite their continued assertions to the contrary, evidence pointed to them being in a relationship. The CIN plan continued and a further CIN meeting was planned for seven weeks later in mid-December.  The SW continued with the pre-birth assessment, albeit with considerable difficulty, mother   accepted only two of the required five assessment visits.  Father did not take part, despite repeated requests. The SW finally spoke to him on the phone in late November when he was in the car outside school waiting for mother who was collecting Alfie.   He told the SW:  “there had not been domestic incidents since the last reported one and added that all this had 'been dragged out' if he were to be honest. He said that he currently did not want social services involvement which he said was stressing him and (the mother) who was worried about what was going to happen with the baby.”14  The views of six agencies were sought in completing the pre-birth assessment. Apart from midwifery none were able to report any engagement with the parents. A significant number of concerns were reported, these included the increased risks of domestic abuse associated with pregnancy, anxiety that the parents were back in a relationship, parental disengagement with services and school noted unexplained absences for Alfie, whose attendance was just six weeks into the school term recognised as low.     Mother, who had previously been attending the Family Hub on a regular basis (daily when Alfie was in nursery), had not been seen and she had stopped attending the Boost course, despite previous good attendance, which ‘was not like her’.  Case Analysis  This was an important reflection by the Family Hub.  They had worked more than a year with mother who had been a regular user (often daily) of their resource. For mother to stop all engagement was highly unusual and should have been followed up. Had she offered any explanation? Had her views been sought?  But this issue was not explored within the meeting.  She was pregnant with their second child, father voiced his unwillingness to work with CSC and she maintained the clearly false position that they were not in a relationship. This was important information and the possibility that she may be a victim of coercive control should have been considered.    Domestic Abuse can typically involve coercive control that traps a victim in the cycle of abuse and in silence; this needed to be considered as the dangers for children in these households are significant.   13 The Boost course is specifically targeted to empower women to address confidence and self-esteem.  14 Pre-birth assessment dated Nov 2019. 13   Women’s Aid define coercive control as:  Domestic abuse isn’t always physical. Coercive control is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.  This controlling behaviour is designed to make a person dependent by isolating them from support, exploiting them, depriving them of independence and regulating their everyday behaviour. 15   Despite these agency misgivings, in late November 2019 Children’s Social Care concluded their pre-birth assessment with the decision that their involvement could cease.   The reasoning given was that:  ‘there have been no further incidents of domestic violence since December 2018, father has completed work with the domestic violence Adult Worker, and both parents say that they do not want the ongoing support of Children's Services.’  It is important to note the domestic violence work was not complete.   Case analysis The BWSCP procedures note that a pre-birth child protection conference should be held where:   • An adult or child who is a risk to children resides in the household or is known to be a regular visitor.  Other risk factors to be considered are: • The impact of parental risk factors such as mental ill health, learning disabilities, substance misuse and domestic violence.  In seeking to reconcile why practice was so different from these requirements and the recommendation was closure, it is important to consider the circumstances.  The family were resisting engaging and were actively challenging when they did engage. Father had reiterated that no incidences had happened recently, and that CSC were themselves a source of stress to the family.   In the summary of the pre-birth assessment the December 2018 domestic abuse incident which prompted the CP response was recorded as ‘verbal only’. This is a factually correct quote from the police report, in that no-one was physically hurt, however it minimised the impact on Alfie and his mother and the seriousness of the risk to him as set out in the two previous Child Protection conferences. The incident when father sought to jump from a bridge was noted as ‘more of seeking attention than actually attempting to jump.’   There was no information from Mental Health services to support this interpretation, it was also contrary to the information provided by the DA worker.  This perspective was reliant only on father’s self-reporting and suggested the risk posed by father’s mental health difficulties and potential of suicidal intent was minimised.    Lord Laming in the Victoria Climbie Inquiry stressed the need for SWs not to passively accept information they are given by their clients, and they should keep an open mind: ‘respectful  15 The Victoria Climbie© Inquiry (publishing.service.gov.uk) page 205  14  uncertainty should lie at the heart of the relationship between the social worker and the family. It does not require social workers constantly to interrogate their clients, but it does involve the critical evaluation of information that they are given. People who abuse their children are unlikely to inform social workers of the fact’. 15  Social workers need to be supported to question, validate, and challenge what is being presented to them. Management and supervision should help facilitate reflection and give guidance and advice in critically examining information.    At the Learning Event practitioners advised that:  ‘Copies of pre-birth assessment are not shared with them routinely, only the outcome. Midwives noted they can go back and ask for a copy if they have concerns, but the family need to give their consent.’  No evidence has been provided to suggest any agencies were informed of the Pre-birth assessment outcome.  Case analysis Positive emphasis was made of previous engagement, but the recent disengagement of parents was not analysed as presenting a risk to Alfie. Father told the SW they did not want to work with CSC, and mother repeated the same comments when she was in the car with father shortly afterwards.  It is not known if these were her views, or she was prompted to make them.   The pre-birth assessment should have been shared with agencies who contributed to it.  By not having sight of it, agencies were not aware of assumptions and decisions and their opportunity to provide informed challenge was diminished.   Eileen Munro’s article on Common errors of reasoning in child protection work: 16  ‘It was found that professionals-based assessments of risk on a narrow range of evidence. It was biased towards the information readily available to them, overlooking significant data known to other professionals…A critical attitude to evidence was found to correlate with whether or not the new information supported the existing view of the family. A major problem was that professionals were slow to revise their judgements despite a mounting body of evidence against them. 17’  Finding 9:  The summary and outcome of pre-birth assessments should be shared with all agencies that have contributed to the process.    Case analysis When the CP conference stepped the case down to CIN, there were clear requirements that were included within the CIN plan to ensure Alfie’s safety and promote his welfare. Within 2 months the plan had not been complied with and parents were expecting their second child together and it was evident that they were in a relationship.  There was a considerable change in the parents’ engagement with agencies, what had formerly been limited, following the step down to CIN, became completely resisted.    16 http://eprints.lse.ac.uk/358/1/Common_errors_of_reasoning_1999.pdf  17 Children and Family Services, West Berkshire Council. Closure letter dated 4 Dec 2019.  15  They were no longer willing to work with CSC, were not engaging with any other agencies that were seeking to support them address the identified concerns. This was an important issue that needed to be explored and reflected upon, and strategies employed to address the disengagement.  It appears this acceptance was wholly related to the parents’ consent, i.e., the parents chose not to cooperate, therefore because it was CIN it was judged that nothing could be done.    Consent is an important issue but must not be confused. The Duty to Investigate under section 47 of the Children Act 1989 enables the LA to make enquiries of partners about the welfare of a child, about whom there are concerns, without requiring parental consent. Any CP conference and plans are entirely similar to CIN, in that parents can decide to work together with the LA and their partners, or indeed not.    The LA must consider what action it may propose should a family not engage, in either circumstance.  CIN does not suddenly become a threshold through which parents can opt out because it is ‘consent based’. All engagement with the LA is by nature ‘consent based’ and, is through negotiation between both parties. The skill is to ensure parents engage with the LA to improve safeguarding for their child. Local authorities (LAs) have the option to commence the Public Law Outline, (alert the parents that the LA will be seeking the intervention of the Courts). Family Group Conferences can be helpful in ensuing wider family support to address ongoing issues and contribution towards safety planning. If efforts to engage the family with a CIN plan are unsuccessful, then the concerns need to be reviewed collectively by the multiagency team and considered if it is safe to instigate a Team Around the Child (TAC) approach, which may involve universal services, charities, and the voluntary sector.  This is not a free pass for LAs to absolve themselves of engaging with CIN cases, rather the opposite; for LAs to develop their workforce to build skills and recognise disguised compliance. The safeguarding workforce require support to work with resistance and, in cases where resistance is an enduring feature, to recognise the risks this poses to children and take action.    For Bobby’s parents, their compliance was no longer disguised, it was openly resistant.  The formal process of holding a multiagency CIN meeting before case closure was required to explore this across the partnership.  This did not happen.   CSC undertake monthly group supervision and have suggested this could be opened on occasion to include the multiagency network.  Whilst this may be useful, utilising the already established procedures would seem more appropriate, rather than seeking to create another process.     The case was closed to CSC in early December 2019; the CIN Plan ceased, and the December CIN Review meeting was cancelled.  Two services who attended the CP conference in September were sent written notification of the case closure (Health visitor (HV), and Family Hub) and the school and midwife were informed.   The closure letter asked they get in touch with the team direct if they had any further safeguarding concerns, there was no explanation as to why the case had closed.  There is no record of any other agencies being informed of the case closure.   The parents were each sent a letter notifying them of the case closure which encouraged them to: continue to seek support from the midwife and health visiting team.   Practitioners advised at the Learning Event that they were unclear about the difference between CP and CIN and advised there seemed to be different thresholds applied across the different Berkshire 16  areas. They felt CP was more robust and valued the challenge of an independent chair, and services were more likely to be provided to CP cases.   These are some of their comments: ‘Understand CIN means level of risk is lower but could still be significant and chronic.’ ‘CiN not as formal, if family doesn’t meet the plan, then not as significant.’ ‘Major difference is consent.  If parents don’t want to engage then difficult to force them.’ ‘The CiN was closed so the implication is that the situation felt safe.  The feeling is that it is downgraded by the SW, so the situation is OK.    Case analysis The Annual Review of LCSPRs and rapid reviews published in 2021 found: 18 In relationships dominated by domestic abuse and coercive control, it may be very hard, even impossible, for a parent to engage with services…Patterns of engagement and withdrawal should prompt an escalation of concern, and not closure of the case. Refusals of offers of support should be recorded and assessed.  There were other examples of cases that were closed too soon when families and/or children did not engage. A key message is that services should consider the reasons for non-engagement – in the family and in the response of practitioners and agencies – and how to engage, rather than close due to non-engagement. Progress should be evidenced prior to closure, the reasons for closure should be clear and closure should not be viewed simply as the end – that is, there should be clarity about what to do if new concerns emerge.   There is a formal procedure that CIN cases will not close without a multiagency meeting taking place, but that did not happen.  The closure occurred just a week before the next planned CIN review meeting. It remains unclear why the decision was made not to hold the multiagency meeting and to close the case.  The perspective from CSC appears to be that professionals were not raising any concerns. However, the closure letter suggests agencies get back in touch with any further safeguarding concerns, which seems to suggest ‘new’ concerns, not any existing ones. But there is no information given about challenging or disagreeing with the closure decision.    Finding 10:  CP cases which are stepped down to CIN should remain open for a minimum of 3 months.  Finding 11:  An audit should be conducted to determine whether multiagency meetings are being held prior to the closure of all CIN cases.   Finding 12 Escalation procedures should be easy to use. The BWSCP should produce multiagency guidance to ensure it is accessible to all agencies. Future audits will include related questions to determine if the guidance is being used.   Management oversight and case supervision should be in place and audited.   West Berkshire Local Safeguarding Children Board conducted a Serious Case Review into the death of Child K, a baby of 18 weeks who died of extensive head injuries in 2017.    18 Annual review of LCSPRs and rapid reviews (publishing.service.gov.uk)page 17 17  His father was subsequently convicted of his murder. Recommendations relating to CIN plans and working with resistance were made which are relevant to Bobby’s case, whose death occurred almost 3 years later.    Practitioners at the Learning Event were not familiar with the SCR or the recommendations: SCR Child K Rec. 4 The LSCB should ask that the Local Authority Children and Families Services review their Children in Need procedures and how they apply across the service to ensure practice is safe, robust, and consistent and that all staff have clarity and procedures are followed.  SCR Child K Rec. 7 The LSCB should request reassurance from partner agencies that professionals are being appropriately supported to recognise disguised compliance and work with resistance, this should include consideration of the impact of domestic abuse, control, and coercion on a non-abusing parent’s ability to work with professionals as required.  The SCR Child K Action Plan notes that these actions are not yet complete. The BWSCP was able to share copies of training provided in respect of learning in respect of several Serious Case Reviews, plus a presentation illustrating disguised compliance. It is unclear how far reaching this training has been. There is not a case for suggesting it has been embedded across the BWSCP.  The SCR Child K report was not published because of sensitivity, a Learning Report was published.  Finding 13:  Child in Need plans are invariably multiagency, and all partners need to be aware of their importance in safeguarding children. The relevant action set out in SCR Child K Rec 4 is long overdue.   Previous plans had always relied upon paternal grandmother for support, with managing and supervising contact.  Alfie had a close, reliable relationship with her, and it begs the question why grandmother was not involved or alerted to the concerns?   Grandmother had on occasion minimised the negatives and over-stated alleged positives of her son’s behaviour, which would not be highly unusual. Although at conference she did actively voice her concerns about the parents’ ‘toxic’ relationship in respect of Alfie’s welfare. Her commitment to Alfie’s contact had demonstrated that she was consistently proactive about keeping positive contact with her grandson. She did not attend the CP conference in September 2019 despite being expected to continue with an important role in Alfie’s CIN plan.  This was an important omission.  Finding 14: Extended family or kinship to be included in CIN planning to explore sources of safety and risk when they have been integral to a CP Plan.   In 2017 West Berkshire Council adopted the Family Safeguarding Intervention Programme19  a service to work with the whole family. A team of multidisciplinary staff are available to work on differing family issues, such as social workers, domestic abuse, mental health, and recovery workers, as well as family support workers and psychologists.   The ethos is to engage with families using the relationship-based practice model (see Appendix Two) to identify and support changes needed to improve the quality of children’s lives. As part of this approach all staff in the Family Safeguarding Teams are required to trained in Motivational Interviewing (MI) an important tenet in relationship-based practice. Train the trainer MI training was  19 FSM_flyer_families.pdf (westberks.gov.uk) 18  provided so the training could continue to be delivered. It was also provided to CP Chairs, Independent Reviewing Officers as well as some local Head Teachers.   Donald Forrester explained:  MI is perhaps best thought of as a way of having purposeful conversations about difficult issues…The concept of resistance as an understandable response to the circumstances people find themselves in is particularly helpful. Yet most important of all – and for me the point at which MI and social work converge – is in the concept of self-determination…the right for individuals to make their own decisions and to be treated with respect, is at the heart of both social work and MI. In child protection work this concept of parents (in particular) as active actors often becomes lost: they are treated as if they are problems to be solved rather than partners to be engaged. MI provides one of the best descriptions of how to have more respectful and purposeful conversations with parents, even about difficult issues such as child abuse, alcohol or drug problems or violence.20  In seeking to determine why these previously agreed SCR recommendations have not been achieved it is important to recognise that the statutory responsibility, which previously lay with the LSCB (Local Safeguarding Children Board) no longer applies.  Between the deaths of Child K and Bobby there was a significant structural change. LSCBs had statutory responsibilities for safeguarding training and ensuring learning from case reviews.   Following the review by Sir Alan Wood21, LSCBs were required to change to develop their own Multi Agency Safeguarding Arrangements (MASA) effective no later than September 2019. LSCBs were separate entities led by an Independent Chair, the Wood Review sought to place responsibility directly with the three statutory partners, the Local Authority, the CCG, and the Police. This was supported by the Children and Social Work Act 2017,22 the legislation which removed the requirement for LSCBs and their statutory duties.    Case analysis Parents had agreed at the CP conference that they needed to work on a number of areas. Yet 6 weeks later the compliance and agreement had ceased. Parents seemingly saw social services as the cause of their stress and were no longer willing to engage. Unfortunately for Alfie and then unborn Bobby, the risks had not changed. It could be argued they had increased as there was less likelihood that help would be sought by the parents. Despite the MI training and the multidisciplinary Family Safeguarding team around the family, no solutions were offered to address the parents’ intransigence.    Finding 15:  It is important to ensure practitioners can recognise disguised compliance and are supported to work with resistance. The relevant action set out in SCR Child K Rec 7 is long overdue.    The subsequent Berkshire West Safeguarding Children Partnership covers three authorities of Reading, Wokingham, and West Berkshire. Previously the six unitary councils which make up the county of Berkshire each had their own safeguarding children board.   It was felt that the change in these arrangements has resulted in some loss of the impetus and oversight previously provided by the LSCB. The BWSCP has delivered training on Working with  20 https://www.theguardian.com/social-care-network/2016/mar/08/motivational-interviewing-quick-guide-social-work 21 Wood review of local safeguarding children boards - GOV.UK (www.gov.uk) 22 Children and Social Work Act 2017 (legislation.gov.uk) 19  Resistance and on the findings from the most recent SCRs but doubt this has been embedded across the workforce.   It is hoped that sessions being offered across the BWSCP will attract greater numbers than previously seen at the individual LSCBs. Also, it is thought the commonality of issues can make a stronger case for mandatory training.   Finding 16 The BWSCP should provide guidance as to what multiagency training is to be made available and how Partnership actions disseminating learning and providing training from SPRs is to be achieved.    Case analysis The Triennial analysis of serious care reviews published in 2016 noted: The impact of all domestic abuse is harmful to children and a step-change is required in how we understand and respond to domestic abuse. There is a need to move away from incident-based models of intervention with domestic abuse to a deeper understanding of the ongoing nature of coercive control and its impact on women and children, and also on men. 23  The prevalence of using incident-based models means that absence of reporting of any incidents can lead to a false sense of security, in thinking that nothing has happened. Whereas some may see incident disclosure as a potential risk of greater intrusion and escalated intervention, therefore are not reported. This can be used as a threat also, to ensure compliance in an abusive relationship.  Both parents knew that professional concerns were heightened when they were together, so it would be reasonable to assume they would have been wary about agencies finding out their circumstances.    Finding 17 The BWSCP should review their procedure, risk assessment tools and responses to children living in households which experience domestic abuse. This includes risk ratings and the use of MARAC and DARIM Panels, and the prevalence of relying upon incident-based models.    2020 In early January 2020, Police received a call from a neighbour who reported loud shouting and swearing by father and a child crying. Previous history at the address and a ‘child at risk’ marker was identified, so officers immediately responded and attended the address.      Father confirmed that Alfie had been crying, he told Police that Alfie was: ‘kicking his parents whilst they were lying in bed to try to get them up and had been told off which has resulted in the crying.’   Case Analysis  It is important for staff to consider what level of noise and distress and length of time would prompt people to call the police to such an event. We are reliant upon such reports to give a real time window into the child’s lived experience.    23https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf  20  Officers tried to speak with Alfie, who was noticeably upset, his parents advised this was because he was scared of Police, although no further explanation was given or requested. Alfie confirmed with nods that he was okay. It is understood that a ‘Welfare Check’ was carried out as Alfie had been noted to previously have a CP Plan for neglect, therefore officers checked the property and established there were no signs of neglect. The Police passed on the information to MASH24 with their view that there were no safeguarding concerns. The caller was not approached by the officers to ascertain if the family’s explanation was consistent with their report.   The information was passed to social care where no checks or action was taken. It is understood that the previous team that held Alfie as a CP case were alerted and concurred with the Police that it was not a safeguarding matter.    CSC records state: ‘Record incident only, no role for Children Services.   The vulnerable women’s midwifery team were working with mother but were not informed of this incident.  This incident suggested that father was living in the home which was a known risk for Alfie and a potential risk for the unborn baby.  Also, this was at complete odds with the previous response to the December 2018 incident, which prompted a full CP response.  Case analysis Police routinely interview those involved in domestic abuse incidents separately, but this incident was not regarded as domestic abuse. There was a history of such and of previous incidents involving harm to Alfie, therefore it would have been helpful to determine the perspectives of each adult. This is particularly important if there are issues of coercive control. Thames Valley Police have provided assurance that the child is always engaged with now, to ensure their wellbeing.  Finding 18 Police attending any incident at homes where domestic abuse has been a feature should interview the parties separately.   Finding 19 The BWSCP to review the CP categories used for children exposed to Domestic Abuse. The use of neglect as a category is misleading.   Six weeks later, in February 2020, Housing alerted CSC to a neighbour reporting that father was living in the property and that Police had attended.  The Housing Officer commented:                     ‘As there have been problems in the past with toxic arguments that Alfie had been exposed to, I felt it necessary to alert CAAS25 with maybe a view to investigate.’          Social Care assumed that this was a reference to the January incident and decided it was not a safeguarding matter and again took no action.  Case analysis This was good practice; even if it did relate to the January incident, the Housing Officer had attended the December 2018 and March 2019 CP conferences and knew the risks associated with the father being back in the home and was right to highlight those concerns.   24 MASH, Multiagency Safeguarding Hub 25 Contact Advice and Assessment Service https://directory.westberks.gov.uk/kb5/westberkshire/directory/service.page  21  The assumption by CSC about this report, compounded the poor response to the January incident, were important factors.   Evidence was growing about father’s regular presence in the home, father admitted he was in bed and shouting, and Alfie was crying, so the concern was substantiated and needed to be explored.             In March 2020 mother (8 months pregnant) contacted Police to complain of a neighbour confronting her and kicking her door at 6.30 a.m. asking why Alfie was crying and making a noise.   Initially the Police dealt with this by way of a telephone resolution. When it was passed to the Smarter Resolution Team, they identified the previous CP concerns and neighbourhood police officers were asked to do a welfare check on Alfie, which is good practice. This was treated as a neighbourhood dispute, although despite speaking with the neighbour, they did not establish the reason for their 6.30 a.m. visit.  The information about this incident was not shared with any other agency.   Case analysis This was an important omission. Police held a history of attending domestic abuse incidents at this address and concerns about the child which had resulted in father’s imprisonment, and CP plans being made. Again, the question arises about whether the use of the neglect category skewed the focus of concern?    The other aspect of this incident is that mother had brought it to the attention of the Police. She was complaining about the neighbour, but the original concerns were that Alfie was crying so much at 6.30 a.m. that it prompted a visit from a neighbour to make a complaint.  Because the neighbour was not asked about her concerns it is difficult to draw any strong conclusions about whether the neighbour was concerned about Alfie’s wellbeing.  And, without any other information, it is not known whether father was present.    In March 2020 mother reported to the vulnerable women’s midwifery team that the couple were getting on well. Alfie was released from school the week prior to lockdown because of his asthma and was visited at home weekly with relevant schoolwork and food parcels.   At the end of March, mother advised midwifery that father had moved into the home because of the Covid lockdown.  Case analysis Whilst previously, there may have been suspicions that father had been living, or at least staying at the home for some time, this was the first formal confirmation of him doing so.  Despite this being a known risk to Alfie and the expected baby, this information was not escalated within Health or shared with any other agency. The vulnerable women’s midwifery team were involved specifically because of the safeguarding risks identified when it became known that mother was pregnant in September 2019.   In seeking to explore why, despite knowing the history, such significant information was not shared, it seems that by the time the baby was born, it was overlooked.  There seems to have almost been a general assumption that everyone knew he was living there. Whilst father had not attended ante-natal appointments, he was said to have attended all baby scans. Mother was stating to those she did see that she and father were ‘getting on well.’    22  In early April 2020 Bobby was born at full term, his father was present for the delivery. Mother and baby were discharged home the next day. Midwives visited mother and Bobby at home on 3 occasions, on one of those visits, they noted father and Alfie stayed in the bedroom playing. On the 10th day, as is customary when mother and baby are regarded as doing well, Bobby and mother were discharged from midwifery care.   The next day the HV was due to undertake a video assessment of mother and Bobby rather than a home visit because of the Covid restrictions. Mother advised that she could not do this, so it was conducted via telephone. Mother reiterated to the HV that she and father were not in a relationship, but they did spend family time together. It is not clear what she meant by ‘family time’ as this was not explored.   Case analysis This was at odds with the information held by midwifery who knew that father was living there. This was important information that should have been passed to the Health Visitor, who was aware of the history and risks associated with father being back in the home.    When Bobby was 14 days old mother sought advice from the GP as Bobby was not feeding; he also appeared to have conjunctivitis and breathing difficulties due to a blocked nose. The GP called an ambulance, and he was transported to hospital for admission. Bobby was discharged from hospital the same day.   The health visitor contacted mother to check up following the hospital visit who confirmed that his feeding had improved.  The health visitor asked about mother’s emotional wellbeing and mother said she had no concerns, and all was well. An appointment was arranged for Bobby’s 6-8 weeks check.  Case analysis It was good practice to quickly follow up on a hospital admission for such a young infant; also, to use the opportunity to check on mother’s own wellbeing and set the date for Bobby’s development check.   It is not clear whether there was any exploration about father’s involvement in Bobby’s care or father’s wellbeing.  Mother had told everyone, apart from midwifery who were coming into the home, that father was not living there. Observations of the home would have provided the opportunity to challenge and ask questions about what was seen in addition to directly interact with Alfie. Mother was able to establish, on disclosing that information to midwifery, that seemingly nothing changed, there was no sudden intervention from other agencies.   Telephone contact is vastly different from face to face home visits, which were not available to the HV team at that time because of advice with respect to the Covid pandemic.   Mother had resisted the video calls, advising that her phone could not be used for them.  All such information would have to be taken at face value, as there was no evidence available to suggest anything to the contrary. It would not be unusual for a DA perpetrator to be in the home keeping oversight and control of all conversations, especially those with professionals.   As this was during the early stages of the pandemic, there was little in place to guide practitioners in conducting virtual risk assessments and interventions. This has been recognised since as particularly difficult in circumstances of domestic abuse.    23  Two weeks later, in May, at 1.30 a.m. an ambulance was called to the home, 4-week old Bobby was said to have been found unresponsive in his cot, both parents and Alfie were present.    Case analysis This was a fast-moving, emotive and difficult situation with the worst possible outcome, that of a young infant losing his life. Within less than 24 hours, a host of agencies and professionals had worked together to try to address all the aspects of the complicated scenario.  The ambulance service quickly identified this was a safeguarding issue and Police attended the scene.  This was good practice.  Following police attendance at the home the CAIU were alerted, and a police detective was able to attend the hospital at the crucial time. This was good practice.  Whilst all efforts were made to seek to preserve Bobby’s life, these proved to be unsuccessful.  His physical presentation raised concerns and despite his death the hospital response was quick and thorough in undertaking CT scan and x-rays and other tasks in accordance with the ‘Kennedy Guidelines’, the Royal College of Paediatrics and Child Health 2016 guidance on Sudden unexpected death in infancy and childhood. 26  This was good practice.   Although the Emergency Duty Service were notified of events in the early hours, they were left somewhat to play catch up.  Their speedy contact with CSC alerted them to prioritise the welfare of Alfie.  This was good practice.  The main area of contention, although subsequently rectified, was the difference of approach from the Police towards to parents to that of CSC.  Although the home had been sealed, the Police did not advise EDS they were treating the parents as witnesses, which meant mother and father returned to be with the grandparents and Alfie.  For CSC this was a clear risk to Alfie and therefore was not acceptable.   As soon as these issues were identified, EDS made arrangements for the parents to be provided with alternative accommodation and mental health support. This was good practice.       26 https://www.rcpath.org/uploads/assets/874ae50e-c754-4933-995a804e0ef728a4/Sudden-unexpected-death-in-infancy-and-childhood-2e.pdf  24    5. Recommendations As some of the findings relate to similar themes, these have been grouped together.  Rec. 1 - Supervision Orders (Finding 1) Cases of children who have been the subject of a Supervision Order, should remain open on a multiagency Child in Need Plan for a minimum of 3 months, to ensure they can be stepped down safely.  Rec. 2 - Child Protection Case Conferences (Findings 2,3,4,5,8 & 16) a) For children in transition, the next school or nursery should be invited to a child protection conference, even if they have not yet started.  b) All reports submitted to a CP conference should be formally considered, openly shared, and commented upon during the conference. c) Issues of non-engagement and self-reporting must be actively addressed during the conference. d) The BWSCP should conduct a review of how Mental Health services are engaged in CP conferences including the requests made, and the provision of Mental Health reports to CP Case Conferences when the parent and/or carer is known to Mental Health services.  e) The CP Procedures should specify that if there is a significant change within 3 months of the conference that removes a child’s name from a CP plan then a multiagency strategy meeting should be convened, to determine whether a s47 enquiry is necessary to enable the local authority to decide whether it should take any action to safeguard and promote the welfare of the child, for example,  a CP conference should be held.  f) The BWSCP should review the CP categories used for children exposed to Domestic Abuse. The use of neglect as a category is misleading.  Rec. 3 - Children in Need (Findings 10,11,13, & 14) a) CP cases which are stepped down to CIN must remain open for a minimum of 3 months and be subject to management scrutiny and review before closure. b) An audit should be conducted to ensure that a multiagency meeting is held prior to the closure of all CIN cases. c) Child in Need plans are invariably multiagency, and all partners should be aware of their importance in safeguarding children. Reference to SCR Child K Rec 4 for a similar ongoing action in relation to regular review and revision (if required) of local Child in Need procedures. d) Extended family or kinship should be included in CIN planning to explore sources of safety and risk.   Rec. 4 - Domestic Abuse (Finding 17 &18) a) Police attending any incident at homes where domestic abuse has been a feature should interview the parties separately. b) The BWSCP should review their procedure, risk assessment tools and responses to children living in households which experience domestic abuse. This includes risk ratings and the use of MARAC and DARIM Panels, and the prevalence of relying upon incident-based models.   Rec. 5 - Pre-birth assessments (Finding 9) The summary and outcome of pre-birth assessments should be shared with all agencies that have contributed to the process. If necessary, consultation with agency Data Sharing officers should be undertaken.    25  Rec. 6 - Escalation and multiagency debate (Finding 12) Escalation procedures should be easy to use. The BWSCP have agreed to produce guidance to ensure it is accessible to all agencies. All future audits undertaken will include questions to determine if they are actively being used.   Rec. 7 - Learning and development (Finding 7,15, & 16) a) BWSCP should gauge if there is an appetite across the partnership for multiagency case conference training. This could be considered as mandatory training for some agencies.  b) Working with resistance and disguised compliance: It is important to ensure practitioners can recognise disguised compliance and are supported to work with resistance. Reference to SCR Child K Rec 7 for a similar ongoing action.  c) The BWSCP should provide guidance as to what multiagency training is to be made available and how Partnership actions disseminating learning and providing training from SPRs is to be achieved.   Rec. 8 - Agency engagement with the SPR process (Finding 6)  Attempts to be made by BWSCP to clarify with Mental Health services the evident confusion about the requirement to disclose information to a CSP Review. If the matter remains unresolved, this should be escalated to the Partnership Executive.    A response from Berkshire Healthcare NHS Foundation Trust has been received (noted as footnote 9 on page 10) and this has been accepted by the local CSPR Panel.    6. Conclusion  The death of such a young infant is a dreadful tragedy and examining the minutiae of practitioner engagement with Alfie and Bobby’s lives is a difficult undertaking for all concerned and especially for those who knew them.  The BWSCP extends their gratitude to all the practitioners and agencies who have taken part in this review with such helpful candour and careful thought.    Our deepest sympathy goes to the family and to Alfie for the terrible loss of Bobby.     26   APPENDIX ONE  Triennial Analysis of SCRs 2011-2014:27 In this model (Figure 1), it is important to recognise that not all child maltreatment consists of discrete incidents of harm. Thus, there may be ongoing contexts of harmful actions or omissions by carers; and fluctuations in the degree of vulnerability and risk; changes in the background context; and reductions as well as exacerbations of risk. This is illustrated by the curved arrows in the model. Figure 1: Pathways to harm in child maltreatment  Preventive and protective interactions between professionals, parents and wider society, along with the underlying systems and processes which may support them, are illustrated in Figure 2. Figure 2: Pathways to prevention and protection    27 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf  Pages 25/27 27  APPENDIX TWO  