Death of 10-year-old girl in April 2020, found in bed with a ligature around her neck. Her father was in prison following a violent assault on the mother. Learning themes include: the lived experience of domestic abuse for a child; vulnerable children remaining the focus of agency concern when they move areas; parental alcohol abuse; cultural and language considerations; signs and triggers of emotional distress in children; and online safety and the dangers of children viewing age-inappropriate content. Recommendations to the Partnership include: all guidance should emphasise the importance of understanding the lived experience of the child; re-emphasise the message that domestic abuse is always harmful to children; proactively offer support to those families who are transitioning from refuge into independent living; review training needs to ensure professionals have a better understanding of the complexity of parental alcohol misuse and include training on interpretation and understanding of hair strand samples; continue to emphasise the dangers of children viewing age-inappropriate content; ensure processes are in place so that when children on a Child Protection Plan move areas, they are not removed from systems automatically and their information is reviewed; ensure schools display the appropriate level of professional curiosity and proactively seek information for new pupils transferred in; ensure that third sector organisations such as refuges share information so that partner agencies have clarity about their role in safeguarding existing and previous residents; ask the 'Victim Care' service to consider reviewing the current arrangements governing the sharing of information regarding the prison release of perpetrators within the family.
      
 Title:  Child safeguarding practice review concerning Child QDS 20. LSCB: Derby and Derbyshire Safeguarding Children Partnership Author: Russell Wate 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.                           Page | 1  Final       Child Safeguarding Practice Review concerning Child QDS 20                Independent Author: Dr Russell Wate QPM  Page | 2  Final 1.0        Introduction and Background to this Child Safeguarding Practice Review         In April 2020, a 10-year-old child (QDS) was tragically found in bed with a ligature around their neck. The East Midlands Ambulance Service attended the home and declared the child to be deceased.          The child lived with their mother (MQDS) and a younger sibling (SQDS) in private accommodation. The father (FQDS) was in prison following a violent assault on the mother. In May 2019, the family moved from Warwickshire to live in a refuge in the Derbyshire area.         The child’s death took place during the first lockdown period of Covid-19 and QDS was not in school as they didn’t fit the criteria the government had set at that time for a child to be classed as vulnerable. This was for those children who were open to children social services or subject of an education health care plan.         QDS had been on a Child Protection (CP) plan in Warwickshire. The plan was still in place when the child moved to Derbyshire, with Warwickshire retaining ownership of the plan. The plan had however ended several months before the child’s death. The CP plan concerns were in relation to domestic abuse and mother’s misuse of alcohol.        The family are not originally from the UK, but their culture and heritage was from another part of Europe. Although QDS was born outside the UK, she moved to the UK as a young toddler. The family’s first language was not English.  Following the death of QDS, Derbyshire Children’s Social Care Services made a Serious Incident Notification to the National Child Safeguarding Practice Review Panel. The Derby and Derbyshire Safeguarding Children Partnership (DDSCP) completed a rapid review which led to the Safeguarding Partnership’s Independent chair agreeing to commission a local child safeguarding practice review (LCSPR) in accordance with Working Together to Safeguard Children (2018) and the Child Safeguarding Practice Review Panel: practice guidance (2019). Terms of reference for the review were agreed and can be seen in full at appendix A. A LCSPR panel was established by the DDSCP to assist with the review and report progress to the DDSCP through its Chair. Membership included representatives from key agencies who had been involved with QDS.  The agreed time period for the review covers the period from April 2019 to April 2020.  The Partnership also appointed an Independent lead reviewer Dr Russell Wate QPM to assist with the review and to produce a report on the DDSCPs behalf.  A learning event was held with front line practitioners involved in the case. This included practitioners from the previous Local Authority, local agencies including schools and a member from the refuge. This learning event was supplemented by a managers learning event. Both the practitioner and managers events were extremely helpful to the author in developing the learning and to compile this report. The review author has also had a conversation with MQDS and he has benefited greatly from her insight into the life for QDS and the family.   Page | 3  Final 2.0 Analysis of Learning Themes          The rapid review process and the LCPR panel who confirmed the Terms of Reference identified several learning themes arising from the tragic death of QDS. These themes were discussed at the practitioner and managers event, where other key themes for learning were also identified. The themes are articulated and analysed in turn in the below sections of the report.         Domestic Abuse          The lived experience of domestic abuse for QDS, are that in 2015 a referral was made by the Police highlighting allegations of domestic abuse between parents, this led to QDS becoming subject to at this time  a Child in Need Plan. Over the subsequent two-year period there were reports that both the mother and father consumed alcohol to excess. The result was that direct work by a Social Worker (SW) was undertaken with QDS, and MQDS, they received support through the Domestic Abuse Counselling Services in Warwickshire until the case was closed in 2017.         In March 2019 there was a significant domestic abuse incident during which FQDS strangled MQDS causing her to lose consciousness. He also kicked and punched MQDS, breaking her nose and damaging her kidneys, which resulted in her being admitted into hospital. When the Police attend this incident, they found that they both had been consuming vodka and SQDS who had witnessed the assault, was covered in her mother’s blood. The Police acted promptly and the following day, FQDS was charged with criminal offences relating to the assault on MQDS and he was remanded to prison and was subsequently sentenced at Crown Court to 33 months imprisonment. QDS and SQDS were moved into a foster placement under a section 20 agreement with MQDS’s consent.         Warwickshire Local Authority were prompt in their actions to protect QDS and her sibling and when MQDS was fit to leave hospital arranged for her and the children to be protected in a refuge. The Warwickshire SW at this time worked closely and well with MQDS and her children as well as the refuge, which was situated some distance away in Derbyshire. The refuge carried out support work with MQDS and the refuge Children Young Police worker did do a significant amount of direct work with both QDS and SQDS whilst they were in refuge, this took place in group sessions and one to one around the domestic abuse, boundaries, wishes and feelings, emotions etc.         A few days before QDS died, MQDS received a letter from Victim Care that her ex-partner, FQDS would be eligible for release on electronic tag, in October 2020. It is not known what the emotional impact that this may have had on QDS as it is felt that the child would most certainly have read the letter and may have translated it for MQDS. When MQDS spoke to the review author she was adamant that QDS would not have seen the letter, so in her view there was no impact on QDS.         MQDS had previously been contacted when her address was obtained through her DA contact worker and Victim Care wrote to her outlining the sentence dates.  When MQDS and the children moved into their own accommodation they were sent another letter, with a request for contact if she wanted any additional licence conditions. MQDS made no response, so the Victim Care team as is their usual practice made the case dormant at that time.  Page | 4  Final        A learning theme for services here is in relation to sending letters like this with sensitive information to victims of DA. The victim service needs to take account of the emotional impact that the letter contents may contain to their victims and also is in an accessible format for them for example in this case written in their first language.        The Adoption and Children Act 2002 extended the definition of ‘Harm’ from the Children Act 1989 to include ‘impairment suffered from seeing or hearing the ill treatment of another’.          Prolonged or regular exposure to domestic violence can have a serious impact on a child’s development and emotional well-being. QDS lived in this type of household environment.          The Department for Education published in March 2020 ‘Complexity and challenge: a triennial analysis of SCRs 2014-2017.’  As can be clearly seen from the table (Table 13 in the report) domestic violence is a major factor featuring in death and serious harm to children.                  Alcohol Abuse         Parental abuse of alcohol is a major feature of this case. Almost all the parental neglect of QDS and SQDS stems from this abuse of alcohol. History of alcohol abuse is a feature in the mother and father’s past.          In 2015 Warwickshire Police and Children Social Care (CSC) first got involved with the family this was due to a suicide attempt by FQDS and issues of DA and excess alcohol use were noted by both agencies. As a result of these issues a CIN plan for QDS commenced. Over the subsequent two-year period there were reports of both parents consuming alcohol to excess.         In May 2019 as part of the Warwickshire children social care parenting assessment an investigation of MQDS alcohol abuse and dependency was undertaken. The results of the hair strand test taken as part of the assessment showed significant and chronic alcohol use.  Warwickshire children services SW advised MQDS to seek support from alcohol services, which she didn’t do due to her imminent move.          The family subsequently moved into the refuge in Derbyshire in 2019. The refuge completed a report for the rapid review process and when they attended the practitioner event, they stated that other than when she first arrived at the refuge, where a bottle of cider was found in her belongings, the refuge found no sign of her drinking.   Page | 5  Final         A practitioner at the event who is not an expert, but offered an opinion that a person who is dependent on alcohol will not have just stopped drinking like that, and she would have become very good at disguised compliance of their alcohol consumption. The refuge representative at the event though was clear that there was no sign of drinking during her time with them. Which could suggest that whilst in the refuge MQDS felt very safe and secure and did not need to depend on alcohol until her circumstances changed.  This safe and secure environment changed when MQDS left the refuge and went to live by herself. During the Warwickshire SWs visit to the refuge, alcohol was discussed and was a factor in trying to encourage mum to seek support for triggers etc. However, professionals involved with working with her at that time did not highlight any evidence or concern around mum using/misusing alcohol. In support of this QDSs school at this period never suspected MQDS of being intoxicated or smelt alcohol on her breath. MQDS in her conversation with the review author was adamant that she didn’t drink alcohol whilst at the refuge.         A few days after leaving the refuge in October 2019 MQDS sent a text message to her former SW in Warwickshire to say they were now in their own property and happy they were grateful for the support the SW had provided.  MQDS was also grateful to refuge's consistent support. The refuge offers up to four "move on" visits when someone leaves refuge to help them settle into their new accommodation and support them to set up their tenancy. MQDS engaged with three of these before stating she didn't feel she needed support anymore. MQDS was then offered "outreach" which is an additional 12 sessions with a different team, however mum declined. This surprised the professionals that knew her from Warwickshire, that MQDS did not take the refuge up on their offer of the out-reach support team. MQDS when speaking to the review author re-iterated her thanks to her Warwickshire SW and the staff at the refuge.         It is not until February 2020, which is the first time since June 2019, that MQDS and alcohol is mentioned by any of the professionals in the case. The main agency involved in this period was QDS’s school who did not notice anything unusual. SQDS though was under the care of a HV who also made no previous observations of any concerns. A referral was made in relation to MQDS by the refuge regarding mum's alcohol use. The information had come to them from one of their current residents who had visited MQDS in her home. There is no record of this referral being received by Derbyshire Children Social Services; this is subject to comment in a later section of this report.          MQDS told professionals immediately following QDSs death that on the 28th of April 2020 she started drinking before midday and drank vodka to the same amount as she usually does.  She described how she finished drinking by approximately 9pm that night.  The review author has been told that QDS was not found by their mother until the early afternoon on the 29th of April. This led to questions about why MQDS had not checked on QDS in the morning, but it is now understood that QDS regularly did not get up until midday. This brought further concerns to the review author about neglect of QDS.        The Police informed the rapid review process that the attending police officers to the death were concerned about the home conditions, as there was evidence of significant alcohol consumption and vomit evident over the downstairs of the property. No alcohol bottles were seen on the first visit, however on the second visit, 11x1 litre empty bottles of vodka were found under the sink in the kitchen.  Page | 6  Final          MQDS told the professionals from the Police and Health immediately following the death of QDS, that she previously drank a lot of alcohol.  MQDS reported that this was historic misuse of alcohol and only happened at the times when her partner FQDS was drinking heavily.  She explained that at around that time Warwickshire children social care did some work with her with regards to her alcohol intake.  She told the professionals that she still drinks alcohol and will drink vodka. She explained that her usual drinking pattern would be to start before midday and to drink approximately half a bottle of vodka over the course of the day.  She explained that drinking alcohol makes her feel nice, relaxed, in a better mood and that time passes better.             MQDS stated shortly after the death of QDS that she has suffered from schizophrenia. There is no agency record of this, and the SWs from Warwickshire had not known of it before it was mentioned at the practitioner event. MQDS felt a deterioration of her mental health around February 2020 which led to her drinking. MQDS did not tell anyone or seek any professional support. MQDS told the review author that she was diagnosed 15 years ago in her home country with schizophrenia. She never sought help in the UK for this and there will be no record that she did. She used alcohol and staying in her bed as her method to cope with it.         There was a comment posed at the practitioner event about whether social workers have training relating to substance misuse. SWs have experience in supporting families with drugs and alcohol problems and a large volume of their day-to-day work and case load includes this vulnerability. In this case, the SWs Review Child Protection Conference report, accurately reflected the assessment of risk associated with the uncertainty of MQDS alcohol use and the report also recommended an ongoing CP Plan and a repeat hair strand test. The fact that this was raised does suggest further learning is required for all practitioners of the extreme risks of parental alcohol dependency and misuse. A lot of the de-escalation of risk was put down to the fact that the family did feel safe knowing that father was in prison and mum had taken significant steps as part of the CP plan to move and safeguard the children and there was no evidence of drinking.  Her parenting of the children during this time was noted by the professionals at the refuge and the SW as positive.          To support the findings of this learning theme being highlighted in this review report of the risk to QDS and SQDS of parental alcohol abuse, the below table taken from the Department for Education’s March 2020 publication, ‘Complexity and challenge: a triennial analysis of SCRs 2014-2017.’1 It states that over a third of children who either died or were seriously harmed had parental alcohol misuse in their home circumstances. This is entirely relevant to the lived experience for QDS and SQDS.  1 Brandon M et al (2020) ‘Complexity and challenge: a triennial analysis of SCRs 2014-2017’ Department for Education. Reference: DfE-00027-2020 Page | 7  Final            Cultural and language considerations         It would appear that MQDS and her children were isolated from their own community including friends and family members from the area where they used to live in Warwickshire. The main reason stated by MQDS for this, was because FQDS was well known in their community. He had family and a network, that MQDS was worried would let him know where they were living, when he came out of prison. This she said frightened her, so she steered clear of associating with them. MQDS told the review author that she was quite happy with this situation and was content with her use of Facebook to keep her connected with those members of her community that she wanted to.         The review report author was under the impression that MQDS only spoke or understood very little English. The rapid review also thought that QDS acted as a translator for her. Hence the concern that QDS would have translated the letter from Victim Care articulating that FQDS would be released from prison in a few months’ time. This would have undoubtably caused unnecessary worry to QDS for their family safety. The contents of the letter may have also been the trigger for MQDS’s increased alcohol consumption.        However, at the practitioner event there was a divergence of opinion on whether MQDS could speak and understand English. Those practitioners that knew her well, found that her English was good, in particular her spoken English, but, probably less so for written English. Those that knew her less well thought she understood a lot less than she seemingly did. MQDS told the review author that she felt that she spoke, but also could read English really well.        One of the reasons for this conflicting understanding of the level of English comprehension was because, MQDS told professionals that FQDS did not like her speaking in English so she feigned that she could not speak English so as not to annoy him. An example that as well as inflicting physical DA, FQDS also made use of coercive controlling behaviour in his relationship with MQDS. Page | 8  Final        A Department for Education funded project ‘Safeguarding and community inclusion’ looked at several of the issues raised in this section and supports the view that MQDS would not reveal her level of knowledge of English and local systems and processes until she had developed a trusted relationship.         ‘There is a high level of anxiety and low levels of trust and confidence within eastern European communities about the services that are provided locally. Migrant families are not receiving all the information that they need to make informed choices about using services. There is a lack of knowledge within the community regarding UK legislation relating to safeguarding children.’2        Child perceived herself as a young carer.        There is no suggestion that any professional regarded QDS as a young carer either for her younger sibling (less than three years old) or her mother. However, there were numerous signs and comments made by MQDS that she did overly rely on her to help with caring for SQDS.          QDS also mentioned to others including her Warwickshire social worker that they felt they needed to support and help their mother. A good example of this is after MQDS was severely assaulted by FQDS in March 2019, it was clear that QDS told professionals that they felt guilty that they were not at home to prevent the assault and to protect their mother. It was said by the professionals involved at the time that QDS felt that they were able to calm the father down and if they had been present it would not have happened. This must have put an emotional burden on QDS with their mother in hospital and father in prison.         In 2017 the Department for Education published a report ‘The lives of young carers in England Omnibus survey report Research report3’. The below citation is important to consider for the life of QDS and other children in similar situations.        ‘It is clear that young carers in this survey are taking on much higher levels of responsibility in the home than their peers who do not have to provide care. In some instances, the effects of caring on children’s physical and mental health and well-being are considerable and, without formal identification, assessment and support - including early help prevention-based interventions - these could have profound long-term effects on children’s lives.’         MQDS stated to professionals shortly after the death of QDS, that QDS helped her by checking on her and helped with looking after the sibling. She stated that this was especially the case, when MQDS had thoughts in February 2020, that she had a brain tumour and was drinking heavily. Following the death when police asked mum for clothes and nappies for SQDS, MQDS said that she did not know where they were as QDS did that.  This evidences further the carer responsibilities taken on by QDS. In contrast to this MQDS did though tell the review author that in her view QDS had no caring responsibilities for her or SQDS.  2 Final-Report-Innovations-Project.pdf (safeguardingcambspeterborough.org.uk) 3 Sarah Cheesbrough et al (2017) ‘The lives of young carers in England Omnibus survey report Research report. Department for Education. Page | 9  Final       Signs and triggers of emotional distress in children        The purpose of this report is not to make a recommendation in relation to whether QDS intended to take their life or not, that is the role of the Coroner in this case. At the inquest the Coroner made a narrative conclusion. ‘On the evidence QDS must have deliberately tied a scarf around her neck in the fashion of a ligature, but given her young age it is not possible to find that she fully understood that her death would result from that.’    MQDS was absolutely adamant when talking to the review author that this was a very tragic accident. However, it is important to consider for professional learning, what were the signs of the emotional distress that were occurring for QDS’s in their life.           An important consideration here is whether QDS was suffering from any adverse childhood experiences (ACEs). The term 'Adverse Childhood Experiences ' is credited to Dr Vincent Filletti who carried out a study in the United States of over 17,000 people in the 1980's.  His study was the first to identify the relationship between experiences in childhood and problems with health and social integration throughout a lifetime. His ten identified ACEs are:          A number of these ACEs were experienced by QDS for example they had grown up in a household where serious DA, parental substance misuse, maternal mental health and neglect, were a frequent lived experience for them with the associated emotional impact a major factor in their life. FQDS incarceration for the serious assault on MQDS, which caused parental separation. MQDS substance misuse was another ACE experienced by QDS. Practitioners are aware of ACEs but helping children with similar experiences to QDS will need a trauma informed approach taken by professionals.  Page | 10  Final         At birth QDS was diagnosed with a myelomeningocele4 of the thoracic spine and she was also diagnosed with a congenital hydrocephalus (increased build-up of fluid on the brain). QDS had surgery within 24 hours of birth.  This surgery involved repairing the myelomeningocele on her back and inserting a ventriculoperitoneal shunt5 at the same time. There have been no complications from this early childhood medical history or apparent impact on QDS’s physical development. There is information that QDS’s attainment scores when younger were significantly below expected and that they were well below average for their age.  At the time of death though QDS’s development seems to have improved.         QDS’s death occurred during the period of the first lockdown for Covid-19. QDS was not at school and the school had not been informed of her and the family’s history so was not deemed as one of their vulnerable cohort of children. This period of lockdown would have increased the isolation for not only QDs but for the whole family.        Online-Safety        QDS had her own mobile phone which they had had for a couple of years. The phone was examined following their death and there was nothing untoward found on it. The family laptop that QDS used on a regular basis had within its search engine history, sites that were not age appropriate. Pinned to the search bar was a site that involved sexual activity that involved asphyxiation. This site was readily accessible and available for viewing by QDS. MQDS agreed that QDS did view the laptop, including sometimes in her bedroom at night.        The problem with QDS accessing age-inappropriate material on the internet was not a recent issue. The accessing of this content by her was of concern when QDS was in Warwickshire. They did extensive work in relation to this with both QDS and their mother. The Warwickshire SW had no knowledge of the extent of the content being accessed, until the practitioner event when the police officer outlined what was found on the laptop. It would appear that the material being viewed, agreed by MQDS, was an extreme escalation of the age-inappropriate content.         The referral from the refuge in March 2020 also mentioned watching a horror movie that was felt by the family from the refuge providing the information to be totally inappropriate.        The evening before QDS died, MQDS and QDS watched a horror movie rated 18 certificate and completely inappropriate for QDS to watch.  This movie had graphic violent scenes including killing on the movie including images of being grabbed around the neck and strangulation.          MQDS reported that she herself liked watching horror movies and QDS would join her watching them together.          At the practitioner event, health professionals were really shocked by QDS accessing this level of internet content and they expressed a professional view that they were very worried about what could have amounted to long-standing neurological damage to QDS.        Information Sharing  4 Myelomeningocele is a birth defect in which the backbone and spinal canal do not close before birth. The condition is a type of spina bifida. 5 A ventriculoperitoneal (VP) shunt is a medical device that relieves pressure on the brain caused by fluid accumulation. Page | 11  Final        During the period that this review is focussing on, there was some good information sharing between Warwickshire Local Authority and the refuge. At the practitioner learning event both the SWs and the refuge commented on how excellent communication and information sharing had been between them.         The review has been informed that the school which QDS attended in Warwickshire sent all educational information to the new school in Derbyshire. This information contained all the previous history. This information the review understands was not received by the first school that QDS attended. The Head of the school was though aware of QDS being on a CP plan, as they liaised with SWs and sent information to update the CP core group. It is important that schools are proactive in finding out information about new pupils, who may have a number of vulnerabilities, that they need to take account of. If Schools do not receive the information that they require in order to understand their pupils risks, they should escalate this absence of information sharing to the child’s SW if they have one or to either the local authority education department or the regulator in exceptional cases.         The agreed process for Warwickshire Local Authority is to notify a local authority when a child is transferred into their area who is on a child protection plan from Warwickshire. This happened in this case. Due to the fact QDS and their family were in a refuge, this was considered by Derbyshire Local Authority as temporary accommodation and therefore Derbyshire did not receive the case as a transfer in.          On the 8th May 2019 Warwickshire children’s social care services notified Derbyshire children’s social care services, via a telephone conversation, of the family’s move to the refuge and that the two children were subject to Child Protection Plans. Derbyshire Children’s Services were informed that Warwickshire would maintain case responsibility and there was no request from Warwickshire for a transfer of Child Protection Plan conference or a request for service.           Following this telephone conversation, Derbyshire’s Child Protection Office sent a letter to Warwickshire to confirm that the children had been added to Derbyshire’s list of Children subject to another Local Authority Child Protection Plan. The letter further noted that Warwickshire would continue to have case responsibility for the children. The letter goes on to add that; ‘If we have received no further update 3 months after the date of this letter, we will remove child/ren from our List of Children Subject to Another Local Authority Child Protection Plan.’          In July 2019, the Warwickshire review CP conference for the two children decided to end the CP plan. The conference members had been informed that FQDS had been sentenced to 33 months imprisonment and his risk to the family had now ceased and that the family had settled in well at the refuge. The SW had recommended that the plan be continued so repeat hair strand tests could be carried out in view of the results of the previous ones and to ensure a transfer over to Derbyshire Children social care. This was also in line with recommendations from the parenting assessment. There was a level of over optimism from the other professionals at the meeting who didn’t agree with the recommendation for a continued plan, so it was agreed for it to end. The chair of the conference who attended the practitioner event now feels in hindsight that a step down to CiN might have been more appropriate but wanted it borne in mind this was his hindsight reflection. The plan ended in September 2019 for QDS and SQDS.  Page | 12  Final         QDS and their family left the refuge at the end of October 2019 and moved into their new home within the Derbyshire area. QDS transferred schools starting after the half term holiday at the beginning of November. The new school at the practitioner event stated that they had no information shared with them by the previous school about any concerns in relation to the family.           Within a week of starting there, the school recorded a concern about QDS. The concern was that they were presenting as being unclean with dirty unkempt hair and with dirty hands, nails, neck, wrist, and ears. A member of staff spoke with QDS about their personal hygiene.  The remaining four days of that week, QDS did not attend school, when QDS did return to school there were no further concerns raised regarding QDS’s hygiene and QDS continued to present as clean and tidy. The schools only other concern were about QDS’s attendance and after MQDS was spoken to, the attendance improved greatly.               The neglect concerns were not shared by the school, as they felt they were low level and having spoken to QDS they improved. Taken in isolation this is seen by the review author as a legitimate view. However, the school stated at the practitioner event had they been aware of the previous CP concerns, they would have formed a different view and have shared their concerns with Starting Point (Derbyshire's contact and referral service for children's services).          In March 2020, as already stated in this report a referral was made from the refuge regarding mum's alcohol use and the inappropriate use of the internet by QDS. The information was provided to the refuge from one of their then current residents who had visited MQDS and children in their home. There is no record of this referral being received by Derbyshire Children social care services and the refuge have established that a call was made on the 6th of March 2020, but can’t confirm this was definitely about QDS, as they have no record of who exactly this was to, or who was spoken to.  The review panel have enquired further into this and there is no record of any call being received in Starting Point. There is no facility to make a direct call into Starting Point this happens through ‘Call Derbyshire’. The review panel have made further enquiries with ‘Call Derbyshire’ and there is again no record of a call having been received about QDS.           On the 27th of April 2020, an anonymous referral was received by Starting Point. This referral corresponded with another referral that was received by Starting Point a short while later on the same day, which came from QDS’s Primary School. The school made the referral as they had been provided with information from one of QDS’s neighbours, who had become concerned because of what they had heard. The information provided in the referral detailed that ‘mother could be heard crying, screaming and vomiting at home and that there was a two-year-old child in the home who was often heard upset.’  In their referral the Primary School further advised that there were some previous concerns about QDS’s attendance and that they had held meetings with the mother about this and QDS mainly interpreted for her.  On the same date, the contact record was screened by a Starting Point Team Manager and a screening decision was made that the Child in Need Plan threshold had been met. On the 29th April 2020, a triage of the case commenced, and three attempts were made in the morning to contact MQDS. One of the calls was answered by a young child (it is assumed that would have been SQDS) but professionals were still not able to speak with MQDS. Later Page | 13  Final the same day at 15:40 hrs, Derbyshire Children’s Services received notification from Derbyshire Police that they had attended an emergency at the family home and that QDS had been found deceased.           On reflection and with analysis when QDS transferred to the refuge in Derbyshire, Warwickshire children services complied with their agreed process and demonstrated continuing and consistent care to the family. The letter response from Derbyshire children social care seems a bureaucratic process that might need to have a professional view taken on each case rather than a standard automated procedure.                 Taking full account that the chair of the review conference said that his was a hindsight view, the review author and panel are of a view that the CP plan should at the very worst have been stepped down to a CiN plan. This should have been the case until it was seen how MQDS coped when not a resident in a safe place like the refuge. In particular because the Warwickshire SW who worked with the family and knew them felt the CP plan itself should have continued.  This could have then involved local Derbyshire agencies and supported the neglect concerns seen by the school only two weeks after they left the refuge.                  A Child Protection Transfer conference should also have been considered to enable partner agencies to understand the vulnerability of the children in the family and make an informed decision of their needs. This would have enabled at the time consideration of the need for a CIN plan to enable a safe transition from the refuge.         The referral by the refuge in March is a key piece of missing information that may have involved crucial involvement with the family. It is at this time that MQDS told professionals after the death of QDS that she was drinking heavily and felt although she didn’t seek medical assistance that she had a brain tumour and stayed in bed trying to recover.          This in turn would hopefully have meant that there could have been local professional involvement and then the opportunity for the school during the first Covid-19 lockdown to have kept QDS in school as a vulnerable child fitting in with the government guidance at the time or at least had this in mind when they had their regular virtual contact with QDS and MQDS. This could have also alerted SQDS’s HV and the families GP.          3.0 Conclusion         In summary, QDS’s lived experience was one where they had early medical issues that were resolved but did require follow up a few years after arriving in the UK. QDS and SQDS lived in a very violent DA household, resulting in their father receiving a substantial period of imprisonment for assaulting their mother. In this household both parents drank alcohol to excess, this continued when MQDS was the lone carer of QDS and SQDS. QDS also had a level of self-appointed caring responsibilities for MQDS and SQDS.  This was a missed opportunity for professionals to provide extra support for QDS.        There is no information seen by the review author or panel that would suggest that QDS intended to take their own life. As already mentioned earlier in this report QDS had suffered Page | 14  Final several adverse childhood experiences. There is evidence that QDS viewed on a regular basis very age-inappropriate internet content that included asphyxiation.        The voice of QDS has not always been sought or strongly heard as often as it could have been.        The family were isolated from their own community it is thought by the review panel by the mother for safety reasons. MQDS had, until October 2019, a consistent circle of a professional network but no personal or family support. When living alone this support had finished leaving MQDS and family isolated in particular when the first Covid-19 lockdown occurred and QDS was not in school. The offer of offsite support from the refuge was not accepted by MQDS.        The perceptions by some practitioners that MQDS only spoke or understood very little English would appear not to be true. What is now clear to the review author and panel is that MQDS only spoke English freely with someone who they trusted. The key learning is for professionals to understand why this reluctance may exist and to consider strategies to overcome any cultural and language barrier.        The level of viewing age-inappropriate internet content by QDS was thought by professionals at the practitioner event to be a major emotional experience for QDS that they would have found it hard to neurologically process. The review author highlights that though it is difficult to know the impact on QDS, their alleged level of familiarity with this sort of content is highly inappropriate.        The work the Warwickshire SWs and the refuge did with MQDS to keep her safe and provide a period of stability is seen as good practice. As was the work of the Derbyshire Health Visitor who attended and worked with the family diligently during the time at the refuge.        A good level of information sharing did take place at times but could be improved for example in relation to the referral in March 2020. This report has already outlined what has been ascertained in relation to this referral, the learning though relates to professionals ensuring that they record who they spoke to. The refuge has already put this learning in to practice.         On reflection and with hindsight the ending of the CP plan would appear to have been premature and the process to just close cases of notification of residents with a CP plan in another Local Authority area could do with refinement.        The sending of the letter by ‘Victim Care’ in relation to the release of FQDS was felt by professionals at the practitioner event a trigger of concern for QDS and MQDS. News like this to vulnerable victims should be if possible be conveyed through a SW if one is in place or other local multi-agency agencies or voluntary support services.   4.0 Recommendations             This CSPR has identified learning and made some recommendations, as detailed below, and the implementation of these will assist the DDSCP to deal more effectively with similar circumstances in the future, resulting in the improved safety and welfare of children.  These recommendations are also of importance to Warwickshire Safeguarding Children Partnership and should be considered by them accordingly. Page | 15  Final Recommendation 1 a) The Derby and Derbyshire Safeguarding Children Partnership (DDSCP) should seek assurance that all practice guidance and learning material they produce emphasise the importance of understanding the lived experience of the child. b) The DDSCP should review the current awareness raising, training and development of staff across the partnership around ACEs and look to see how this learning could be enhanced. Recommendation 2 a) The DDSCP must re-emphasise, to ensure the message that Domestic Abuse is always harmful to children living in households that DA is occurring. The DDSCP should combine this learning message with action plans arising from two local domestic homicide reviews. b) The DDSCP should seek assurance that support is proactively offered to those families who are transitioning from refuge into independent living and are isolated with a number of risk and vulnerability’s which may impact upon parenting ability. Recommendation 3 The DDSCP need to be assured that professionals have a better understanding of the implications and risks associated with the complexity of parental alcohol misuse and how this is harmful and neglectful to children. This will include a review of the training needs of professionals to help them understand the vulnerability of adults who abuse alcohol and the impact of that abuse on children and include training on interpretation and understanding of hair stand samples, as the results are a very key indicator of current and future risks that need to be acted upon. Recommendation 4 The DDSCP should continue to provide the resources they have on online safety, which includes the message of the extreme dangers of children viewing age-inappropriate content. This is with an intended outcome to raise professional and parental confidence to reduce the viewing of children’s of age inappropriate content. (The DDSCP already has in place several online safety resources for professionals to use. The resources can be readily accessed on the safeguarding children partnership website. The information also includes guidance for parents and carers in relation to protecting their children from age-inappropriate content.) Recommendation 5 a) The DDSCP should be assured that processes are in place for children that are temporarily in the area that are on a Child Protection Plan in another area, are not removed from their systems automatically and the information relating to the child is reviewed. This will ensure that all agencies put in place child centred arrangements and are aware of their continuing role in safeguarding children who have been at risk of significant harm in another area to Page | 16  Final Derbyshire and what information should be shared to enable the child and family to start and continue to live in their new home with secure arrangements in place. b) The DDSCP should seek assurance that schools within their area display the appropriate level of professional curiosity and are proactive in seeking information for new pupils transferred into their schools. c) The DDSCP should share this review with Warwickshire Safeguarding Children Partnership inviting them to ask for assurance in relation to cases involving Domestic Abuse where the victim and family is in a refuge and the step-down to no plan whilst they are residing in the safety of the refuge. d) The DDSCP should seek assurance that ensuring that robust safeguarding arrangements are in place and that information is shared with partner agencies by  third sector organisations such as refuges, so that they have clarity about their role in safeguarding existing and previous residents. This should include services commissioned by community safety departments.  Recommendation 6 The DDSCP should ask the ‘Victim Care’ service to consider reviewing the arrangements that are currently in place governing the sharing of information regarding the prison release of perpetrators within the family. This will hopefully bring about an understanding how vulnerable families that are victims of DA are informed of planned release of offenders and how the emotional impact on these vulnerable families might be managed better for the victims through effective multi-agency support. Recommendation 7 The DDSCP should seek assurance from its partnership agencies that cultural competence training is taking place which highlights awareness raising about the impact of cultural difference and how these are being taken account of in practice? This will help to raise the level and knowledge, confidence, and skill within the local workforce.          Page | 17  Final          Appendix A Derby and Derbyshire Safeguarding Children Partnership Terms of Reference  Terms of reference for Serious Case Review QDS 20   1 Introduction  This Child Safeguarding Practice Review is being commissioned by the Derby and Derbyshire safeguarding Children Partnership (DDSCP) in accordance with Working Together to Safeguard Children (2018) and the Child Safeguarding Practice Review Panel: practice guidance (2019). A multi-agency panel established by the DDSCP will conduct the review and report progress to the Partnership through its Chair.  Membership will include representatives from key agencies with involvement.  The review will consider the lived experience of a young person (primary school age) who died at home because of hanging by a ligature. The purpose of the review is to draw out learning arising from the young person’s individual experiences and identify improvement measures that should be taken to address systemic practice improvement.   The review will consider the learning arising about the services provided to: Page | 18  Final Code    QDS Subject Child   SQDS  Sibling   MQDS  Mother   FQDS  Father    The review will: • Explore all areas of potential learning about the way in which local professionals and agencies work together to safeguard children including seeking the views of professionals involved in the cases; • Determine the extent to which decisions and actions taken were child focussed and considered the children’s lived experience;   • Seek contributions to the review from appropriate family members and keep them informed of key aspects and progress;  • Identify any actions required by the DDSCP to promote learning to support and improve systems and practice.   Methodology The review will be completed in a proportionate way that enables the partnership to learn from the experiences of the family, practitioners involved in the case and relevant managers and promote a positive learning culture. The detail of the methodology will be linked to the key theme and explained below.  • Learning events will be held with front line practitioners involved in the case including and include practitioners from the school.  • Learning events will be held with managers involved in the cases and strategic managers as needed. • At the learning events a series of exploratory questions linked to the themes below.  • The parent will be invited to participate in the review and be interviewed by the overview author. • Reports may be commissioned from agencies to provide specific additional information not included in the Rapid Review. The specific requests for information may be identified Page | 19  Final following the practitioners’ meeting. There may be generic points for clarification and specific requests for individual agencies. A child safeguarding practice review report will be completed to provide: • A brief overview of what happened and the key circumstances of the lived experience for the child and their sibling in a way that does not identify them and is sufficient to understand the context for the learning and recommendations.  • A critique of how agencies worked together and analysis of good practice and systemic areas for development.  • Analysis of what would need to be done differently to prevent harm occurring to a child in similar circumstances; and,  • What needs to happen to ensure that agencies learn from this case.  2 The key themes and questions that the review seeks to answer. These themes incorporate the areas identified in the rapid review and are presented thematically together as below:  • Understanding how systemic improvements could be made to ensure that vulnerable children remain the focus of agency concern when they move to live in another area. A review of the policies and procedures governing the transfer of children from one Local Authority to another will be undertaken to ensure that safeguarding arrangements are transferred seamlessly, and that information is shared in a complete and timely manner. This will ensure that all agencies are aware of their continuing role in safeguarding children who have been at risk of significant harm in another area and what information should be shared to enable them to start and continue to live in their new home with secure arrangements in place. • Exploring signs and triggers that can help parents and professionals be alert them to emotional distress in children and promote learning from this case and additional national research that will assist in strengthening responses.  • Identifying how to improve the professional analysis of the impact of parental substance misuse on the welfare of children and clarify the actions necessary to address that impact to secure the safety of children. This will include a review of the training needs of practitioners Page | 20  Final to help them understand the vulnerability of adults who abuse alcohol and the impact of that abuse on children. • Understanding how vulnerable families are informed of planned release of offenders and how the emotional impact on vulnerable families might be managed through effective multi-agency support. This would involve reviewing the arrangements that are currently in place governing the sharing of information regarding the prison release of perpetrators within the family and role of victim care in this process. • Understanding how systematic improvements can be made so that agencies, such as refuges, have clarity about their role in ensuring that robust safeguarding arrangements are in place and that information is shared with partner agencies to ensure on-going support is in place post transition from the service. • Understanding whether features in the case lead to wider learning will additionally be explored within the review. These include: the role QDS may have had caring for their younger sibling; the impact of the extreme horror film (and any others) watched in the household; and whether there is learning to support members of the community who may have concerns about their neighbours. • The review will consider whether there is learning emerging from the analysis of the individual experiences of the children and their parent in respect of their race, ethnicity, gender, age, religion, or disability. The parent did not speak English and QDS translated for her. Understanding the impact on QDS and access to appropriate services will be a specific feature of the review. Whilst there were no specific early learning features arising from the impact of restrictions arising from Covid19 this will be considered during the learning events.  Additional features emerging after the Rapid Review include: • Understanding the impact of the medical condition “precocious puberty” on QDS development and identify relevant systemic learning for primary school, social care, and health staff to ensure that the needs of other children experiencing the medical condition are understood and addressed.  Page | 21  Final The review will establish an understanding of the causal or contributing factors that affected “why things were done well” or “why there were gaps in practice” to draw out the learning that is most likely to be effective and lead to future improvement.  Timeframe for the review The review will cover the period of April 2019 to April 2020. Any significant incident relevant to the case but prior to the start of the period may be included in the analysis completed by each agency.  The review is undertaken by one reviewer appointed by the Review Panel. They will have responsibility for examining how the statutory duties of all relevant agencies were fulfilled and reporting on this to the Review Panel and the DDSCP.  Review Panel members:  • Derbyshire Children’s Social Care  • Warwickshire Children’s Social Care • Derbyshire Police • Named GP • Designated Doctor • Designated Nurse • Hospitals – Chesterfield Royal Hospital • Health Services – Derbyshire Healthcare Foundation Trust, Derbyshire Community Health Services Trust,  • Education –  • Derbyshire Primary School’s • The (Domestic Abuse) Refuge   3 Specific tasks of the Review Panel • Identify and commission a reviewer to work with the review panel in accordance with guidance for concise and extended reviews.  • Plan with agencies involved in the review for the completion of key tasks as required Page | 22  Final • Plan with the reviewer a learning event for practitioners and separately their managers (if directly involved in the case), to include identifying attendees and arrangements for preparing and supporting them pre- and post-event, and arrangements for feedback. • Plan with the reviewer/s contact arrangements with the children and family members prior to the event.  o Contact arrangements will be agreed with the Senior Investigating Officer and will occur following the conclusion of interviews carried out with family members. • Receive and consider the draft overview report to ensure that the terms of reference have been met, the initial hypotheses addressed, and any additional learning is identified and included in the final report. • Agree conclusions from the review and an outline action plan and make arrangements for presentation to the DDSCP for consideration and agreement. • Plan arrangements to give feedback to family members and share the contents of the report following the conclusion of the review and before publication.  4 Tasks of the DDSCP • Consider and agree any learning points to be incorporated into the final report or the action plan. • Ensure the Review Panel complete the report and action plan. • Confirm arrangements for the management of the multi-agency action plan by the Review Panel subgroup, including how anticipated service improvements will be identified, monitored, and reviewed. • Plan publication on DDSCP website. • Agree dissemination to agencies, relevant services, and professionals.                      