Death of a 5-year-old child in November 2018 due to injuries sustained in a serious and reckless incident at the family home. Learning includes: gathering and analysing family history, which includes history of contact with services, is a core task when working with children and families; it is important that appropriate empathy towards the parents does not cloud professional judgement or challenge; supervisors and managers should consider how busy front-line workers make trade-offs in order to resolve goal conflicts and cope with uncertainty and system pressures, and ensure this does not compromise children's welfare and safety; the language used to describe services, forms, tasks and activities carries weight and can create expectations; professional curiosity is the ability to think, and communicate, in a way that explores what is happening rather than making assumptions or accepting things at face value; exploring and reconciling differing perspectives about the risks a child or family is experiencing is a necessary task when operating in a multidisciplinary context; when working with parents who are, or become, resistant it is important that expectations are transparent about the professional response to such resistance and that these are clearly stated from the outset; when new, and potentially serious information emerges about risk to children the response should be measured and match the level of seriousness; when undertaking assessment work, professionals should be alert to all risks that children may face, and not make assumptions about mothers naturally being protective. Recommendations include: to ensure the learning is disseminated across the multi-agency safeguarding partnership.
      
    Serious Case Review No: 2022/C9362  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.      OFFICIAL - Sensitive         Serious Case Review Family M  Date: 19/02/2022  Lead Reviewer: Kevin Ball                                  OFFICIAL - Sensitive  CONTENTS   Section   Page  1.Introduction to the case under review & synopsis of findings   1  2. Process for conducting the review   1  3. Family structure & contribution to the review   2  4. Synopsis of relevant case history   3  5. Findings & analysis  5.1. The use of case history to inform assessments & decision making  5.2. Considerations about thresholds for intervention, including step-up & step-down arrangements  5.3. The quality & effectiveness of safeguarding supervision and/or management oversight & scrutiny  5.4. The extent of professional curiosity, challenge and escalation  5.5. The consideration of risk posed by other adults who had contact/lived with the family   5  6. Good practice   16  7. Conclusion   16  8. Recommendations   17   1  OFFICIAL - Sensitive  1. Introduction to the case under review & synopsis of findings 1.1. This Serious Case Review examines the circumstances of agency contact and involvement with four children that lived together in a family home. The children, aged between 11½ years and 5 years, lived with their mother. In November 2018 a serious and reckless incident occurred at the family home. As a result of the incident and the significant injuries suffered the youngest child later died. The children had been known to services since 2008 and at the time of the death were subject to a support plan via the local authority Strengthening Families Service.  1.2. As a result of the Rapid Review process undertaken by the Local Safeguarding Children Board (LSCB) in January 2019 information emerged that at the time of the serious incident an adult male (to be known as Adult 1) was in a relationship with the mother, and living at the family home. This adult male was of concern given his history of violence against women. Despite services being involved with the family, the adult male’s presence was not known about at the time.  1.3. The decision to conduct a Serious Case Review has been based on the fact that a child suffered serious harm (potentially through abuse and neglect), and then death, and there was cause for concern about the way in which agencies had worked together to safeguard children. Whilst the serious harm, and death, was not directly attributable to abuse or neglect as may be the case in other such case reviews, the concern about the way in which agencies worked together remains, particularly so, given the lack of knowledge about the adult male’s presence in the family home.  1.4. The outcome of a Police investigation and trial in a criminal Court resulted in no convictions. Both Adult 1 and the children’s mother were present at the time of the serious incident and each carry some culpability for events. Children’s Services remain involved with the surviving children offering support.  1.5. By way of a summary, the following findings have emerged from this case review; - Despite being known about, family history and previous involvement with services, was not fully evaluated and not consistently used by professionals to inform assessments and decision making by some agencies involved.  - A small number of professionals were determined in their efforts to raise the profile of the concerns they had about the children, particularly the eldest child. Their efforts to raise the threshold of concern with the Multi-Agency Safeguarding Hub (MASH) were mostly unsuccessful due to systemic pressures the Hub was experiencing but also a degree of sympathy being expressed for the mother’s situation; decisions made as a result of these issues were not in the children’s best interest. - Contextual safeguarding issues which were of concern about the eldest child were not recognised, explored or responded to.  - Professionals became aware of the presence of an adult male in the family home prior to the incident; this adult presented a risk to children and adults. Information was not best used to assess for any risks he may have posed.   2. Process for conducting the review 2.1. The Board commissioned Kevin Ball as the Independent Reviewer1. The approach taken has complied with the expectations as set out in statutory guidance2 and has provided a way of looking at and analysing frontline practice as well as organisational structures and learning. A Soft Systems Methodology3 has been adopted allowing system  1 Kevin Ball is an independent and experienced safeguarding consultant, with specific experience of chairing and authoring case reviews.  2 Working together to safeguard children, 2015, HM Government.    3 i) Soft Systems Methodology by Checkland, P., & Poulter, J., in Systems Approaches to Managing Change: A Practical Guide, Reynolds, M., & Holwell, S., Open University, 2010, and ii) Soft systems methodology in action, Checkland, P., & Scholes, J., 2003, Wiley.     2  OFFICIAL - Sensitive  thinking ideas to be applied, enabling the review to capture and identify opportunities for professionals and organisations to learn and improve safeguarding practices from a whole safeguarding system perspective. 2.2. The decision to initiate a Serious Case Review was taken in January 2019 by the Independent Chair of the Board following a Rapid Review of agency contact with the children. Following the appointment of the Independent Reviewer an initial scoping meeting was held at the end of April 2019. At this point the following steps were taken; - Single agency reports4  and chronology were requested and submitted in May 2019, which in turn generated a combined chronology of agency involvement. This process provided each agency with the opportunity to reflect on their involvement with the children. As a result, agencies have been able to consider actions required of themselves in order to make improvements to practice early on in the process, - A facilitated multi-agency workshop was convened in early July 2019 involving practitioners who had come into contact with the children, - Following the conclusion of the Police investigation and criminal trial, the Independent Reviewer spoke with a close member of the children’s family; the mother declined the opportunity to contribute to the review.  - Due to the Police investigation and criminal trial, it was not possible to finalise the review until these parallel processes had concluded; as such, the review process from start to finish took 29 months to complete. The report was accepted by the LSCB’s Review Subgroup Group in September 2021 and the LSCB’s Safeguarding’s Executive Board in November 2021. The Covid-19 pandemic and associated restrictions were also a contributory factor to the pace of the parallel processes. 2.3. The timeframe under review was from August 2015 to December 2018. Relevant information prior to this period has been included as necessary.  3. Family structure & contribution to the review 3.1. For the purpose of conducting this review the following individuals are relevant; Child A (youngest), Child B, Child C and Child D (eldest) with ages ranging from 5 to 11 years – all of whom lived with their mother at the time of the incident. Also, at the time of the incident, Adult 1 was spending a considerable amount of time in the family home. The children’s father died some three years prior to the incident.  3.2. Seeking the contribution of family members has been an important consideration. The mother was offered the opportunity to contribute to the review; this was declined. The Independent Reviewer spoke with a close family member once the criminal trial had concluded. The family member described a number of incidents over many years where it was known that the children were witnessing domestic abuse or being on the receiving end of abusive and emotionally harmful behaviour. Despite concerns being shared the family member felt that little changed.  3.3. Given the children’s circumstances, their age and trauma they had experienced, a decision was made to not offer them the opportunity to contribute to the review.    4 Single agency reports were submitted from the following agencies;  - Borough Council in the local authority area                 - School 1 - Strengthening Families Service     - Local Hospital - Community Rehabilitation Company    - Children’s Services - NHS Foundation Trust      - Adult Social Care - School Health & Wellbeing Service     - University Hospitals NHS Trust - Clinical Commissioning Group                       - National Probation Service - Police       - Specialist Secondary School 1    3  OFFICIAL - Sensitive  4. Synopsis of relevant case history 4.1. Relevant history of note, prior to the timeframe under review shows that the family were known to Children’s Services, the Health Visiting Service and the Police. Children’s Services conducted a number of Initial Assessments5; - December 2008: Initial Assessment - concerns related to domestic violence. Following assessment, the case was closed to Children’s Services with no further action.  - March 2009: Initial Assessment - concerns related to domestic disputes, the cultivation of cannabis in the family home, the children living in poor conditions, domestic abuse. Following assessment, the case was closed with no further role for Children’s Services. - September 2009: Initial Assessment - concerns related to a domestic dispute and the children being heard screaming by passing Police officers. A further assessment was completed based on the history resulting in the concerns not being substantiated and no further role for Children’s Services. - September 2010: Initial Assessment - Police attended the property with a drugs warrant. Traces of cannabis were found along with drug paraphernalia. No-one was present in the property at the time of the Police visit, the house was in a poor state of repair and considered dangerous for young children, the bedrooms smelt of urine, there was no bedding, few toys, the environment was unsafe and unhygienic and there was little food in the house. Records indicate that once the Initial Assessment was completed no further work was undertaken although the mother and father agreed to attend a Family Centre. The findings of the Initial Assessment refer to the housing and conditions being clean and tidy, make no reference to drugs or the conditions of the property as discovered by the Police. The summary of the account by the Police does not match with the summary of the assessment by Children’s Services.  - July 2011: Initial Assessment - concerns were raised by MARAC6 and related to the mother not engaging with the local domestic violence support service, concerns she was taking anti-depressants and struggling, and concerns about Child D’s behaviours towards other children are home and school. The decision was that there was no further role for Children’s Services and the case was closed.  4.2. The father moved out of the family home in February 2011 but saw the children on a daily basis. In January 2013 the Police referred information to the Children’s Services locality team regarding a strong smell of cannabis from the family home, and banging and shouting being heard. This resulted in Children’s Services sending a letter to the family with advice and then no further action. 4.3. In August 2016 the family experienced an unexpected significant bereavement. This event was referred to the MASH. The outcome was that the Health Visitor would provide support to the family and the matter would be closed to the MASH. In September 2016 information was sent to the MASH that the children were found in the local park in the evening by a local Council worker; the worker knew the children from school noting that that they had not been seen in the park before, therefore making it unusual behaviour. 4.4. In March 2017 there was a further Contact & Referral to the MASH made by School 1, stating that Child A had arrived at Nursery crying saying that the mother had smacked him. Bruising was seen on Child A’s legs. This resulted  5 An Initial Assessment was described by statutory guidance at the time as a ‘… brief assessment of each child referred to a local authority children’s social care, in which it is necessary to determine whether the child is in need, the nature of any services required, and whether a further, more detailed core assessment should be undertaken …’, Working together to safeguard children, HM Government, 2006 & 2010.   6 MARAC – Multi-agency risk assessment conference, held in relation to domestic abuse.    4  OFFICIAL - Sensitive  in a Strategy discussion7 taking place and further enquires and assessment being conducted. The outcome was a support plan being offered, via Family Support workers. 4.5. In December 2017 a single assessment was conducted following a CAMHS referral to the MASH about the mother’s ability to keep Child D safe due to his behaviour. He was involved with older youths who were affiliated with gangs, criminal activity, vandalism, drugs and dangerous behaviour. At the time Child D was attending School 1 two afternoons per week due to his aggressive behaviour. School 1 were trying to support the mother however she had refused to work with the allocated worker. The outcome of the Initial Assessment was that the family should be supported by Family Support workers. The Police were informed of this referral however no further enquiry or action was taken by them. 4.6. In March 2018 a single assessment was completed following information from CAMHS that Child D and siblings, who were being supported via the Strengthening Families Service, due to Child D not accessing the bereavement support available. No safeguarding concerns were identified and the recommendation was that the Strengthening Families Service should continue to work with the family.  4.7. In May 2018 there was a Contact & Referral made by the Family Support worker who referred concerns about the mother struggling, trying to support Child D’s return to full time education and offering parenting support to the mother following the family bereavement.  A full history was included in the referral documentation. The referral noted ‘… Early Help have been involved with the family for about 18 months now with little or no improvement, this is a very long time for Early Help to be open …’8. The decision from this referral by the MASH was that Strengthening Families Service should continue their involvement.  4.8. The National Probation Service became aware that Adult 1 may have formed a relationship with the mother in August 2018. This information was swiftly shared with Children’s Services and the Police. There was further follow up by the Strengthening Families Service with the mother about this possible relationship; which the mother strongly denied.  4.9. In August 2018 there was agreement by the Family Support Worker about needing to review the support offered to the family at the next meeting, scheduled in September. This next scheduled meeting did not take place and no additional review meetings were ever scheduled until the serious incident. This meant that in the interim there was no active oversight or management of the case. Records do however show that Child D had recently started attending Specialist Secondary School 1 (although records highlight this was not without a number of incidents being noted), Siblings A, B & C were reportedly doing well at school, and the mother reported being pleased with progress.  4.10. In October 2018 there was a Contact & Referral made from the Family Support Worker concerned about Child D’s behaviours which appeared to be escalating, but also citing concerns about potential radicalisation. This particular issue was reported as being monitored by School 1 and there being support from Prevent9 discussed. A full history was provided in the referral documentation. The outcome of this referral was that the threshold for Children’s Services involvement was not judged to be met and that the family should continue to work with the Strengthening Families Service. The case was closed to the MASH.  4.11. In November 2018 a Contact & Referral was received following the serious incident. The mother and Adult 1 were implicated in the incident. A Strategy discussion took place, followed by an Initial Child Protection Conference.  7 Strategy discussion is convened under Section 47, Children Act 1989; where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable to them to decide whether they should take any action to safeguard or promote the child’s welfare.  8 Local authority area contact & referral record, May 2018, submitted to the review.  9 Prevent is a Government strategy to prevent people being drawn into extremism, Prevent duty guidance   5  OFFICIAL - Sensitive  This resulted in all four children being made subject to Child Protection Plans under the category of emotional harm. Child A died some weeks later due to the significant injuries suffered.  5. Findings & analysis 1. Having mapped the professional and agency contact with the children over the timeframe under review there are a number of features that stand out that help us understand what happened, and why events occurred as they did. These features are relevant from a multi-agency safeguarding system and practice perspective and, as such, provide us with the greatest insight into the quality and effectiveness of the response to the children at the time. Where possible, an explanation of why events occurred as they did, has been provided. Learning points for use by all professionals and trainers have been emphasised. The following area are explored; - The use of case history to inform assessments & decision making. - Considerations about thresholds for intervention, including step-up & step-down arrangements. - The quality & effectiveness of safeguarding supervision and/or management oversight & scrutiny. - The extent of professional curiosity, challenge and escalation. - The consideration of risk posed by other adults who had contact/lived with the family.  5.1. The use of case history to inform assessments & decision making 5.1.1. Statutory guidance10 in place at the time stated ‘… Assessment is a dynamic and continuous process which should build upon the history of every individual case, responding to the impact of any previous services and analysing what further action might be needed. Social Workers should build on this with help from other professionals from the moment that a need is identified …’.  5.1.2. A defining moment occurred for this family in August 2016 when the family experienced an unexpected and significant bereavement. This significant incident provided the professional network with an opportunity to reflect on the impact of this experience for the children against the known case history and what support the mother and children might need.  5.1.3. In this context family history not only includes historical information from 2008 but should also be viewed as taking account of chronological information gathered over the course of single, or multi-agency, involvement. An event that happened yesterday may be as relevant as something that happened last month or some years ago, and forms a chronological account of professional contact with a child and family. It is the accumulation of information that forms history and which needs to inform assessment and decision making.  5.1.4. When assessing risk from a safeguarding and child protection perspective, risk can be categorised into those factors that are currently presenting themselves as a concern, for which it may be possible to manage i.e., situational risks, and those where there is less likelihood of effecting change and which occurred prior to the current circumstances i.e., pre-disposing risks. In this case there were a number of pre-disposing risk factors that were known, and knowable, by the professional network at the time of the family experiencing the unexpected and significant bereavement which justified consideration. These included; - The Initial Assessments conducted between 2008 and 2011 which highlighted a range of worrying issues, indicative of concerns reaching a sufficient threshold to warrant an assessment by Children’s Services. - There was historical evidence of parental domestic abuse. - The parents using cannabis and misusing alcohol, and the impact this may have had on the children. - The children living in neglectful home conditions. - The mother experiencing post-natal depression following the birth of the eldest child.  10 Working together to safeguard children, p., 24, HM Government, 2015.    6  OFFICIAL - Sensitive  - The father’s criminal activity relating to drugs, violence and theft, and the impact of this on the children. - The father’s attendance at appointments with the Community Rehabilitation Company11 (CRC) was poor, resulting in work with him being ineffective and him being breached in November 2015. - The mother’s lack of engagement with professionals, with the exception of the Health Visiting Service. - School 1 expressing concerns in 2015 – 2016 about the children smelling of cannabis, and the uncle that was collecting them from school smelling of cannabis, plus Child D becoming increasingly challenging in school.  - Child D receiving a fixed term exclusion from School 1 due to an attack on another pupil in July 2016.  5.1.5. Information about the unexpected significant family bereavement was referred to the MASH by the Ambulance Service at the time. Evidence indicates that the outcome of this referral was that the Health Visiting would make attempts to contact the family the following month to offer support. Attempts by the MASH to contact the mother were unsuccessful resulting in a letter of advice being sent advising that she could access support via the Health Visiting Service, school or GP. Records indicate that the mother did meet with the GP during this period. Arguably, this was a missed opportunity.  5.1.6. There is limited evidence to indicate that the considerable pre-disposing information and historical contact with Children’s Services was considered as a repeating pattern, and no evidence to indicate that School 1 was contacted once the summer holiday period was over to gain a better understanding about the children’s welfare or whether they might need additional support. Matters were processed by the MASH with an onward expectation that an Initial Assessment would be completed by the Children’s Services Locality Team; whilst these assessments were completed the quality is variable and inconsistent. This is a pattern that is repeated throughout the remainder of the timeframe under review, up until the Initial Child Protection Conference in November 2018 following the serious incident. 5.1.7. Following the unexpected and significant family bereavement it is possible to see the emergence of other situational risk factors, against a background of significant pre-disposing risks. The recognition of these situational risk factors mostly appears to originate from School 1. - Child D’s behaviour becoming more challenging in School 1 during the 2016/2017 academic year resulting in him receiving seven fixed term exclusions, requiring extensive pastoral support to help manage his behaviours and a bespoke reintegration programme on, and off, site. Alongside this the school recognised concerns about the family and made a series of referrals to the MASH. - January 2017: further concerns about the smell of substances/cannabis from the children’s clothes and bags. - March 2017: Child A disclosing being smacked by the mother. This resulted in Strategy discussion and a joint visit by the Police and Children’s Services. There was no consideration of the case history in the single assessment that followed.  - July 2017: general concerns expressed by the school having received information from agency staff who provided sporting activities, other parents and neighbours about the children’s welfare.  - October 2017: Sport agency staff witnessed incidents of concern outside of school hours and passed their concerns to the school.   5.1.8. The emerging concerns outlined above show an accumulation of factors which, when coupled with the other known history, justified a level of professional curiosity. As cited above, there is no evidence to indicate that there was any multi-agency reflection following the unexpected significant family bereavement in August 2016. With the steady stream of additional and concerning information from School 1 over the 12 months following the family bereavement up to the autumn months of 2017, it would not be unreasonable to expect wider professional curiosity and collective  11 CRC is a criminal justice agency tasked with managing low to medium risk offenders sentenced to community orders or imprisonment. To protect the public, probation staff assess and manage the risks that offenders pose to the community. They help to rehabilitate these individuals by dealing with problems such as anger, drug and alcohol misuse and lack of employment or housing, to reduce the prospect of reoffending. They monitor whether individuals are complying with court requirements, to make sure that they abide by their sentence. If offenders fail to comply, probation staff enforce order through the court or request recall to prison.   7  OFFICIAL - Sensitive  interest beyond the school’s involvement. This could have included the Health Visiting Service, GP, School and Children’s Services.  5.1.9. Children’s Services have reflected on this noting ‘… a lot of the single assessments did not properly consider the history, make sense of this, and then compare this to current concerns. There was a lack of checking information with partner agencies, for example School 1 and CAMHS … a number of single assessments were completed by a newly qualified social worker … but no evidence of challenge from the team manager and instead a focus on completing the assessment quickly …’12. Learning point: Gathering and analysing family history, which includes history of contact with services, is a core task when working with children and families. This allows professionals to identify possible patterns of behaviour, and how the parents might respond to offers of support. Failing to do this can result in workers becoming caught in a thinking trap of having to start again, each time the family come into contact with services.   5.1.10. The above accounts reveal a clear pattern of case history not being considered in assessments and decision making. The reasons for this will be further examined in the following sections. 5.2. Considerations about thresholds for intervention, including step-up & step-down arrangements 5.2.1. Statutory guidance13 in place at the time noted ‘… the provision of early help services should form part of a continuum of help and support to the different levels of need of individual children and families … having clear thresholds for action which are understood by all professionals, and applied consistently … should ensure that … the right helps is given to the child at the right time …’. 5.2.2. An underlying pattern which has emerged is a difference in perception, with conflicting views, about thresholds for intervention by Children’s Services; this is particularly so from School 1’s perspective who were identifying concerns in relation to Child D yet did not see a shift in response.  5.2.3. School 1 demonstrated tenacity and persistence in recognising concerns and referring them to the MASH. School 1’s frustration was that this was not matched by a suitably robust and effective response by the MASH/Children’s Services. This was compounded by the knowledge that when Child D had moved on to a secondary school, Child A sometimes attended School 1 upset describing that Child D ‘… goes mad at people …’ and had ‘… smashed up my room …’ (October 2018) highlighting continued problems for the children which, it seemed, were still not effectively being dealt with or listened to. School 1’s view was that an Early Help Plan was not a suitably robust mechanism to deal with the weight of issues the children were experiencing. Prior to this there is only one recorded Strategy discussion taking place in March 2017 as a result of Child A reporting being smacked; at no other point do concerns appear to be judged as reaching a threshold of actual, or likely, significant harm or even as a Child in Need14. The involvement and contributions of the Strengthening Families Family Support Worker failed to add weight to any views expressed by School 1. 5.2.4. As noted above, an Early Help Plan was developed in December 2017 despite earlier attempts being dismissed by the mother. Review of the Early Help Plan highlights a recording format that is not reader friendly and with no specific section that confirms who will be responsible for which actions nor which professionals might be involved with  12 Children’s Services, submission to the review.  13 Working together to safeguard children, p. 15, 2015, HM Government.   14 Child in Need - Section 17 of the Children Act 1989 imposes a general duty on the Local Authority to safeguard and promote the welfare of children who are ‘in need’ and to promote the upbringing of children in need by their families by providing a range and level of services to meet those children’s needs. A child in need is defined as a child: i) who is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of services; ii) or a child whose health or development is likely to be significantly impaired, or further impaired, without the provision of services; iii) or a child who is disabled.   8  OFFICIAL - Sensitive  the plan. The content within the documents in relation to the actual case management changes little over the duration of the Service’s involvement and there is no indication of progress made. 5.2.5. The implementation of this Early Help Plan was not without problems, which have to be seen alongside concerns about Child D not diminishing. Complicating factors included;  - The mother’s engagement was problematic and often focused on her own needs rather than those of her children. This included a focus on the mother’s mental health and bereavement issues over the course of five home visits between April and May 2018. - The mother was reluctant to engage in parenting work, yet continued to struggle with Child D’s behaviour.  - Five home visits scheduled between June and November 2018 were cancelled by the mother and she displayed inconsistency in her engagement. The impact of this was that neither the children nor the home environment was seen on a regular basis. During successful visits age-appropriate toys and a clean, tidy home environment were observed. The children were also observed to be clean and wearing clean clothes. There was no obvious reason for the Family Support Worker to be concerned about the children’s safety and welfare. - There is evidence of some mitigating factors that would complicate a decision to increase intervention. Factors included Child A, B & C usually presenting well in school, being compliant with the uniform code and other expectations. The children were also able to achieve age-appropriate educational expectations and their attendance, although not ideal, was not a major concern. These factors are indicative of children that are receiving an adequate level of physical parenting with routines and standards. Whilst the mother did not engage with events relating to educational matters for the children e.g., parents’ evenings, she did attend summer fayre’s, sports events and school performances. These inconsistencies complicated decision making.   5.2.6. However, these factors have to be balanced alongside the knowledge about concerns for Child D continuing to emerge, such as; - School 1 reported concerns that Child D carried a knife, although this was not substantiated.   - Concerns about Child D accessing inappropriate material online including extremism and radicalisation.  - In October 2018 Child D had moved out of the family home to stay with a relative.   5.2.7. The further referral in May 2018 from the Strengthening Families Service resulted in a decision from the MASH which concluded by stating ‘… the social care history illustrates that the family have had significant input, having been through seven single assessments since 2008. Four of these … have been since the beginning of 2017. There are therefore legitimate concern around the family bouncing between Early Help and Child in Need, and therefore [we should]  ... not … encourage statutory involvement unless necessary, in order to prevent the family being passed back and forth unnecessarily … it was identified that [current work] appears to be having a positive impact and that positive change can only be sustained if [the mother] continues with it … it is felt unfair, and arguably oppressive, to not provide the mother with the opportunity to implement positive change. As there has been recognised improvement in the last fortnight, it is felt it may be beneficial for the work to be given a fairer chance to further improve the family’s situation … give it a chance for a few more weeks; then the option to re-refer in the future remains … it is therefore recommended that the case close to MASH …’15. This advice/recommendation which received management endorsement reflects a number of issues; - The ‘… significant …’ level of input provided since 2008 which is mentioned, is not evidenced in the referring information; basing a decision to continue with a Strengthening Families Service offer therefore appears to be made without knowing what level of input the family had actually received since 2008 and was therefore flawed as a decision. The evidenced chronology held on file did not drive a reasoned threshold decision.  15 Local authority contact & referral record, May 2018, submitted to the review.    9  OFFICIAL - Sensitive  - There is no reflection or analysis about the ‘… family bouncing between Early Help and Child in Need …’ and what this might mean in terms of the system’s ability to respond to welfare concerns for the children. Alongside this, not wishing to ‘… encourage statutory involvement unless necessary …’ fails to recognise the growing body of concern which had been re-referred and that applying a different threshold to the situation may have been a justifiable option and pathway worth pursuing.  - The hope that the current work would have a positive impact failed to consider case history, re-referrals and instead focused on the immediate and presenting issues. This was over-optimistic and is indicative of a mind-set which seeks short term fixes for situations that are more embedded.  - The rationale of basing the decision on ‘… it being unfair and … oppressive to not provide the mother with the opportunity to implement positive change …’, suggests of a degree of sympathy for the mother and her situation and is not child focused; it was not based on the weight of evidence from the Family Support Worker and School 1 that the plan for Child D was failing and concerns were not reducing. The daily experiences for the children, especially Child D, were not shifting.   Learning point: Research16 into other Serious Case Reviews highlights ‘… the quality of empathy embraces considering both the voice of the child and the needs of the family. It must be grounded in the centrality of the rights and needs of the child, while being sensitive but not colluding with the needs and views of the parents … it is important that appropriate empathy towards the parents does not cloud professional judgement or challenge …’. 5.2.8. The information set out above leads to a conclusion that there were some problems with the quality and effectiveness of the decision making and the application of thresholds at the MASH, at this time and on this case.  Evidence reflects over-optimistic gatekeeping at the MASH and over optimism about the extent to which the Strengthening Families Service could intervene given the voluntary and consent driven principles behind any early help offer. Those attending the workshop for this case review almost unanimously reflected this view and that with the benefit of hindsight different decisions could have been made.  5.2.9. The Strengthening Families Service have reflected on their involvement during this timeframe and noted that ‘… the … presenting and escalating concerns during our involvement indicated that in our professional opinion that the threshold for Early Help was exceeded and in May 2018, August 2018 and October, resulting in MASH referrals from Specialist Intervention Team Family Support Worker [being] made.   The outcome of all the referrals from our service to the MASH recommended that the support should be met by Early Help support and signposting to counselling support ...  The repeated view was that the case did not meet threshold for Child in Need or Child Protection and did not require further assessment from statutory services …’.  The Service has further reflected their analysis ‘… throughout our involvement and our three MASH referrals there was a lack of consistency in the analysis by the MASH and Assessment and Intervention Team of the information and consideration that statutory service maybe required. ...  We did not use the escalation process following the outcome of these referrals …’17. 5.2.10. Two clear reasons why decisions were made at the time have been captured through documentary review and discussion with practitioners. 5.2.11. Firstly, there was a need to prioritise cases and other children judged as being in higher risk situations; this viewpoint can be justified given some of the complicating and mitigating factors outlined above which are likely to have provided a degree of reassurance. From a system thinking perspective the prioritisation of cases in such scenarios  16 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 202, University of Warwick & University of East Anglia, May 2016  17 Strengthening Families Service, submission to the review.     10  OFFICIAL - Sensitive  can be described as a trade-off. Trade-offs18 are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to prioritise. Trade-offs, such as these, help us understand behaviour and system outcomes. At the time around 2018 the MASH triaged referrals and information, then passing any further work required to the district-based Assessment & Intervention teams or Strengthening Families Service. In this case, the MASH relied on the assessments and judgements of the Strengthening Families Service that had been involved with the family and had been swayed by the mother’s intentions of continued engagement with the Service (which whilst not ideal, her engagement was seen as sufficient). This triage activity was viewed with a level of bias, with no scepticism about what other assessment work might be useful to dig deeper into what might be happening for Child D and the family. This appears to have been driven by the system demands and pressures. Additionally, the district-based teams had difficulties recruiting staff and were forced to place some inappropriate expectations on newly qualified staff, alongside experiencing management absences. On this basis, decisions were unwittingly made about prioritising workload. The trade-off in this situation was an assessment and decision-making process that moved the work through the system, but which offered limited reflection about what might actually be happening and what the children’s day to day experiences might be. The findings of an Ofsted inspection confirm that system pressures were causing difficulty at the time and it is reasonable to conclude that those pressures were contributing to the way in which this case was managed. Those system pressures included; there being a high demand on the MASH, inconsistency in decision making and the application of thresholds, particularly in relation to cases that are stepped up and down across the continuum of services, and some cases not being responded to with the right level of service and in a timely manner.  Learning point: The need to prioritise an inevitable consequence of a system and process managed by people – especially prioritising efficiency against thoroughness. For supervisors and managers, it may be worthwhile considering how busy front-line workers make trade-offs in order to resolve goal conflicts and cope with uncertainty and system pressures, explore how they balance efficiency and thoroughness in light of the conditions and environment in which they operate; and ensure this does not compromise children’s welfare and safety.  5.2.12. Secondly, there was a lack of challenge and escalation due to, what has been described by some practitioners as, ‘referral fatigue’ inasmuch as the case had been re-referred on at least two occasions by the Strengthening Families Service with the same outcome; the decision each time creating a sense of hopelessness. Also, there was no challenge and escalation by the MASH upon re-referrals coming in on the family; the MASH could have challenged the district-based teams’ assessment and intervention in an attempt to reduce the likelihood of further re-referrals. The lack of escalation can be indicative of issues such as; differences in perception and thresholds being applied, system demand and human factors. The escalation process was also described by a small number of professionals outside of Children’s Services as time consuming and not a lean process, thereby adding to the burden of trying to raise concerns about a child’s welfare. Developments have been made to the way re-referrals received in the MASH are viewed. Learning point: Using the escalation and professional differences procedure is an acceptable course of action to take if you are dissatisfied with the response to the concerns you raise about a child’s safety and welfare. Informal resolution should always be the starting point and having robust and clear communication with professional colleagues should be seen as the norm within a healthy and well-functioning safeguarding partnership.  5.2.13. There is also a third point that has been highlighted and which provides rich learning for the Partnership. The phrase 'early help' is broad and has the potential to create confusion between agencies and practitioners. The local authority area implemented the Common Assessment Framework (CAF) and the associated Lead Professional process from 2007 and it was well established across the county and used widely until late 2016.  At that time, terminology changed so that what had been the CAF became an Early Help Single Assessment (EHSA), based on the principle of  18 a) Learning into Practice: improving the quality and use of serious case reviews, Masterclass 2: Systems thinking, SCIE & NSPCC, 2016 and b)          Systems thinking for safety: Ten principles – A White Paper, Eurocontrol, 2014.    11  OFFICIAL - Sensitive  creating one consistent assessment framework that could be used by all agencies at all levels of assessment, i.e., the EHSA framework was identical to the Single Assessment tool used by Children's Services. 5.2.14. There has never been an 'Early Help service' as such in the local authority area and yet professionals involved in this review and agency submissions consistently refer to such a service.  Indeed, the ‘Early Help Single Assessment’ phrase, in itself, suggests an ‘Early Help Service’ and has existed for several years; also, the work plan for this family was titled ‘Early Help Work Plan’. Since 2007 there has been a team of Network Support Officers, later known as CAF Officers, whose job was and is to train, offer advice and support frontline practitioners in universal services when using the CAF/EHSA process and acting as lead professionals.  That team is still in place.  It has never been referred to as a service because the CAF Officers have never delivered direct services to children or their families - their role is facilitative, not operational. However, a team of CAF Family Support workers was recruited around 2009, working directly with parents to improve outcomes for children directly as an outcome of CAF/EHSAs. This family had contact with the Family Support workers up until around the end of 2017. That team then became part of the Strengthening Families Service from early 2018, providing support to families that did not reach threshold for social work intervention either in response to EHSAs or Child in Need referrals.  The model is direct intervention by Family Support Workers, who have access to a qualified social worker for consultation.  The team is managed and supervised by a qualified social worker. This family were in receipt of services from this team as part of the Strengthening Families Service. 5.2.15. In this case it is clear that the family’s contact with the Family Support worker spanned a period of time when the service was in transition. From an organisational and system thinking perspective transitions can create risk to service delivery, but also confusion about the application of thresholds. Whilst the Strengthening Families Service have demonstrated a grasp of what risks the children were facing in this family and made attempts to escalate their concerns via the MASH, it is evident that this perspective was not shared by the receiving MASH. Not only was the decision making flawed, but the concept of what an ‘early help’ offer might look like was also misinterpreted by the MASH.   Learning point: The language used to describe services, forms, tasks and activities carries weight and can create expectations. Being accurate and describing details as they are, is important.  5.2.16. The Police had been involved with the family on 14 occasions during the timeframe under review, 3 of these were from a child protection perspective and others relating to allegations that Child D was engaged in criminal behaviour and criminal activity. During the timeframe under review Child D would have been aged between 8 and 11 years of age. The Police have reflected on their response to these contacts and judged them to be in line with procedural expectations.  5.2.17. Child D is recorded as being accused of committing five assaults, including causing criminal damage, racism and associating with older youths who were engaged in criminal activity. On these occasions no formal action was taken by the Police, which given his age, was a proportionate and reasonable decision. However, there are two learning points to emerge from the Police’s contact and involvement with Child D and the family. Firstly, not all of the incidents that Child D was involved in were referred to the Police’s Harm Assessment Unit meaning that there was no onward notification to Children’s Services about his worsening behaviours. Secondly, there is a sense of the Police operating in isolation of other agencies to consider the risks to a child (aged between 8 – 11 years), but also what might be happening in the child’s family. Whilst the three ‘child protection’ incidents were appropriately screened and investigated by the Police it reflects narrow thinking about the wider circumstances of the family, and fails to consider safeguarding from a broader perspective. Learning point: Statutory guidance19 refers to contextual safeguarding and notes ‘… As well as threats to the welfare of children from within their families, children may be vulnerable to abuse or exploitation from outside their families.  19 Working together to safeguard children, p. 23, 2018, HM Government.     12  OFFICIAL - Sensitive  These extra-familial threats might arise at School 1 and other educational establishments, from with peer groups, or more widely from within the wider community and/or online …’.  5.2.18. The local Borough Council had contact with the family and Child D through involvement with a local youth & sports facility, community safety officers, and housing services. Due to anti-social behaviours the Community Safety Team issued an Acceptable Behaviour Order in October 2017 and then updated it in June 2018 due to persisting anti-social behaviours. Whilst referrals were sent to the MASH by the youth & sports facility in September 2016 and October 2017 there is no evidence to indicate this made any difference to the threshold decisions taken to maintain the family at an early help level. 5.2.19. The NHS Foundation Trust, responsible for Health Visiting Services had contact with the mother and children. However, records and discussions confirm that the Health Visitor was not aware of, or involved in, any early help meetings or any actions relating to the Plan. This reflects silo working by the Strengthening Families Service; the reasons for this have been discussed above.  5.2.20. Records indicate discussion about Child D being considered under the Prevent duty given his behaviours. In practice this could have led to a referral to the local Channel Panel20. There is no evidence that this ever happened and the idea that this might have been a source of support, guidance or education for Child D was never put into action because it was felt that the behaviours could be managed via the school and Strengthening Families intervention.  5.3. The quality & effectiveness of safeguarding supervision and/or management oversight & scrutiny. 5.3.1. Research21 notes ‘… All those working with children in need or at risk of significant harm, whatever their agency or role, need someone who is not directly involved in the case to help them deal with the complexities and challenges of the work and to make sense of what they are seeing, hearing and feeling. Supervision can provide a much-needed space for reflection, critical review and for probing, thinking and analysis …’. 5.3.2. The Strengthening Families Service has confirmed case discussion and management oversight between worker and manager. This is also evidenced by the frequency with which the case is re-referred to the MASH. The use of further challenge and escalation beyond this is absent, as is discussion between the Team Manager and the Operations Manager within the MASH. Reasons for these deficits have already been highlighted above.  5.3.3. The Police have noted that the single child protection investigation in relation to Child A’s disclosure and bruising was appropriately overseen and supervised in accordance with expected policy. 5.3.4. School 1 have highlighted that their Pastoral Manager was fully engaged in the early help process and liaised with the Family Support Worker on a regular basis.  5.3.5. Children’s Services have noted that there was no supervision whilst the family were being managed by the district-based team, which was in operation prior to the MASH becoming operational. Following on from this there is evidence of management oversight for the single assessments completed in April and October 2017 and January and November 2018.  5.3.6. The NHS Foundation Trust, responsible for Health Visiting, have confirmed that there is no evidence that safeguarding supervision was accessed. As stated above, because the Health Visitor was not involved with the early help offer of support there was no reason for them to be any more worried and seek 1:1 supervision to discuss safeguarding issues; from the Health Visiting perspective there were no issues that reached a threshold above other issues needing to be dealt with on their caseload.  20 Prevent: a Government strategy implemented at a local level to identify and prevent individual’s being drawn into extremism.   21 Gordon, R., & Hendry, E., Supervising assessment of children and families: the role of the front-line manager, p. 141, in Horwath, J., The Child’s World, second edition, 2001, Jessica Kingsley.     13  OFFICIAL - Sensitive  5.4. The extent of professional curiosity, challenge & escalation. 5.4.1. Research into other Serious Case Reviews22 states ‘… without professional curiosity professionals fail to recognise risks, downplay them, or focus on parents’ needs to the detriment of the child’s … professional curiosity requires professionals to think ‘outside the box’ …’. Learning point: Professional curiosity is the ability to think, and communicate, with children, families and professionals in a way that explores what is happening rather than making assumptions or accepting things at face value. Sometimes it can be described as ‘respectful uncertainty’ – applying critical thinking skills to information received and maintaining an open mind.  5.4.2. The Strengthening Families Service has demonstrated a level of professional curiosity in their dealings with the family. In the information set out in the preceding sections there is reference to the Strengthening Families Service’s attempts to challenge and escalate, although these could have been more robust.  5.4.3. As referred to in section 3, the contributions of the Family Support Worker appeared to add little weight to the referrals made. The status of the worker making a referral to the MASH was discussed by practitioners involved in this case. There was concern that some professionals’ views were not given the same weight as others, and that the culture at the time was one of there being disconnect between the MASH, early help referrals and the status attached to professionals’ roles. The Strengthening Families Service have noted ‘… At the time there was a common view within the family support work team that a family support workers professional opinion was not as valid as a social workers opinion. This was based on a number of MASH referrals that had been made on a number of cases where the outcome had been to remain at Early Help without full consideration of family support workers professional assessment and intervention.  This led to Family Support Worker’s feeling frustrated and a perception that thresholds were high and that we were not clear on what would warrant a Child in Need Assessment or Plan …’23. This is relevant system and contextual information, especially from the perspective of workers being asked to be increasingly curious, to challenge and escalate decisions where there is disagreement or dissatisfaction. Whilst all workers can be as curious as we hope them to be, if their rank and professional opinion is not valued or afforded an equal status, curiosity will go no-where. Contributory factors have already been discussed above in respect of the pressures the MASH was experiencing at the time. The Safeguarding Partnership will wish to assure itself that all referrals are treated equally and that regardless of professional status, the welfare of children remains the driving principle behind assessment and decision making.  Learning point: The quality of professional relationships and the extent to which professionals trust one another is an important consideration when working in child protection. Exploring and reconciling differing perspectives about the risks a child or family is experiencing is a necessary task when operating in a multi-disciplinary context. All views are valid and bringing them together, alongside examining the case history is a core requirement for timely and effective assessment and decision making. Managers and designated post-holders have a role in facilitating this.24 5.4.4. From a Police perspective it is evident that on those occasions when information was not shared with their Harm Assessment Unit about Child D’s criminal behaviour, thereby preventing the incidents being looked at from a child protection angle, Officers did not exercise professional curiosity about the impact of such events on the children’s safety. There was also no consideration or curiosity about contextual safeguarding issues and the use of local intelligence to inform safety planning or risk management.  22 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 159, University of Warwick & University of East Anglia, May 2016  23 Strengthening Families Service, submission to the review.  24 Heasman, P., Dimensions of risk: Professionals tipping the balance, in Calder, M., Contemporary risk assessment in safeguarding children, 2008, Russell House Publishing.     14  OFFICIAL - Sensitive  5.4.5. School 1 exercised curiosity and persistence in the attempts to escalate their concerns however have recognised that they could have used the formal escalation procedure rather than relying on verbal challenge and escalation and the efforts of the Strengthening Families Family Support Worker. 5.4.6. The local Borough Council Housing Service were curious and challenging of the initial decision to not re-house the family following the unexpected and significant family bereavement. This led to helpful exchanges, some discretion being applied to the situation and ultimately facilitated a house move.  5.4.7. The NHS Foundation Trust, responsible for Health Visiting Services, report that the Health Visitor challenged the parents about their use of cannabis during the early timeframe under review, but that a Nursery Nurse was less curious about the identity of an unknown male in the household during one visit in November 2015. Records indicate no details about the home conditions, the presentation of the children or the interaction between the parents and children. 5.4.8. There is no evidence of professionals challenging the mother about her inconsistent levels of engagement with services; the over-riding pattern is one of acceptance regardless of the impact this may have on the children’s safety and welfare. The mother partially engaged by having discussions, agreeing to assessments and taking phone calls but then fails to follow through with any consistency. This has the effect of complicating the professional assessment of the situation; on the one hand potentially reflecting her desire to enter into a working relationship with professionals because of her struggles and on the other, appearing to be dismissive of the need for support. As the case remained at an early help level, all activity and contact by professionals would have been based on a universal level of service and consent driven. This style and pattern of engagement was knowable given the historical information held by Children’s Services however it is not considered as a risk factor following the more recent referrals made. It is likely that the sympathy bias discussed above accounts for this lack of challenge. Some practitioners have referred to the mother’s behaviour as disguised compliance. This can be defined as ‘… patterns of ‘closure’ or ‘flight’ when families need to reduce their contact with the external world in an attempt to regain control by shutting out professionals. Often when professionals took a more controlling stance, this was defused by apparent co-operation of the family, the effect of which was to ‘neutralise the professional’s authority and return the relationship to … the previous status quo …’25. Research26 into other case reviews notes ‘… once families are in the child protection system or child in need ‘system’, their engagement with plans can be difficult for professionals to manage. Professionals may be tempted to … close the case when there is poor engagement, further compromising child safety. Making clear plans from the outset … and reviewing concerns if non-engagement arises could lead to more effective working …’. The mother’s style of engagement was clearly a distraction for the assessment and decision making by the MASH and Children’s Services.  Learning point: When working with parents who are, or become, resistant it is important that expectations are transparent about the professional response to such resistance and that these are clearly stated from the outset. Ensuring good quality and regular reflective supervision will assist the worker, as will creating a combined chronology of agency contact in order to build a holistic account of what the impact of parental resistance might be on the child.  Learning point: Ensuring those professionals who are more likely to be making referrals have a shared, and agreed, understanding about what is meant by ‘early help’ and what a reasonable set of expectations might look like (expectations of professional and parents/carers) is an important step to creating an equitable safeguarding system.  5.5. The consideration of risk posed by other adults who had contact/lived with the family 5.5.1. As a result of the investigations into the serious incident it has emerged that at the time of the incident Adult 1 was at the family home. Due to the information gathering process connected to the decision to initiate a case review, information from agencies has confirmed that Adult 1 was of interest because of his history; being a dangerous  25 Pearson, R., 2013, Guide to working with disguised compliance, Community Care On-line, based on work by Reder, P., Duncan, S., & Gray, M., Beyond blame: Child abuse tragedies revisited, 1983, Routledge.  26 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 144, University of Warwick & University of East Anglia, May 2016   15  OFFICIAL - Sensitive  offender with a history of violent offences, being a perpetrator of serious domestic abuse and posing a high risk of harm to children and adult partners. It is therefore appropriate for this case review to consider whether the involvement of Adult 1 with the children and mother was a contributory factor to the circumstances at the time, potentially increasing the likelihood of abuse or neglect and which may have a causal link to Child A’s death. 5.5.2. Reports submitted to the review indicates that Adult 1 was effectively managed by the National Probation Service in relation to other known relationships he may have had with adult females who also had children, but also Adult 1’s contact with his own children. At the point that the National Probation Service became aware of a possible relationship between Adult 1 and the mother in August 2018, the information was shared the same day with Children’s Services and the Police. At the time the Adult 1 was not subject to active supervision by the National Probation Service – the information came to their attention via a third-party source, but nonetheless despite them not working with him the information was shared. The National Probation Service has reflected on their actions and found that, although they shared information immediately with the relevant authorities about the possible relationship, they did not submit a full referral to the MASH. Had this been actioned, it would have strengthened their information sharing practices albeit based on the limited information they had about the mother and her four children. 5.5.3. The mother strongly denied this relationship when questioned by the Strengthening Families Service 18 working days after the information was received. Although taking 18 days, records clearly indicate some pace with attempts to liaise with others and make contact with the mother. When seeking clarification about the relationship, the Family Support worker could have been accompanied Adult 1’s allocated Social Worker – thereby increasing the strength of questioning.  5.5.4. There is no information to indicate that the Police took any action on the receipt of the information being passed to them by the National Probation Service other than passing the information to Children’s Services and the Integrated Offender Manager coordinator. The Police have confirmed that given there were potential discrepancies with the accounts given and the source of the intelligence was not wholly reliable, this would be their routine action taken in such circumstances.  5.5.5. There is no further evidence to indicate that the mother was asked again about the possible relationship, but also no known information to indicate that the mother was actually in a relationship with Adult 1 until the serious incident in November 2018.  This has been confirmed by all agencies involved in this case review. Learning point: When new, and potentially serious information emerges about risk to children the response should be measured and match the level of seriousness.  Learning point: When undertaking an assessment work, all professionals should be alert to any, and all risks that children may face, and not make assumptions about mothers naturally being protective.  5.5.6. In terms of future multi-agency sharing of information about adults that may pose a risk to children it is worth noting that Adult 1 presented to A&E (University Hospitals NHS Trust) on two separate occasions (May and July 2018). One presentation related to being stabbed – an incident which would ordinarily arouse some degree of curiosity. This was reported and known about by those agencies involved with Adult 1 at the time. Also, at the time University Hospitals NHS Trust did not share information with the local MARAC Co-ordinator; since August 2018 this has now changed and an alert is added to the victim’s medical records along with any associations with children. At the time it would not have made a difference to this case as Adult 1’s relationship with the mother was not known about. However, the implementation of this information sharing mechanism has the potential to improve joint working and risk management.   6. Good practice 6.1. This Review has identified a number of areas which can be highlighted as good practice. It is important that good practice is recognised and shared. These areas include;   16  OFFICIAL - Sensitive  - The Health Visitor sought and shared information with other professionals despite the age of the child being beyond the service’s remit.  - School 1’s persisting attempts to raise the profile of their concerns about the family and Child D. - The Strengthening Families Family Support Worker’s attempts to elicit a change in threshold decision from the MASH. - The Strengthening Families Family Support Worker’s attempts to engage the mother in bringing about change for the children.  - Children’s Services, Educational Psychology Service, School 1, and the Strengthening Families Service contributing to the decision to support a house move for the family.   7. Conclusion 7.1. This Serious Case Review has examined the circumstances around the involvement of agencies and professionals with a family where there were concerns about abuse and neglect. The review was prompted following a serious incident at the family home, in which the youngest child died as a result of injuries suffered. A Police investigation and subsequent criminal trial did not result in any convictions.  7.2. The review has gathered and analysed documentary information from all of the agencies involved over a period of nearly three years, whilst also recognising relevant background information. It has benefitted from the involvement of many of the practitioners involved with the children and gained their perspectives about what happened, and why events may have occurred as they did. The review has benefitted from the views of a close family member, although the children’s mother declined the opportunity to contribute.  7.3. The review has made a number of findings, which should be used as a platform to learn and improve practice. These include:  - The family history and contact with professionals was not consistently used to inform assessment and decision making by all professionals involved. - Attempts to raise the profile of concerns about the children’s safety and welfare were mostly unsuccessful when referred to the Multi-Agency Safeguarding Hub but also followed through by the locality Children’s Services Team where decisions were made; system pressures, new ways of working and a degree of sympathy for the mother contributed to decisions being made that were not in the children’s best interests. - Whilst some professionals demonstrated tenacity in their attempts to raise concerns, this was not matched by all professionals involved resulting in decisions that frustrated attempts to safeguard the children. - Contextual safeguarding in respect of Child D were not recognised; consequently, opportunities were missed to assess and potentially intervene.  - Risk posed by Adult 1 were not fully assessed and information sharing was not as effective as it needed to be.   7.4 The review has captured learning points for use by practitioners, managers and trainers. As a result of this review agencies that have contributed have been able to identify learning that can be taken forward internally. Action plans have been provided by each agency involved, and where relevant and appropriate to do so, improvements have been initiated. It is the role and responsibility of the Safeguarding Partnership to monitor, scrutinise and challenge progress against single agency action plans. The report concludes with a number of recommendations for the multi-agency Safeguarding Partnership which may strengthen practice. 8. Recommendations 8.1. As noted in section 2, this review began in early 2019 but has taken over two years to draw to a conclusion due to parallel legal processes. At the outset, agencies were asked to identify their own learning from review of information   17  OFFICIAL - Sensitive  held, and take this forward following the submission of their respective single agency action plans in May 2019. However, given the passage of time from the review being initiated to its conclusion, actions and practice has changed – as a result of targeted improvement activity but also within an overall programme of development. In September 2019, with the submission of version one of this report, a series of recommendations were made for the Safeguarding Partnership, prior to the review being placed on hold pending the outcome of parallel processes. These included; 1. To ensure the learning from this Review is disseminated across the multi-agency safeguarding partnership to practitioners and managers. 2. To seek assurance that the actions identified by each partner agency, as a result of this Review, have been managed, implemented and embedded in a timely manner. 3. The Safeguarding Partnership should review the professional escalation procedure and ensure it is fit for purpose, and user friendly. Following review, professionals across the safeguarding partnership should be reminded about where to find it, how to use it, and expectations. 4. Children’s Services to review the effectiveness of the Early Help Plan document to ensure that the format is fit for purpose, contains a section which names who has responsibility for tasks/activities, and is user friendly. When reviewing the format, and given the findings of this review, there should be an expectation that it will naturally lead to reviewing the quality of current Early Help Plans for children and the effectiveness of the multi-agency contributions to such plans. 5. Based on the perspectives articulated in section 5.4.3. the Safeguarding Partnership may wish to seek assurance that referrals to the MASH, particularly re-referrals, are not discriminated or screened based on the status of the person referring, but based on the actual or likely risks to children. This may be best conducted via a focused audit exercise covering a defined and recent timeframe. 6. The Safeguarding Partnership to consider the findings of this review alongside the findings from another recent review (yet to be finalised and published) in relation to contextual safeguarding and be assured those local arrangements are efficient and effective. This should include the use of intelligence about youth crime, deviant behaviour and exploitation from Boroughs/Districts and that it is used at a tactical level to inform operational safeguarding activity. 7. The Safeguarding Partnership to review their thresholds document to ensure it is fit for purpose and provides clarity about the differences in what to expect at each level. The Partnership should then ensure that the document and framework is widely publicised with consistent messaging that reduces the likelihood of different perceptions emerging about how thresholds might be interpreted. 8.2. It is the role and responsibility of the Safeguarding Partnership to scrutinise and seek assurance about not only progress with the single agency action plans, but also the above recommendations since they were first made. Those agencies, as well as the Partnership, will wish to test and evaluate the effectiveness of how well changes and improvement activity has been implemented and hopefully become embedded.  