Serious sexual abuse of a 5-year-old girl. Child C's second cousin, OF, pleaded guilty to charges including rape of a female child under 13-years-old and taking and distributing indecent images of children; he was sentenced to 13 years imprisonment in January 2014. Child C had previously been subject to a Child Protection plan under the category of sexual abuse in relation to an identified risk posed by her paternal step-grandfather and paternal great-uncle, both convicted sex offenders. The Child Protection Plan was stepped down to a Child in Need plan and the case was later dealt with under the Common Assessment Framework (CAF). OF had no previous history with police and had not been identified as posing a risk to Child C. Issues identified include: extensive and complicated family networks of Child C's parents; frequent moves between maternal and paternal families (residing in different local authorities) impacting on effectiveness of interventions and continuity of care; use of private landlords for accommodation removing the involvement of housing professionals, making usual organisational contact more difficult; plans focusing on risk of sexual abuse despite significant evidence of neglect; and lack of apparent safeguarding oversight in the out of hours service. Identifies learning, including: need for agencies to be aware of the capacity of parents and to be sure that parents are able to fully understand what is being asked of them; and a need for healthy professional curiosity and challenge. Review was undertaken using the Significant Incident Learning Process (SILP).
      
   Serious Case Review No: 2014/C5299   Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.         A Serious Case Review into the circumstances  Surrounding Child C          1 CONTENTS  1. Introduction to SILP      Page 3   2. Introduction to Child C     Page 4  3. Family Structure      Page 4  4. Introduction to the case     Page 4  5. Voice of the family     Page 5  6. Terms of Reference     Page 6  7. The Process       Page 6  8. A brief background prior to the scoped period  Page 7  9. Key practice episodes      Page 8  10. Analysis by theme      Page 16  11. Conclusions and lessons learned    Page 26  12. Recommendations      Page 29                           2 1. Introduction to SILP  Introduction to the Significant Learning Incident Process (SILP)  1.1 SILP is a learning model, which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in the new Working Together to Safeguard Children published in March 2013.  1.2 The SILP model of review adheres to the principles of;  • proportionality • learning from good practice • the active engagement of practitioners • engaging with families and significant persons, and • systems methodology.  1.3 It has been generally accepted that over recent years the Serious Case Review agenda had become over-bureaucratic and driven by Ofsted ratings. The practitioners in the case have often been marginalised and their potentially valuable contribution to the learning has often been under-valued and underutilised.  1.4 SILPs are characterised by a large number of practitioners, managers and Safeguarding Leads coming together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved are discussed and valued. The same group then come together again to study and debate the first draft of the Overview Report.  1.5 The Local Safeguarding Children Board has requested that the SILP model of review be used to consider the circumstances surrounding the serious sexual assaults against a child known as C, in order to learn lessons about the way that agencies can work together to safeguard children.  1.6 Working Together 2013 states that SCRs and other case reviews should be conducted in a way which; • recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations 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.  1.7 This serious case review has been undertaken in a way that ensures these principles have been followed.      3 2. Introduction to Child C  2.1 The background for C has come mainly from her school. When she first attended the school she was seen as a very emotional child who required more support than her peers. She was insecure and clingy and regularly sought attention of adults.  When she first attended the school her appearance was untidy and unkempt, she did not have a coat for a large part of the year and suffered regularly from nits. She was brought to the school very early each morning by her mother and as a result was offered the services of a breakfast club but her attendance did not last. Academically C was operating at a low level.  2.2 Since October 2013 the school has witnessed a distinct improvement in C’s appearance and behaviour, they describe her as flourishing and her learning and participation in class has improved. She is well accepted by her peers and it has been noted that she is much less clingy and more independent.   3. Family Structure  3.1 The subject of this review is C, her mother is M and her father is F. C has two other siblings both of which are younger and born with in the scope of this review, Sib1 and Sib2. Whilst Sib1 shares the same parents as C, the father of Sib2 is  another male.  3.2 C and subsequently her sibling (Sib1) were placed on a Child Protection plan due to the risk of Sexual abuse, the risk of which was presented by SGF who is her paternal step-grandfather. It was considered that there was also a risk from U, her father’s uncle. Both SGF and U have convictions for sexual offences against children, which would put them within the category of an offender who posed a risk to children.  3.3 The person who committed the offences against C, which lead to this review, was OF, who is her father’s cousin (C’s second cousin). At the time of committing these offences OF was residing with U, his uncle. U is also a convicted sex offender who was being managed under Multi Agency Public Protection Arrangements (MAPPA)   4. Introduction to the case  4.1 The subject of this review is C who was born in Authority 1 in May 2008 to parents F and M. Both F and M have a complicated family network spread over Authorities 1 and 2, parts of which have been known to agencies in both authorities for some time.  C and her parents moved to authority 2 in October 2008. At this time Childrens Social Care in Authority 2 were engaged in proceedings with three of C’s cousins regarding a risk of sexual abuse posed by the paternal step grandfather, SGF, who was an offender who posed a risk to children. The risk to C was recognised and C was subsequently placed on a Child Protection Plan as being at risk of suffering sexual abuse.   4  4.2 It is apparent that the family moved between authorities 1 and 2 but due to them taking up permanent residence in Authority 1 in December 2009, the Child Protection case was transferred to this authority. Two further siblings Sib1 and Sib2 were born in May 2010 and November 2011 respectively. C continued on a Child Protection Plan until September 2010, at which stage it was stepped down to Child in Need and subsequently under Common Assessment Framework (CAF)1 in December 2011. Dealing with the case using a CAF and team around the child never started, the reason stated was the parent’s lack of willingness to engage.  4.3 In September 2013 Police in Authority 1 received a notification from Child Exploitation and Online Protection Service (CEOP) that a person was claiming to have committed serious sexual offences on a five-year-old relative and to have possession of photographs of this abuse he wished to share. The person was identified as OF and the victim identified as C. OF had no previous history with the police and although part of C’s extended family network was not a person who had been identified as someone specifically posing a risk to C.  4.4 OF was arrested and subsequently admitted to a number of offences of rape, sexual assault and offences relating to possessing and distributing indecent images of children, he was charged with offences and appeared at the Crown Court in January 2014 where he was sentenced to 13 years imprisonment.   5.Voice of the family  5.1 The reference group discussed the significant members of the family who should be approached to be part of this review, they identified: - • The mother and father of C. • The natural father of Sib 2 • The offender, OF. The mother and father agreed to be spoken to, the natural father of Sib2 did not respond to requests to be interviewed. The offender OF did agree to be spoken to and was interviewed in prison, the following views were provided.  5.2 The parents described their history with services in particular Childrens Social Care. They stated that they felt they achieved little from the Child Protection process. They claim that they did not really understand what they were being asked to do and disclosed that they both have significant dyslexia and this impacted on their understanding and how they were treated in meetings and conferences. They claim that they were never made aware of the risks presented by their wider family network and that the work concentrated on the paternal step grandfather and uncle. This does not concur with agency records, which show that wider relationships were discussed. 1 ‘This framework for children and young people is a shared assessment tool used across agencies in England. It helps practitioners to develop a shared understanding of a child’s needs, so they can be met more effectively. It is an important tool for early intervention and is not for when a practitioner is concerned that a child may be harmed or may be at risk of harm”- The Common Assessment Framework: a Practitioners Guide- 2006.  5                                              5.3 The offender OF states that in his view there was little that agencies could have done to prevented him committing the offences as he was not known to or engaging with any agencies at this time or indeed previously. He did have a short period of being looked after in another authority as a teenager but no dealings with either authority 1 or 2. OF did disclose that for a significant period of time he was engaging on the internet to source indecent images of children. At this time he recognised that his behaviour was of concern but was not aware of any help that he could access. He claims that had some help been available he would have accessed it at the time. He feels this may have limited his later offending. This fact cannot, of course, be substantiated but OF was unaware of any organisations such as Stop it Now2, which is led by the Lucy Faithfull Foundation and provides a helpline and support for potential offenders. The Safeguarding Board should consider ways in which raising the awareness of this support could be achieved.   6. Terms of Reference  6.1 The reference panel agreed the scope of the review to cover C together with the siblings Sib1 and Sib2 between 21st December 2009 (when the Child Protection Case was transferred to Authority 1) and 25th September 2013 (when the children were accommodated). A report was also requested from the Children’s Social Care of Authority 2, to give the background and context to the reasons for initiating child protection and to achieve a greater understanding of the transfer process to Authority 1.   7. The process  7.1 A meeting for authors of individual agency reports was held on 13th January 2014, where the SILP process and expectations of the agency reports were discussed. A full day Learning Event took place on 27th March 2014. Both the report author and staff, including managers, who had been involved during the scope period, attended from the agencies involved. Absences were accounted for, and reasons included staff that were no longer employed, which was notably the case for Childrens Social Care in Authority 1. All the agency reports had been circulated in advance, to ensure all staff attending were able to fully understand the multi-agency information and focus of the review.  7.4 The police investigation into the offences perpetrated against C had completed with the offender OF pleading guilty to the below offences and being sentenced in January 2014. • Rape of a female child under 13 yrs x 2 • Assault by Penetration x 3 • Sexual assault x1 • Taking Indecent Images of Children • Possessing Indecent images of Children • Making and Distributing Indecent Images of Children. 2 http://www.stopitnow.org.uk  6                                              All the offences occurred between 24th March 2013 and 25th September 2013, OF was sentenced to 13 years imprisonment.  7.5 Local Authority 1 is currently in legal proceedings in relation to the child arrangement orders for C, Sib1 and Sib2.   8.  A brief background prior to the scoped period  8.1 C was born in Authority 1 in May 2008. Her mother is M and her father F. It was noted by the health visiting service that M was known to services having been subject of Child Protection for risk relating to contact with a sex offender. This period of Child Protection and the reasons for it are relevant as it involved the mother’s contact with SGF and her mother’s (GM) apparent willingness to expose her to this risk. After the health visiting service had engaged in routine early contact the medical notes were requested by Authority 2 Health visiting team.  8.2 C and her parents moved into the address of the paternal grandmother whose partner, SGF, was an offender who posed a risk to children. Childrens Social Care in Authority 2 were involved in legal proceedings on three children who were C’s cousins and the social worker involved, on becoming aware of C’s arrival, made a referral to Childrens Social Care on 24th October 2008.  8.3 Initial and Core assessments were completed for C, resulting in an initial child protection conference on 1st December 2008. The child protection plan was that C and her parents should leave the address and her parents (M and F) should undertake a non-abusing carers risk assessment.  8.4 On the 5th December 2008 Authority 2 Childrens Social Care met with legal services to discuss the issuing of a letter before proceedings unless the family moved from the address forthwith. The authority received confirmation within a couple of days that the required move had taken place.  8.5 Reviews of the child protection plan took place in February and June 2008. In February it was noted that the family network was complicated, involving four families, and that some ‘family history and profiling should take place’ but it is not clear that this ever occurred. In June it was noted that C and her parents had been staying back in Authority 1 but it was not clear that this was a permanent arrangement.  8.6 There were further review meetings in August, October and December 2008. The non abusers carers risk assessment had not been completed and during this time F and M had separated. By the December review it was noted that M had moved permanently to Authority 1 and Childrens Social Care in Authority 1 had accepted the case on a temporary Child Protection basis. The risk assessment had still not been completed.  8.7 U is the uncle of C’s father and is also an offender who presents a risk to children, having been convicted of rape on a child under 13 years (his niece) in  7 2000. After serving a custodial sentence he was managed by both Probation and Police. This management included home visits. It was noted as early as 2008 that OF, the offender in this review, was residing with U, although this represented no breach of any management conditions.  8.8 What is evident is that the family network for C and her parents is extensive and spread over the two local authority areas. During the short early period of C’s life she moved, with her parents, frequently between the maternal and paternal family. This created difficulties for agencies to initiate and complete interventions with the family and was seen by agencies as unwillingness to engage. This is clearly demonstrated by the regular moving of registration with General Practitioners, 4 in 9 months, which had an effect on the continuity of care in other services, such as health visiting.  9. Key Practice Episodes  9.1 This review will now focus on the key practice issues during the period identified in the terms of reference. There were four, which separate as follows:  1. The transfer of the case from Authority 2 to Authority 1. 2. The management of the case in Authority 1 until the step down to Child in      Need. 3. The management of the case as a Child In Need until the step down to Universal Services. 4. The management of the case in Universal Services.   Key Practice Episode 1 – The transfer of the case.  9.2 It is evident that there was communication between Authority 1 and 2 during the course of C being on Child Protection, it is recorded that transfer was first being discussed in June 2009 but C then moved back to Authority 2. Whilst C and her family were moving between Authorities 1 and 2 it is clear that they themselves did make at least one attempt to notify Childrens Social Care of their moves and that some agencies were aware of their whereabouts. The Health Visitor in Authority 1 visited in December 2009 initiated by C’s registration with a GP and afterwards, immediately made contact with the relevant Childrens Social Care and health visiting service in the current and other authority area.  9.3 On 21st December 2009 C was placed on the Temporary Child Protection list in Authority 2 and a letter was sent to all partner agencies to inform them. On 1st February 2010 a Transfer in Case conference was held. This meeting was not quorate and not attended by the receiving authorities social worker or team manager. There does not appear at any stage to have been liaison between the allocated social workers of either Authority.  9.4 At the Transfer in conference the decision was to keep C on a Child Protection Plan under the category of sexual abuse on the basis that there were members of the extended family who are believed to pose a risk and that a non carers risk assessment had not been completed. The core assessment and Child Protection plan were adopted from Authority 2, there is no evidence that the assessment or  8 plans were updated or refreshed.  9.5 A Social worker was allocated from Authority 1, but it is not clear at what stage this actually happened.   Key Practice Episode 2 - The management of the case in authority 1 until the step down to Child in Need  9.6 The first core group was set for the 9th February 2010 but this was cancelled by the social worker. At this time C’s mother was pregnant with Sib1 who was due in May. The next core group took place on 23rd February 2010 and on the same day a referral was made to an assessment team requesting Protective Parenting work and a Pre-birth assessment. In the referral the Social Worker notes that they intend to travel to the originating authority to read the case file but it is not clear whether this or the requested pre- birth assessment ever occurred.  9.7 The next core group was scheduled for 25th March 2010 but this was cancelled due to sickness of the social worker. The Health Visitor visited C and her parents on this date as planned, at which time the parents expressed frustration regarding lack of contact from the social worker and the delayed start to the parenting assessment.  9.8 A child protection Review meeting took place on 21st April 2010, which was attended by both parents. It was noted the protective parenting work had not commenced but this was in no way due to any action or inaction on behalf of the parents. It was unanimously decided at this meeting that the child protection plan should remain in place for C and initiate for the unborn baby until the parenting work had been completed, this decision was made without the previously requested pre-birth assessment.  9.9 The Protective parenting work started on 29th April 2010 and involved several sessions at the family home discussing the risk of sexual abuse. During this work both SGF and U were discussed as risks but it is not clear that the envisaged risk they presented was ever communicated to other agencies that may be involved in managing them. The next core group was due to take place on 13th May 2010, the health visitor attended the family home to attend this to find that the family had moved, this had not been communicated to the health visitor, she contacted the social worker who provided the new family address. The sibling (Sib1) was born in May 2010.  9.10 During June and July 2010 the health visitors noted a number of missed appointments for Sib1. There appears to be a lack of communication between agencies as at this time, the health visitor arrived for a core meeting in July to find the family packing for a holiday, a fact which Childrens Social Care were aware of as they had initiated a written and signed agreement with the family over contact with the paternal grandparents. Agencies received notification in August that C’s parents had separated.  9.11 During this period of separation the police became involved on two occasions. On the 15th of August 2010 when C’s mother reported a burglary at the home  9 address alleged to have been committed by C’s father. He was subsequently arrested but not charged with any offences. The second incident, a report on 19th September 2010, in which C’s mother alleged that C’s father would not return the sibling (Sib1). After police intervention the matter was resolved amicably but the police records did not reflect the domestic nature of either incident and no referral was made to Childrens Social Care.  9.12 On 16th August 2010 C’s mother attended Childrens Social Care and spoke with the resource worker. She informed her of the separation and that she had left C with the father the previous week. This represented deterioration in the parental relationship and a risk, as the Protective Parenting work had not been completed.  9.13 The health visitor struggled to make contact with the family during early September but called opportunistically on 15th September 2010, at this time it was confirmed that C’s parents had separated. M stated that she was not coping well, was on Prozac and C was with the maternal grandmother, GM. Also that C’s mother was in a relationship with BF. On 21st September 2010 the written agreement was updated to reflect the parents’ separation.  9.14 A review conference was held on 30th September 2010, the conference was not quorate with representation from Childrens Social Care and the health visiting service only. At this meeting it was recommended by Childrens Social Care that the children be removed from Protection Plan as the Parenting work had been completed. The health visitor disagreed, provided a comprehensive report and still believed a risk existed. The decision of the conference was that C and Sib1 should be removed from a Child Protection plan and the case managed by Child in Need. It would appear that the health visitor did not escalate any concern concerning the decision. The first Child in Need meeting was scheduled for 29th October 2010.  Key Practice Episode 3 - The management of the case as a Child In Need until the step down to Universal Services  9.15 The first meeting for the Child in Need Core Group was set for 29th October 2010; the health visitor contacted and left a message for the social worker the day before to confirm their attendance at the meeting. The health visitor attended on the 29th to find no one present. The health visitor contacted Childrens Social Care to be informed the case had not transferred within Childrens Social Care; this was the same response when the health visitor followed up again on 1st November 2010. The health visitor left a number of messages for the social worker at this time but received no response.  9.16 The health visitor made another opportunistic visit to the family address on 10th December 2010 with no response and followed this up with telephone and email messages to the social worker. It was unclear at this time how the case was being managed or to whom the case was allocated. It would appear that a Social Worker did attend the family address on 10th December 2010 as it is recorded that it was messy and untidy but the activity was not coordinated.  9.17 It is apparent that the Social worker made a referral to an assessment team in November 2010 but it was not until February 2011 that a family aide worker was  10 allocated and a joint visit arranged with the Social Worker on 10th February 2011. There was no reply at the address but it was noted that there was a lot of rubbish in the garden and dog faeces in the living room. During this period the health visiting service noted that M was failing to attend health development checks with Sib1 and they notified the social worker. The health service continued to be tenacious in following these missed appointments. On the 21st February 2011, as a result of another opportunistic visit the health visitor saw both C and Sib1 and carried out developmental checks, Childrens Social Care were notified by email. There appears to have been no coordinated activity between December 2010 and February 2011.   9.18 The family aide worker commenced visiting on 17th February 2011, at this time C’s mother’s new partner (BF) was present. He stated that he had just been released from prison; there is no evidence that the reasons for any prison sentence were checked or followed up even by informal discussion. This may be considered surprising considering the existing knowledge of the risk presented by extended family.  9.19 On the 22nd February 2011 the family aide worker emailed the social worker with a concern that C’s father had contact with the children every weekend and there was a risk that the children were visiting the paternal grandparents, subject of the identified risk in the preceding child protection plan. It is not clear how this information was dealt with but around this time the case finally moved to the Child in Need team, having been moved from Child Protection since September 2010 but there does not appear to have been a Social Worker allocated to the case.   9.20 On 23rd March 2011 Childrens Social Care received information that the mother was allowing the father to take C to visit the paternal grandparents. It is not clear that this information was shared with any other agencies. A decision was made that the existing written agreement with parents would be taken to them for an updated signature. The family aide worker visited the next day and was informed that the mother had separated from BF and resumed her relationship with F. She was pregnant but was not sure if the father was BF or F. This information did not initiate any escalation or consideration to initiate a pre-birth assessment.  9.21 During the following weeks it is apparent that the family moved addresses and the family aide worker effectively lost contact with them. Information was received that they were resident in a caravan owned by the paternal step grandfather. There was still no allocated social worker and this new information appears not to have caused any escalation in concern.  9.22 There is evidence the escalation of risk was considered but not made the subject of any action, on 19th April 2011 an unattributable note appears on C’s Childrens Social Care file to the effect that M and F were failing to comply with the Child in Need plan and both placing the children at risk of sexual harm. Also a supervision record dated 21st April 2011 stated that the parents were believed to be with the paternal grandparents, they were not engaging with the assessment team, they were being evasive and preventing agencies from being proactive. They had left their address in an uninhabitable state with dog faeces around the house. Although recorded this analysis did not initiate any further action.   11 9.23 At the beginning of May 2011 the first Child in Need meeting took place since the case had been stepped down from Child Protection in September 2010, some eight months. The meeting was well attended and a new family resource worker was introduced to the family. The concern over contact with the paternal grand parents was discussed and this formed part of the ongoing plan, the plan showed this should be monitored by M. It is questionable whether M was ever going to be well placed to monitor and effectively ‘police’ this activity. There was still no consideration given at this stage to a pre-birth assessment for the unborn child despite the potential for additional tension presented by unknown and disputed paternity.  9.24 In June and July 2011 the Heath Visitor recorded that the family missed two appointments for health development checks, this information was communicated to the social worker. The Child in Need meeting scheduled for 5th July 2011 was cancelled due to the heavy workload of the Social Worker. During July there were continued concerns over the children’s diet causing health problems and it is at this time the health visitor recorded that the mother has problems with dyslexia, this is the first time that this is recorded by any of the agencies. This is significant as up until this time there has been a reliance on a written agreement with the parents and the parenting course entailed some written work. It is apparent that F still challenged the restriction on access to his family and denied having ever seen any written agreement or having the report on the protective parenting work explained to him. An appointment was made on 13th July 2011 for the report to be explained to him but he failed to attend, this was repeated on the 20th and 25th July. It is evident that F was actively evading any responsibility for undertaking this work. This gives an indication as to the level of compliance that might be achieved.  9.25 On 12th July 2011 the midwife initiated a CAF, in relation to the unborn sibling (Sib2). M continued to miss antenatal appointments and on 27th July 2011 was visited jointly by the midwife and resource worker. M informed them C was going to live with the maternal grandmother, GM, and her partner for a week.   9.26 On 10th August 2011 the resource worker commented in records that after discussing with the parents contact with the extended family, missed health appointments and neglect, she concluded that the parents were not taking in the seriousness of the situation and were minimising it.  9.27 On the 9th September 2011 the resource worker attended the family address and spoke with F who stated that C would be staying the weekend with maternal grandparents as the paternal grandparents were coming to stay. It does not appear that there was any consideration given to the risk to Sib1 remaining at the address or any consideration or assessment as to how much protection the maternal grandmother could afford.  9.28 The health visitor contacted the social worker to enquire when the next Child in Need meeting was taking place, when this was not answered the issue was escalated to the named nurse and a meeting was subsequently arranged in October.  9.29 There is evidence that the parents were receiving messages that they either saw as contradictory or chose to read them this way. Whist the resource worker was  12 on leave in August M commented that as no one had visited they must be doing all right. In September when F challenged on whether the children would be taken into care the resource worker responded that this would only happen if they failed to listen to advice ‘which they currently appeared to be doing’. This was despite non-attendance at health appointments, F consistently failing to keep appointments on the protective parenting work and suspicion that there was contact with the paternal grandparents.  9.30 From the 7th September 2011 to the 21st November 2011 (six weeks) C attended a pre-school, her attendance was at 50%. The pre-school record keeping is poor but there seems to be little knowledge at the pre-school of any child protection history, there is passing reference in the records to a Child in Need meeting on the 9th December 2011 but no further reference or outcome. The name of a social worker is recorded on a “post it note’ but again no context is recorded.   9.31 On the 13th October 2011 there was a Child in Need meeting, which was undoubtedly brought about by the escalation by the health visitor and was effectively only the second Child in Need meeting. There was a different social worker present, there was discussion about contact with paternal grandparents, missed appointments and the paternity of the unborn child but there does not appear to have been any challenge to F on missed appointments for the protective parenting work. The recorded discussion regarding the contact with the paternal grandparents appears confused within the context of this case. It would appear to infer that the children would suffer as a result of not having contact with the paternal grandparents and this raises a question as to the depth of understanding about the family dynamics.  9.32 The attendance at pre-school continued to be poor and this was discussed by the resource worker in November 2011, as was a referral received by Childrens Social Care that M had been seen shouting at C in the street.  9.33 In November 2011 Sib2 was born, the health visitor undertook a new born visit on 5th December 2011, whilst no concerns were noted for the baby the health visitor recorded that C was having crisps for her breakfast and that M re-acted in a confrontational manner with C. Whilst this was recorded it does not appear to have influenced any other activity.  9.34 In early December the health visitor continued to contact Childrens Social Care to bring about the next Child in Need meeting but it was evident at this time that the resource worker and social worker were having conversation regarding ceasing the Child in Need plan. There is a recorded discussion with the family and the resource worker on 9th December 2011 to this effect. On the 12th of December the step down from Child in Need to Team around the Child was discussed between the resource worker and social worker and on 14th December 2011 the resource worker visited the family on a ‘good bye visit’ to inform them that there is no longer a role for Childrens Social Care. None of this was discussed with other agencies, who were in fact, under the impression the Child in Need plan is still in place and pressing for another meeting.  9.35 The February Child in Need meeting was effectively the third and last meeting  13 in 18 months. The social worker recorded “F and M have made and maintained the changes to safeguard their children and home environment, therefore no social work role. The case is now TAC” This decision was authorised by a manger on 13th February 2012. A Team around the Child Meeting was arranged for 27th March 2012 and it is recorded that the family failed to attend. It is not clear what arrangements were put in place for the Team Around the Child to commence or indeed what should occur if the parents do not engage, which should have been anticipated. The parents will contend that they were never asked to engage in or invited to any form of coordinated agency support after the Child in Need meetings had completed.  Key Practice Episode 4 - The management of the case in Universal services.  9.36 The proposed Team around the Child meeting did not occur and with C withdrawn from pre-school, intervention was left to universal services. The health visiting service continued to have contact with Sib2 and there were concerns over diet and the gaining of excess weight above the developmental expectation.  9.37 During the period of this review C was registered with 6 different GP practices, which account for 8 different medical episodes. Most of these registrations were short and this underlines the frequent movement of the family. Most of the episodes were normal child related ailments, in particular some which could be linked to diet. It is apparent that as new registrations were made the knowledge and recording of child protection concerns in GP records became less and less apparent.  9.38 On 2nd June 2012 C attended the walk in Centre with her mother, the condition being a sore vagina. It was noted that there were small splits on the labia, which were attributed to a case of impetigo, which was evident. The walk in Centre has access to current GP records but any reference to the Child Protection concerns or history was not easily accessible and therefore not accessed. No referral or contact with other agencies was undertaken and there was an acceptance without challenge that the genital soreness was connected to the Impetigo condition. It was claimed during this appointment, by the mother, that this visit was following a visit to her own GP. It is possible the timing of this appointment could have coincided with the sexual assaults admitted to by the offender.  9.39 On 17th September 2012 C started primary school, there had been a call to the school by the school nurse on 5th September 2012 disclosing brief details that there had been concerns over ‘poor parenting’. The school was not informed of any previous Child Protection or Child in Need history and the parents did not record any ongoing agency involvement on the standard school entry form that they complete at the commencement of schooling. The effect of this was that the school was effectively ‘blind’ to any concerns or history.  C left her pre-school provider prior to her school place being allocated and at the time of transition into school the pre-school was not identified, which resulted in no handover or information sharing between the pre-school provider and the school.  9.40 On 3rd December 2012 an anonymous referral was received alleging domestic  14 violence in the home. A duty social worker spoke with M the next day, who denied that any domestic abuse was taking place and gave consent for the school and health visitor to be contacted. The school was contacted and the school receptionist spoken to, who confirmed that there were no concerns recorded on file. It would appear that this contact was not recorded at the school. It was not disclosed at this time to the school that there was a child protection history. The health visitor was also spoken to who likewise confirmed that there were no current domestic abuse concerns. The allegation was later discussed between the health visitor and M. The decision for no further action in this case was made without reference to C’s full records.  9.41 On 14th June 2013 the school referred concerns to Childrens Social Care due to apparent changes in C’s behaviour, they noticed that she had become very clingy to her mother and she looked messy. The actual event that triggered the contact to Childrens Social Care was the disclosure from C that her Dad ‘slaps her if she messes up’.  On 19th June 2013 a decision was made that there was no role for Chidrens Social Care, as the allegation was too vague and there was no apparent injury. There was no reference to the history and again the opportunity was not taken to share any historic information with the school or to speak to C. The advice to the school was to initiate a CAF, a decision that must have been made with information available that in March 2012 a CAF had been planned but never occurred. The information was not shared with the police.  9.42 On 28th June 2013 the head teacher and school support worker met with the mother to discuss the disclosure made by C of over chastisement. The mother denied that this was the case and declined any offer of further support. The school feel strongly that, had they been aware of the child protection and child in need history, they would have approached this conversation differently and been more challenging with the mother.  9.43 In November 2012 BF, the father of C’s sibling (Sib2) commenced private law proceedings, as a result on 20th July 2013 a CAFCASS family Court Advisor received information that C and her sibling were at risk by being exposed to paedophiles and visiting a farm where paedophiles live. A referral was made to Childrens Social Care. A duty worker discussed the allegation with M on the phone who initially denied knowing where the farm was but later conceded it was local. It was again decided that there was no role for Childrens Social Care.  9.44 The only other engagement with the family was the ongoing support of the health visitor mainly for Sib1and Sib2.       10. Analysis by theme  The analysis section of the review will consider the information above, which was gained from the Agency Reports and the staff who had worked with C and her family who attended the Learning Event. The key themes can be highlighted and covered in  15 sections. These will lead to the lessons that need to be learned from this review, and any required recommendations and findings.   10.1 Family structure and dynamics  10.1.1 The family structure is complicated and consists of close relationships formed between four families that are spread over two authority areas. There has been agency knowledge, involvement and intervention in various elements of the families that has initiated action in wider relationships and this was the case in this review. Care proceedings in Authority 2, on the three cousins of C, identified that C and her parents were resident with the paternal step grandfather and this resulted in a timely referral to Childrens Social Care. A letter before proceedings was discussed but prior to being sent the family immediately moved, effectively reducing the risk. C was placed on a Child Protection Plan to manage the ongoing risk presented by the paternal step grandfather.   10.1.2 There was no attempt at this or any other stage to fully understand the nature and extent of the family network and therefore the extensive history and risk presented. Although very early on in the Child Protection Plan in Authority 2 it was recommended that a ‘full family history and profiling was to be undertaken for each parent’ this never took place in this authority or subsequently in the second authority and for this reason the inter-relationships of the families and therefore the risk was never fully understood. Had this investigation into the family structure taken place it would have revealed that there was substantial information held within agencies that could have informed professionals that there were other risks in the extended family network, although it is fair to say that OF, the eventual offender against C would not have been specifically identified.  10.1.3 This lack of understanding allowed for assumptions to be made, the maternal grandmother, GM was viewed as a protective factor in C’s life but there was information available which showed that GM had exposed C’s mother to risk of sexual harm in 2003 by exposing her to contact with the paternal step grandfather which led to M being placed on Child Protection in her own right.  10.1.4 The family dynamics resulted in a more accepting culture of sexual abuse as the norm than is present in other family networks and it is not clear that this was ever robustly challenged as the full picture was not ever clear to professionals.  10.1.5 The dispersed nature of the families gave C’s parents the ability to move with regularity which made it difficult for the agencies to work consistently with the family, this was compounded by the lack of understanding and poor inter agency communication. During C’s residency in Authority 2 between December 2009 and September 2013 there were numerous family moves within the authority and between Authority 1 and 2.  This is emphasised by C’s registration with 6 GP practices, at least two early years settings, with evidence to suggest a third, and the family registered at more than one children’s centre across the city. This also meant that where services were locality based the continuity of staff and service was effected by regular changes and handovers between professionals. The family either by design or coincidently made usual organisational contact more difficult by using  16 private landlords for accommodation needs which removed the involvement of housing professionals.   10.1.6 At no stage does it appear that any professional questioned the high level of transient activity or sought to consider whether this could be an attempt to evade consistent and coordinated intervention from agencies. Professionals should ask themselves what were the reasons for the parents’ behavior? Are there other possibilities besides the obvious?   10.1.7 The relationship between M and F was tempestuous with frequent separations and one report of domestic abuse. Although the stability of the relationship did feature as a factor in the Child Protection plan this aspect was never fully explored, in particular what the impact of this was on the children. This was also the case with the relationship between the parents and C. There is evidence that F was treating C differently to the other siblings and M was not coping with her having to place her with the maternal grandmother and witnessed shouting at her in the street but these observations were never robustly challenged or made subject of any specific focus. The culmination of these events could have informed an emerging theme that warranted exploration and discussion.  10.2 Voice of the Child  10.2.1 During the early stages of agency involvement with the family it would not have been possible to speak with C to obtain views but certainly towards the end of agency involvement there were opportunities for professionals to have better interaction with her. Where the children are young, professionals should be urged to observe and comment on the interaction between the parents and the child3. Whilst there are observations of C’s siblings there is not comment on the parent’s interaction with C apart from brief mention of negative interaction of M shouting at C in the street which became the subject of a referral to Childrens Social Care. Whilst the case was in Child in Need there was a high level of contact between the resource worker and the family but it is not apparent from the records that there was much direct interaction with C during these visits or observations of C recorded.  10.2.2 After the cessation of the Child in Need plan the contacts with services did offer opportunities for discussion with C but it would seem that none of these were recognised or taken. In June 2012 the mother took C to the walk in GP service, at the time C was 4 years old but there is no indication that she was spoken to by the medical staff. This was a significant opportunity as the reason for the visit was soreness to C’s vagina that was attributed to Impetigo. Subsequent interaction with C has shown that she is open with professionals and had a more enquiring approach been adopted further information may have been forthcoming. In December 2012 there was an anonymous referral made regarding Domestic Abuse this did not initiate any discussion with C. In June 2013 C disclosed to the school that her father slapped her and the school noticed a change in her behaviour, although the school did obviously engage with C this was without any knowledge of the case history. The opportunity presented to the school may have been significant, as this was the only occasion in this case where C made what could be described as a disclosure to 3 The Voice of the Child: Learning the Lessons from Serious Case Reviews, Ofsted ,April 2011  17                                             professionals.  10.2.3 The interaction that agencies have experienced with C since the sexual offences have come to light have shown that C is unusually affectionate towards men and very accepting of procedures that some children would find difficult e.g. child protection medical. This may indicate that a greater investment into the views and needs of C may have given professionals a deeper understanding of her situation.   10.3 Parents Perspective  10.3.1. The Child Protection Plans in both Authorities 1 and 2 focused on the ability of the parents to protect their children from extended family members but at no stage does there appear to be any consideration to the parents capacity or ability to parent or fully understand what was being asked of them.  10.3.2 Both C’s parents would class themselves as dyslexic but this does not at anytime appear to have have been considered, except fleetingly in a health visitors report. The parents attended Child Protection Conferences and as a matter of course were provided with a paper and pen but they viewed this as a way of undermining their status and confidence in the conference. It is not apparent that their difficulty in reading was ever catered for or explored in the Child Protection meetings. The parenting course necessitated the undertaking of written work and there was a continued reliance on a written agreement during both Child Protection and Child in Need phases. The parent’s dyslexia and lack of support to deal with this left it open for them to claim that they did not really understand the full extent of what was being asked of them, as F did when confronted with the written agreement he claimed to have never seen it before despite it having been repeatedly used to ‘manage’ quite high risk incidents.  10.3.3 Had there been consideration to undertaking a parenting capacity assessment not only would this have assisted in ensuring that the parents achieved a good understanding of what was being required of them but this may have also included an interview with C which could have presented an earlier opportunity to gain her views and for professionals to take a view on her feelings.   10.4 Joint working and intra/inter agency communication  10.4.1 The coordination and meeting structure whilst the case was in Authority 2 seems appropriate although there was delay in commencing the non abuse carers risk assessment but this would appear to be due to a lack of cooperation from the parents. There was early communication between the Authorities and Authority 2 attended the transfer meeting. The transfer meeting which was crucial to understanding the nature and complexity of the case, in particular, the family structure, was not attended by a social worker or team manager from the receiving authority or quorate in terms of other agencies. There is no clear reason for this lack of attendance but this and the quoracy does set the tone as to how this case progressed. The difficulty in attendance at this meeting could be attributed to the  18 organisational difficulties in Authority 1 that are later described. A coordinated meeting at this stage could have identified the wider family network and assisted all practitioners to deal with the case more effectively setting a foundation for the case to move forward more productively.  10.4.2 The ownership and accountability for the case was not clear from the outset, there was no allocated social worker and it is not clear at what stage a social worker did become involved. This lack of ownership had a direct impact on the ability of agencies to work together in a coordinated fashion as meetings were cancelled without communication and there was information known to Childrens Social Care such as the family moving addresses, which was not passed to the health visiting service and other agencies, this undoubtedly caused frustration within agencies and impacted on the management of the case.   10.4.3 The same pattern continued whilst the case was managed as Child in Need, there was no allocated social worker with the case being managed ‘by the duty team’. This resulted in cancelled meetings and frustration in agencies when information was not passed or responses made to queries. There is no evidence of effective joint working during these stages despite a tenacious approach demonstrated by the health visiting staff who followed up appointments that the family did not attend, undertook a number of ‘opportunistic’ visits and frequently attempted to speak with the allocated social worker.  10.4.4 The decision to close the case to social care and cease the Child in Need plan was undertaken after discussion within Childrens Social Care and the decision not communicated to other agencies, this perhaps gives an indication as to how Childrens Social Care, at the time viewed the management of the Child in Need plans. In early December 2011 the family resource worker visited the family to notify them of the closure. It is worthy of note that the family disclosed on this visit that they were unhappy with the health visitor, as she had challenged them for not feeding Sib1 properly. The health visitor continued to try and achieve a Child in Need meeting through December 2011 and January 2012, still in the belief that a plan existed before escalating the lack of a Child in Need meeting to the Named Nurse. The health visitor was finally informed of the closure at a Child in Need meeting in February 2012, two months after the case had effectively closed.  10.4.5 During the progression of the case on Child Protection and Child in Need there were a number of opportunities for reflection and the convening of a strategy meeting under section 47 Childrens Act 1989 on the basis that a child was likely to suffer significant harm. In August 2010 M disclosed that she and F had separated and she had left C in the care of F. This is set in the context that part of the Child Protection Plan focused on the stability of the relationship between the parents and a concern that F did not accept the relevance of the risk presented by his parents and had not participated in the final stages of the parenting programme. This was very quickly followed by further escalation in the form of F breaking into the family address and being arrested by police and dispute over contact with the children. It would appear that none of these changes in circumstances gave rise to consideration for further inter agency discussion. A full disclosure of information held by agencies at this time should have led to re-appraisal of the status of the case.   19 10.4.6 In March 2011, when the case was managed under Child in Need M and F were separated and M had a new partner. The family aide worker informed the social worker that they were concerned that F was taking the children to his parents contrary to the written agreement. During March and April 2011, the family effectively ‘went missing’ to be later located mid April. Despite the apparent risk no renewed inter agency strategy discussion took place.  10.4.7 The decision to cease Child in Need with an intention that it should be managed by Team Around the Child was flawed, it was set against background of non engagement and missed agency appointments by the family. The family will state that they were never asked to participate in a Team around the Child or CAF arrangement, it is therefore not surprising that any coordinated joint working did not occur and any attempts at multi agency working effectively ‘fizzled out’.  10.4.8. In Primary Health care the family moved GP registration frequently; it would appear that the initial link between GP registration and health visiting was good as when the family registered with GP 1 in Authority 2 it initiated a referral to health visiting, which was followed up and led health visiting to contact Authority 2 for the family records. The recording of Child Protection concerns in GP practices was not consistent, whilst the child protection concerns were noted by the first GP practices as they were transferred they became less obvious and became non-existent in most GP records, vital information around Child Protection concerns appears to have been literally ‘lost in translation’. If it was present it was not readily accessible. There is not a consistent approach as to how Child Protection concerns are recorded in GP records and therefore made obvious on transfer. This is a current area of focus for health organisations but should be overseen by the LSCB to ensure that a consistent approach is embedded.  10.4.9 Had the information been more accessible in the medical records it is more likely that a vital referral to Childrens Social Care may have been made in June 2012 by the Out of Hours service, regarding the genital soreness attributed to Impetigo. This said the health care professionals involved in this review are of the unequivocal view that the presentation alone with these injuries, without the background Child Protection history should have initiated a referral and more enquiring approach, in line with the relevant NICE guidance.4  10.4.10 When C started school in September 2012 the school was not provided with good background information regarding the Child Protection and Child in Need history, which is unfortunate considering the significant part they play in a young persons life. This was partly due to the fragmented picture of pre-school settings. The school were informed by the school nurse ‘that there had been some poor parenting’ which inadequately reflected the serious nature of previous intervention. When the school contacted Childrens Social Care with a concern, this lack of information sharing was not rectified. It is now apparent that at the time of this referral Childrens Social Care did not fully access their records and made a poor decision that there was no role for Childrens Social Care on this basis. The school are firmly of the view that they would have approached the subsequent meeting with C’s mother quite differently, if equipped with all the information. 4 http://guidance.nice.org.uk/CG89 - When to suspect maltreatment  20                                              10.4.11 Childrens Social Care made a similar decision that there was no role for them when an appropriate referral was made by CAFCASS in relation to C being exposed to paedophiles at farm premises. The information had been received during the early stages of private law proceedings that had been initiated by Sib2’s natural father. It is apparent that the decision was made without reference to the wider child protection history, which was available. Also the fact that it arose during legal proceedings gave rise to the view that it lacked credibility. A more detailed examination of the history would have revealed the location of the premises being referred to and the identity of the persons alleged to be presenting the risk and therefore, perhaps, added credence to the initial information. There was no consideration given to speaking to C.  10.4.12 From the time that the police received the information on the potential abuse of C the response and partnership working was timely and coordinated. There was early and regular contact between key agencies which led to decisive and robust action.  10.4.13 There is evidence that the police and probation service worked in a coordinated fashion in the management of U, who was the uncle with whom the offender lived. Whilst it is recognised that this relationship did not represent any breach of U’s conditions it would have been good practice for Childrens Social Care to share with the agencies that U was considered a risk in a current Child Protection case, particularly as he was being managed through the MAPPA process. This may have given the managing agencies additional important contextual information.  10.5 Appropriate plans, risk identification and management.  10.5.1 A core assessment was completed in Authority 2 and the Child Protection plan that commenced appears appropriate for the time that the family were resident in the area. The Authority immediately identified the risk presented by the paternal step grandfather and undertook to issue a letter before legal proceedings, which initiated C and her parents moving from the address. There were regular and appropriately attended core group meetings. On transfer of the case Authority 1 adopted the Core Assessment and Child Protection Plan, there does not seem to be any refreshing of the plan or consideration of what new risks the move may have been presented, in particular from the extended family of the maternal grandmother. The plan in Authority 2 had also included the need for family history profiling to take place, this had not occurred at the time of transfer and was not followed up by the receiving authority.   10.5.2 The initial plan did include the need for a comprehensive pre-birth assessment, as M by this stage was around 6 months pregnant with Sib1, this assessment never took place despite the social worker recording ‘there are number of people in the family network who we are familiar with and who pose a significant risk’. There was a second opportunity for a pre-birth assessment when M was pregnant with Sib2 early in 2011, whilst the case was managed in Child in Need. The risk, at this time, may have been considered heightened as M and F had separated and the  21 paternity of the unborn child was in doubt. The only consideration to an assessment at this time was by the midwife who initiated a CAF, which obviously would have relied on parent engagement.  The LSCB guidance on Pre Birth Multi Agency Procedures states that an assessment should be initiated where the parent is involved in a Child Protection plan or has been subject to Child Protection arrangements. The lack of consideration of pre-birth assessment raises a question as to how embedded this process was at this time.  10.5.3 The plans in Authority 1 both at Child Protection and Child in Need were weak, they did not effectively identify and understand the risk presented at various stages. There was no consideration to any contingencies that should be put in place should the parents fail to adhere to the plans and work with the agencies. From the outset of the Child Protection plan there was slippage and what followed was uncoordinated with numerous cancelled meetings. Meetings that did take place where often not quorate and there is evidence that agencies frequently did not receive minutes of the meetings.   10.5.4 There was an over reliance on what is described as a ‘written agreement’ with the parents. It was extremely unlikely that the parents were able to police their own contact with the extended family. Even when it was suspected that C and her siblings were being exposed to the adults that presented the risk, the written agreement was relied on to reinforce the message to parents, this is despite the lack of apparent engagement and their difficulty in absorbing written material. F even denied ever signing the written agreement, which gives a strong indication as to the effectiveness of such an approach. The Child in Need plan in May 2011 identified M as being responsible for monitoring the contact with the paternal grandparents, following a theme of putting unachievable responsibility for compliance on C’s parents.  10.5.5 The plans focused on the potential for sexual abuse but despite significant evidence of neglect professionals never effectively considered this and neglect did not form part of any plan of work. There was evidence of poor diet, living conditions far from ideal with the family having to vacate one address due to poor condition and dog faeces within the house. C and Sib1 suffered prolonged problems with constipation, which was undoubtedly exacerbated by the parent’s inability or reluctance to get her to medical appointments. The sibling (Sib1) was noted to be eating cardboard and plaster, which is indicative of a condition called Pica, an eating disorder where the person ingests non-nutritive substances. A careful review of the family circumstances could have led professionals to conclude that the Child Protection Plan and subsequent Child in Need Plan should have specifically included neglect and therefore increased the focus and actions of agencies in this area. There does not appear to have been any consideration for other causes of the constipation suffered by C. Whilst the most likely cause may have been poor diet professionals could have considered this in the context of the sexual abuse with constipation sometimes seen as a possible presentation of this type of abuse, as identified in the NICE guidance of when to suspect maltreatment.5  5  NICE Guidance CG89, When to suspect maltreatment, http://publications.nice.org.uk/when-to-suspect-child-maltreatment-cg89/guidance  22                                             10.5.6 In Authority 2 the Child Protection Plan recommended a Non Abuse Carers Risk Assessment. This did not occur and was slow to start in Authority 2, the positive parenting course which followed in Authority 1 is questionable as to its effectiveness.  The course undertaken did not provide any conclusive assessment of risk and was not followed through, it could not be said that F completed this course as he repeatedly failed to attend final sessions to go through the report and regularly minimised the risk the family members posed. The resource worker who delivered the course concluded ‘that she would be concerned If F took the children to visit  his family without M.’ As it transpired this is what did in fact occur at a later stage but there was no reference back to these concerns. There is also concern that the worker who delivered the course was not appropriately qualified to do so.  10.5.7 The Child Protection Plan in Authority 1 contained the need for the relationship between F and M to be stable, this was not the case over a number of months with periods of separation, dispute over contact to the children, involvement of the police over allegations of burglary and uncertainty and dispute over the paternity of the sibling Sib2. None of these factors initiated any review of the child protection plan or consideration for a strategy meeting.  10.5.8 Professionals did not demonstrate a high enough level of professional curiosity both in the overall analysis of the case and in relation to specific incidents. When BF was first encountered in the family home he disclosed that he had recently been released from prison but this did not initiate any formal or informal enquiry as to the reasons he had been in prison. This is surprising considering the reasons C was placed on Child Protection. Comment is made about C being sent home from nursery without knickers and this is cited as a reason by the parents for not sending her back. Again there was no robust questioning of the parents or follow up with the nursery. A reflective overview of the case as a whole could have questioned the true engagement of the parents and their true comprehension of the risks presented by some of their family members.    10.6 Supervision and Decision-making  10.6.1 The supervision in this case has been lacking in some agencies, this is undoubtedly partly attributable to the organisational factors prevailing at the time but exacerbated the poor coordination, decision making and the ability for someone to stand back and undertake some critical analysis of the events and risks.  10.6.2 The case was transferred in December 2009 and there is no record of supervision in Childrens Social Care until April 2011. Following an unattributed note on the records stating that M and F are failing to comply to the Child in Need plan and putting both children (C and Sib1) at risk of sexual harm. There is then a supervision record, which clearly articulates the levels of concern, ‘The family are believed to be with the paternal grandparents, they are not engaging with workers, they are being evasive and preventing agencies from being protective. They have left their property in an uninhabitable state, with dog faeces around the house.’ Despite this synopsis the approach to the case did not change nor was there escalation or action emanating from the analysis.   23 10.6.3 There is no obvious justification for the decision for the case to be stepped down from Child Protection to Child In Need in September 2010. The conference was not quorate and there was no evidence that there had been any positive change or that the risks had reduced. In fact the opposite was the case, the parents were going through an acrimonious separation, there were concerns that F was taking the children to contact the paternal grandparents, the children were living with a friend, health appointments were regularly missed and core groups had not been taking place. The decision to step down was not unanimous and was appropriately challenged by the health visitor, who presented a full and coherent report to conference but the chair made the final decision. Whilst the action by the health visitor was appropriate and commendable, it should have been followed up by a formal escalation in accordance with the LSCB escalation procedure.  10.6.4. The same pattern emerges for the step down from Child in Need to CAF in December 2011, there is no clear recording of the decision other than a supervision record which, contrary to factors being presented at the time, states concerns with regard to parenting are lessening. At this time the parents were exhibiting the same pattern of non-engagement, continuing contact with the extended family and there were increasing concerns around neglect of the children. The sibling (Sib2) had just been born and there was clear dispute over the paternity. The decision was taken outside of any Child in Need meeting by Childrens Social Care without the input of other agencies, the resource worker informed the family in December 2011 and the meeting to formally record the decision did not take place until February 2012. This unilateral decision is contrary to the current and previous Child in Need guidance, which states that the views of all professionals should be taken into account. The review has sought to establish why the decisions made to move from Child Protection to Child in Need and then to Universal services were made but the rationale and reasoning was not clear.  10.6.5 Appropriate supervision and management oversight was apparent within the health visiting service, notwithstanding the pressures and vacancies that they were experiencing at this time. There is evidence of matters being escalated to managers and the named safeguarding nurse.   10.6.6 The lack of apparent safeguarding oversight of the Out of Hours service is a concern. C attended an appointment in June 2012, which in the subsequent view of the health professionals should have initiated a referral to children services. There does not appear to be the same relationship with the Out of Hours service that is apparent in other health services. A separate provider to those of Primary, Community and Acute health services delivers the Out of Hours Service. The Out of Hours service is important as any persons wishing to deliberately or inadvertently evade the rigours of safeguarding could opt to use this service. Consideration should be given to including this provider more closely into the Local Safeguarding arrangements to ensure that the same standards apply.  10.7. Organisational Context.  10.7.1 During the relevant period of this case it is important to note that a number of agencies were facing significant challenges, which undoubtedly impacted on the way in which the case was managed.  24  10.7.2 It is apparent that much practice that occurred at the relevant period of this review is not in place now. At the time there was a high turnover of staff, reliance on agency staff and a substantial number of vacancies, this would account for the small number of staff who were involved in this case who are still with the department now and available to contribute to the review. This impact is evident in some of the practice issues that occurred. There was a lack of clear ownership during Child Protection and Child in Need phases with long periods of drift and cancelled meetings that caused frustration not only to other agencies but also to the parents who expressed this frustration in March 2010 as there had been no allocated social worker and a delayed start to the parenting course. Whilst these factors impacted on the service in 2010 and 2011 it cannot be said to be the case when CAFCASS and the school made the more recent referrals in late 2012.  10.7.3 These pressures were reflected in other agencies, the police had a number of vacancies effecting the supervisory levels in the specialist child abuse investigation unit at the time the information regarding images was received and acted upon, although this did not appear to inhibit the response which was timely and effective. The health visiting service was carrying vacancies and the health visitor who was responsible during the Child in Need phase was working with vacant caseloads and managing a student health visitor. Despite these pressures the response from the health visiting service remained consistent with instances of real tenacity noted. They followed up the parents for failing to attend appointments and Childrens Social Care when they cancelled meetings.  10.7.4 The staffing issues were accompanied by changes in organisational Information systems and recording practices. These changes have provided some difficulty in reviewing all the information held by agencies. Childrens Social Care changed their case management system in April 2012 and although all records should have converted is apparent that this was not the case. The health visiting service and primary health care have also migrated to a new system, which will provide benefits in the longer term but provided issues at the time of this review to view all the relevant information.  10.7.5 Although it cannot be specifically evidenced it could be reasonably assumed that at periods within the relevant times there would have been organisational pressure to take action to reduce the numbers of cases on Child Protection and Child in Need and this could have impacted on decision making in this case.  10.7.6 A number of changes have been made that deal with some of the issues raised in this report. • The LSCB has undertaken an audit of CiN meetings and has agreed arrangements to ensure that CiN meetings take place and that there is sufficient scrutiny of plans. • Issues of CP Conference quoracy have been addressed by the LSCB and both non-attendance and non-production of reports are now escalated and monitored. • Arrangements are now in place for minority views at conference to be formally recorded and escalated.  25 • The LSCB has agreed that non quorate case conferences should be reconvened and agencies who did not attend contacted. This is monitored monthly by the LSCB. • There is now a process following all Child Protection Conferences where the families views are sought and this includes ensuring that any discussions and decisions made are fully understood by the family.    11. Conclusions and lessons learned  11.1 This report will conclude with consideration of the lessons learned, a statement of the key messages from this case, and consideration of whether the events that have led to this review were predictable and/or preventable.  11.2 A number of the factors that existed at the time of this review in terms of organisational structure and coordination are no longer present across the partnership but it is nonetheless important that the lessons in this case are used to reinforce the need for staff to follow existing procedures and protocols and to use their professional knowledge and intuition to appropriately escalate their concerns and challenge both within their own organisations and other agencies.  11.3 The risks presented to children within the family network were well known to agencies in both authority areas. There were family members with convictions for sexual offences against children, in some cases children within the family network. These identified risks are what initiated the Child Protection Plan for C. OF, although associating and more latterly living with persons identified as posing a risk, was not someone who was known or believed to pose a risk in their own right. OF did not have any history with the criminal justice system nor was there any known intelligence linking OF to sexual offending. Although the Police and Probation Service had knowledge that OF was living with a sex offender being managed through multi agency processes, no agencies had any knowledge that OF was associating with C’s parents and in turn with C. These factors would have made it impossible for agencies to foresee that OF, specifically, posed a risk to C.  11.4 Whilst accepting that the risk of OF offending against C could not be foreseen the fact that there was a significant risk to C and other children within the family was accepted. It is not unreasonable to also conclude that, in the given circumstances, C’s parents were not capable of ensuring the safety of C from family members who posed a risk. This risk was not mitigated by interventions that were put into place by agencies as there was no clear understanding or assessment of the nature and reach of the risk, the work undertaken was uncoordinated and inter agency communication was poor. A more coordinated and in depth scrutiny of the family dynamics may have given agencies more of a view of the potential for harm, although it would not have identified OF.  11.5 Questionable decisions were made to reduce multi agency focus at times where there had been no reduction in risk and there had in fact been significant escalation, which, should have prompted more robust action, and escalation. These decisions were not sufficiently challenged by the agencies involved although it is clear that they did not always concur with them.  26  11.6 The voice of the Child was not effectively sought by organisations or if it was this has not been effectively recorded. The final referrals to Childrens Social Care in 2012, which were considered not to reach the threshold for assessment and therefore dealt with as contacts, all provided an opportunity for discussion with C but this was never considered.  11.7 A more coordinated approach from the outset would have led to a greater understanding of the family network and how extensive the risk of sexual abuse was. With this knowledge it is not unreasonable to expect that there would have been a more robust and challenging approach taken when dealing with C’s parents, in particular to their apparent intransigence to what they were being asked to do.  11.8 The agency reports have highlighted areas of learning for their organisations and they have made single agency. This includes remedial action that has already been put in place. The learning from this review can be stated as: -  i. When a Child Protection Case is transferred from one area to another there should be a coordinated handover attended by all relevant organisations to effectively share information.  ii. That all agencies should be aware of the capacity of the parents, particular attention should be paid at Child Protection case conferences to ensure that the parents are able to fully understand what is being asked of them.  iii. It is important that professionals are confident to challenge the decisions made by other agencies including those made in multi-agency meetings, that they are aware of the Safeguarding Board escalation procedure and use it appropriately.  iv. That professionals should demonstrate healthy professional curiosity when dealing with families and be prepared to challenge them appropriately. They should gather and appropriately record all information to present a cumulative picture.  v. That all agencies understand, with reference to the Safeguarding Board Threshold document, the process of stepping cases up and down in order that they are able to challenge appropriately.  vi. That Child Protection and Child in Need information is accurately and obviously recorded by all agencies particularly where cases are handed over.  vii. That Child Protection Plans are responsive to the changes in circumstances and risks within families and the plan reflects these changes e.g. where neglect is identified in cases previously recorded as sexual abuse.  viii. That there should be increased multi agency awareness and  27 involvement in Child in Need plans and all relevant professionals should be involved in discussions to end plans.  ix. There needs to be greater awareness of the signs of maltreatment across all agencies.  x. That the voice of the child is paramount and that all opportunities should be made to understand this. Where the child is young there should be effective use and recording of professional’s observations of the child.  xi. Where decisions are made as to how referrals and contacts are to be dealt with there should be reference made to all available case history and this includes sharing this history with agencies who become involved and are expected to take up some role in the management of the case.  xii. It is important that meetings are quorate particularly when key decisions are being made. Where the children are young this increases the importance, as the number of agencies involved are likely to be less.  xiii. Where there is information that named individuals pose a risk to children this should be shared with any agencies that are managing the individuals to provide important contextual information and enable more effective monitoring.    Recommendations  Recommendation 1:-   The Safeguarding Board should oversee and ensure the completion of all the recommendations made by agencies.   Recommendation 2:-  The Safeguarding Board should ensure that the learning from this review is effectively disseminated to all agencies, this to include the awareness and use of the Pre-birth protocol and escalation procedures. This should include the Safeguarding Board satisfying itself that the lessons learned are embedded and continue to be monitored.  Recommendation 3:-  Childrens Social Care should review and the Safeguarding Board disseminate to agencies a clear step up/step down pathway that is cognisant of all current procedures and developments to ensure that all agencies are clear on the status of cases and what support is available and ensure that this is embedded into agencies.  28  Recommendation 4 :-  Childrens Social care should review the current Child in Need procedures and through a multi-agency reference group ensure that all agencies are aware of their roles and responsibilities to ensure the plans are robust and coordinated.  Recommendation 4:-  The Safeguarding Board should satisfy itself that the process for transfer in conferences is robust and attended by all appropriate agencies  Recommendation 5:-  The Safeguarding Board should develop a closer relationship with the health provider for the Out of Hours Service and ensure that they are included in Section 11 activity and that there is appropriate oversight and scrutiny.    Findings  As well as the identified learning points and recommendations that have been identified this review was keen to identify any wider themes or findings that the safeguarding partnership could consider and discuss how these can be achieved through the variety of work it undertakes. Discussion during the review process with professionals has identified these areas:-  • The Safeguarding Board should satisfy itself that it promotes a sense of confidence within all the agencies to achieve a culture whereby professionals are able to appropriately challenge one another, their own and other agencies and families with whom they are working.  • The Safeguarding Board should seek to obtain best practice from partner agencies should be captured with a view to achieving greater consistency of approach to obtaining the voice of the child.   29 Appendix 1- Family structure chart     30 