Life threatening assaults of child by mother, followed by mother's suicide attempt, in 2014 and 2015. On two occasions Child AB, a junior school-aged child, was subject to life threatening assaults by attempted suffocation and strangulation by the mother, who then attempted to commit suicide. Mother was charged with attempted murder and placed on bail, and Child AB became subject to child protection investigation and child in need plan, and was placed with father, with contact arrangements managed by children's social care. After a second assault mother was charged and convicted of child neglect. No indication of child abuse prior to the first event. Maternal history of: mental illness, self-harm, disclosed attempts to harm husband and attempted suicide; disclosure of emotional abuse in marriage. Key issues identified include: management of screening for maternal mental health and domestic abuse not fully embedded in practice; lack of direct questioning regarding thoughts to harm others and extended suicide in primary care and mental health services; ineffective use of child protection processes; lack of a joined-up process of multi-agency assessment and management of risk by adult and children's services; professional decision-making impacted by affluence and status of family ; management of contact arrangement unclear; ineffective staff management and supervision processes; limited practitioner awareness of increased risk of filicide, harm to others and the risk of viewing the child as a protective factor. Makes recommendations to strengthen professionals' understanding of the negative impact of professional biases and beliefs in safeguarding practice, and to review procedures to improve understanding of the child as a protective factor, risk of filicide and harm to others in cases of adult parent or carer mental illness. Please note that this report was written in May 2016 but was published in 2017.
      
    Serious Case Review No:  2017/C6333  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.   CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 1 of 53          A Serious Case Review.  ‘Child AB’  The Overview Report   1st May 2016.               To protect the child’s anonymity, this report has been anonymised for publication on the NSPCC Repository following agreement with the National Panel of Independent Experts on Serious Case Reviews.   The content of the report has been quality assured by the Serious Case Review Team, it is owned by the commissioning Safeguarding Children’s Board.  Copyright of this report remains with the Safeguarding Children’s Board.   CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 2 of 53  SECT ION PAGE CONTENT 1 3 THE SERIOUS CASE REVIEW. 1.1 3 Case Synopsis. 1.2 5 Family Participation. 2 10 CHRONOLOGICAL ANALYSIS & LEARNING FROM SAFEGUARDING PRACTICE. 2.1 10 Relevant History Up to of the First Life Threatening Event in July 2014.  10 Historical Events.  10 Family Life.  10 The Pregnancy, Birth and Postnatal Period.  12 Child AB: The Early Years Up to The First Event in July 2014.  12 Maternal Mental Health Prior To The First Event.  14 The Initiation/Considerations of the Common Assessment Framework (CAF).  14 The Day of The First Event. 2.2 16 Practice Issues and Events Between the Initial and Second Life Threatening Event.  16 The Initial Child Protection Response.  17 The Child Protection Medical Examination.  19 The Strategy Discussions and Meetings.  20 Re-Instating Contact Between Child AB and the Mother.  22 Child AB: The Threshold for Child Protection versus Child in Need.  25 Disclosures of Emotional Abuse.  26 The Management of Home Leave.  28 The Psychologist’s Intervention and Predictors of Risk.  29 Criminal Proceedings.   29 Bail Conditions and Supervised Contact.  31 The Effectiveness of Partnership Meetings.   32 The Involvement of Child and Adolescent Mental Health Services (CAMHS).  33 Escalating Risk Taking Behaviours and Threats to Harm Others.  35 The 2nd Life Threatening Assault on Child AB and The Use of Mental Health Legislation. 3      37 KEY LEARNING FROM PRACTICE. 4      40 CONCLUSION. 5      42 LSCB RECOMMENDATIONS. 6      43 APPENDICES.       43 Appendix 1:  The Serious Case Review Methodology (including the principles, process, Independent Reviewers biographies, structure, themes, key practice issues and key lines of enquiry, completion and limitations).       47 Appendix 2:   Glossary.       51 Appendix 3: Single Agency Recommendations contained in Individual Agencies Internal Management Reviews.    CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 3 of 53  SECTION 1: THE SERIOUS CASE REVIEW. 1. In April 2014, the Serious Case Review was commissioned. The methodology for the Serious Case Review has been developed in consideration of national guidance1 and advice from the National Panel of Independent Experts on Serious Case Reviews 2 and is set out in the appendices of this document.  1.1     Case Synopsis.  2. Child AB, a junior school child, was born 4 weeks prematurely and nursed on a Special Care Baby Unit for 1 week prior to being discharged home care of parents. The family home was in an area of low deprivation with good and mostly privately owned housing stock. The child attended two Early Years Pre-school establishments, prior to starting school. Child AB’s mother (hereinafter referred to as mother) was the main contact point for school and was fully supported by her husband. Nursery Practitioners advised the family had a secure and stable family life. The child was popular, happy, confident, sociable and maintained positive relationships with staff and other children. The child made positive, excellent academic progress and enjoyed good health. The evidence identified that up to the sudden first assault, the child had experienced a happy and stimulating childhood. There was no evidence to indicate the child had been subject to any incidents of abuse prior to the first event in 2014.   3. During 2014/2015 at an interval of 29 weeks, Child AB was exposed to two potentially life threatening events. The mother had perpetrated the assaults, which were followed by an actual attempt on her own life (first event) and a planned attempt on her life (second event). It is remarkable the child survived these incidents and did not sustain life threatening injuries. Children who experience such life-threatening assaults are known to be at higher risk of developing post-traumatic stress disorder3  and other health consequences. Therefore, the long-term outcome on the child’s emotional wellbeing combined with the enforced separation from the mother, who was a main caregiver, will need to remain a consideration for all universal services who remain in contact with the family.  4. In November 2013, the maternal grandparents noticed their daughter was not quite herself. This was thought to be due to several stressful events she had experienced including; workplace bullying and witnessing a car accident. In March 2014, Child AB’s father (hereinafter referred to as father) became increasingly concerned for his wife’s welfare, encouraging her to seek medical support. In April 2014, the mother presented to NHS Primary Care General Practitioner Services with increased symptoms of mental illness. During the next 4 months, various therapeutic medication options and counselling were tried with no positive impact on her wellbeing.   5. In July 2014, following an incident of self-harm the mother was found by her step-daughter, and was immediately taken to hospital by Ambulance Services. Later that day, the child disclosed to the half-sister, that the mother had attempted to seriously harm the child that morning on two occasions. The mother had initially attempted to suffocate the child, who had struggled so she                                                            1 HM Government (2015) Working Together to Safeguard Children: A Guide to Interagency Working to Safeguard and Promote the Welfare of Children. Crown Copyright. Downloaded Www.Gov.Uk 18.10.2015 2 Dfe (2014) First Annual Report National Panel of Independent Experts on Serious Case Reviews, July. 3 See Glossary for Definition of Post-Traumatic Stress Disorder. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 4 of 53  had stopped. Later she attempted strangulation by placing her hands around her child’s throat. The father was told about the incident and informed the nursing staff caring for his wife. The nursing staff made a Child Protection referral. During August 2014, following the initial referral, the Constabulary commenced a criminal investigation, initially charging the mother with attempted murder. Constabulary bail conditions were arranged, including a condition that contact arrangements with the child should be managed by Children’s Social Care.   6. A Section 47 investigation4 was undertaken. Child AB became subject to Child in Need arrangements under Section 17 of the Children Act (1989) 5 and was placed with the father. Initially the child had no direct contact with the mother. Contact restrictions were relaxed, progressing from telephone to regular supervised contact between the mother and child. Contact was initially supervised by multi-agency professionals, progressing quickly to supervision by family members and on one occasion by a family friend. Initially contact between mother and child was positive. Some deterioration was recorded latterly, prior to the second assault in 2015. The father observed a change in the child’s relationship with the mother, as the father provided more of the child’s care. The child initially responded positively to the change but then began to “play up slightly” during contact with the mother.  The mother then became stricter with the child and the father would then have to intervene, which created challenges.  7. In August 2014, the mother was voluntarily admitted to Mental Health Services In-Patient Facilities. In September 2014, she was discharged to her parents’ home. On discharge, she was supported by Primary Care Mental Health Services and a Care Coordinator was appointed. Oversight of the case was by the Care Programme Approach 6 . The mother’s condition showed no real improvement and several serious events occurred in the intervening 29 weeks prior to the second event.  There were incidents of self-harm, significant threats and attempts on her own life and disclosed plans to harm her husband.   8. Following the first event in 2014, the mother disclosed to numerous professionals that she had felt emotionally abused during her marriage. During her time as an in-patient the mother and father were observed to be supportive and affectionate, however they then formally separated four months after the first event. During a contact session one month after their separation, which was supervised by the father, the mother admitted her plans to harm her husband. She had planned to use an item she had secreted and hidden earlier in the day and then had planned an attempt on her own life. The mother was returned to the Mental Health Unit by her husband where she remained as a voluntary patient. The mother continued to have home leave, supervised by her parents. Contact between the child’s parents ceased following advice from Mental Health Services. Contact between the child and the mother continued and was mostly supervised by the maternal grandparents.    9. Child AB initially exhibited signs of emotional distress and anxiety although continued to attend school and maintained normal routines with family and friends. The child’s wellbeing was monitored by an experienced Family Support Worker who provided support around the child’s wishes and feelings. The media interest created significant challenges and distress for the child. The family were concerned about the impact the media interest had on the child’s wellbeing. The family was well known in the local community and the child was aware of community talk.                                                             4 See Glossary for Definition of Section 47 Investigation. 5 See Glossary for Definition of Section 17 Of the Children Act (1989). 6 See Glossary for Definition of Care Planning Approach. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 5 of 53  10. In February 2015, during contact with the child at the maternal grandparent’s home, there was a second serious attempt on the child’s life. The child told the maternal grandfather and mother that she/he was going upstairs to play in the bedroom. The child was then followed by the mother who perpetrated a life-threatening assault on the child. The child screamed and the maternal grandfather entered the room. The mother was returned to Mental Health In-Patient Services by the maternal grandfather, who disclosed the incident to staff. Child AB accompanied the maternal grandfather to the hospital. Mental Health Services reported the incident immediately to the Constabulary and the Emergency Duty Team in Children’s Social Care.   11. On the day of the incident, Child AB was medically examined at a local Accident and Emergency Department, by an on-call Paediatric Consultant and the injuries documented. The child did not require hospital treatment and was discharged home to care of the father. The Constabulary treated this incident as an attempt on the child’s life.  The mother was re-arrested and recharged for attempted murder and all contact with the child was suspended at that point.    12. In October 2015, criminal proceedings were concluded against the mother and a conviction secured on two counts of child neglect. Two charges of attempted murder were left to lie on the file. The mother pleaded guilty to two counts of child neglect under the Children and Young Persons Act (1933). A Hospital Order, under the Mental Health Act 2007, with restrictions was ordered. No custodial sentence was handed down. In summary, the mother was ordered to remain in hospital until such a time the medical professionals deemed her well enough to be discharged. The restriction element of the sentence is understood to mean that prior to her discharge, an Independent Panel from the Ministry of Justice must review the decision to discharge her.   13. The Family Court Private Proceedings have been concluded and the father has care of Child AB. There is a Section 8, Child Arrangement Order in place, which directs no contact with the mother. The court encouraged the father to provide written progress updates every 3 months to the child’s mother. After the initial event the child was missing the mother and regularly expressed a desire to see her. The child will now only discuss the experience with the father and Key Family Support Worker.   1.2 Family Participation.   14. The case review panel acknowledges that over a short period this family has had to accommodate a series of extremely traumatic events which notably changed family dynamics. The assaults on Child AB, the maternal incidents of self-harm and plans to harm others were an extreme shock. The mother’s actions were incomprehensible to family members, who had never previously observed her display signs of aggression towards her child. Despite this, all family members remained child-focused and determined to ensure the child continues with a happy and positive childhood. The case review panel considered the participation of key family members would make an important contribution to the learning achieved through the review. Direct conversations with the child were not considered to be appropriate although the child’s experience, feelings and wishes as described by family members and professionals in regular contact would be included.  15. This section provides a summary of key conversations facilitated with the father, mother, paternal and maternal grandparents. Participation by the child’s half-sibling could not be arranged. Conversations with the mother were delayed for ten months, pending cessation of criminal proceedings and securing agreement with her principle Consultant Psychiatrist. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 6 of 53  Additional contact with family members was secured to share the final overview report, prior to publication.  16. The father, paternal and maternal grandparents praised the General Practitioner, Education Professionals, Head Teacher and Key Family Support Worker for their consistent emotional support, expert advice and practical support. In school the child was always the focus of attention and provided with extra support when needed. The wishes and feelings work undertaken by the Family Support Worker was described as incredibly supportive and beneficial to the child.  The school proved to be the family’s coordination hub in their dealings with the complexity of multi-agency agencies and systems. The paternal grandparents advised the school provided the child with before and after school club activity, flexibly and at no cost to accommodate the father’s working hours.   17. The father and paternal grandparents described the Constabulary as “very good” with the child in their approach during the memorandum interview, therefore making it a positive experience for Child AB. However, the mother felt the way she was treated by the Constabulary was not nice, as they insisted on putting her in a “suicide suit”, left her in a cell with one blanket overnight and she was cold. Her solicitor advised her to make “no comment” and the Constabulary’s reaction to this was quite negative which also “didn’t feel very nice”.   18. It was of concern to all family members that the Constabulary did not have oversight of the bail conditions, leaving their interpretation to Children’s Social Care. The family said, this led to confusion in the management of the conditions and child contact arrangements. The father advised that Children’s Social Care’s written agreements were confusing, quickly piled up and changed every day, therefore were not meaningful or understandable. The maternal grandparents did not receive any correspondence or sign any written agreements from Children’s Social Care despite their significant role in managing child contact arrangements. The coordination of contact supervision arrangements was left to the father, which was difficult due to the discrepant interpretations of supervised contact and the increasing pool of supervisors, which on one occasion was the mother’s friend. The mother felt her parents were not supported in understanding what the contact was about. She was concerned contact was organised in line with her child’s expressed wishes rather than what was in the child’s best interests. She wanted to see her child but did not feel strong. Contact was always difficult as there was always someone else there and she didn’t understand why that was required.  19. The father and maternal grandparents advised that following the second event the Constabulary and Children’s Social Care said the supervision of contact arrangements should always have been 24 hours a day. The family had not been made aware of this and it was not a feasible expectation in dealing with these extreme circumstances. The mother was very ill and there were significant challenges and contradictions in balancing her needs whilst safely supervising child contact arrangements. The paternal grandparents made an offer to Children Social Care to supervise contact but received no further communication.   20. All family members expressed significant concern in the delay in criminal proceedings. The maternal grandparents and mother consider this was a contributory factor in the increase of self-harm incidents leading to the second serious assault on Child AB. The Constabulary’s delay in gaining statements from the Ambulance Service was perceived as a significant factor in this delay. The maternal grandparents feel the delay by the Constabulary was primarily responsible, leading to the delay by the Crown Prosecution Service in progressing criminal proceedings. The maternal grandparents advised that telephone calls and letters to the Constabulary were never responded to.  CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 7 of 53   21. All family members felt the quality of holistic Mental Health Service Provision following the first event and before the second event was of significant concern. They reported that communication was unclear, confused and telephone contact was mostly not responded to. All family members felt that the mother’s illness was not explored and she was merely given medication which made her “zombie like”. The maternal grandparents said there was no planning for home leave and their daughter was out of hospital for frequent, long periods irrespective of her presentation. The maternal grandparents were left to make regular decisions whether the mother was well enough for home leave, which was a significant conflict of interest for them. They understood there should have been a handover by the ward staff when they picked the mother up and took her back but in practice this rarely happened. The mother advised that Mental Health Practitioners seemed to want her to go on leave a lot. There were several occasions when she told her parents she was not going to come out as she didn’t want to, but was not listened to by staff. This put a strain on her relationship with her child as she was not able to look after the child as well as she might have done.  22. The mother feels she shouldn’t have left the Mental Health Unit as early as she did after the first admission, but the Consultant Psychiatrist wanted to get her back out into the community quickly. She thought the unit was under-resourced leading to several difficulties. For example, it was difficult to see her Named Nurse who was always busy in the office and didn’t have time to interact with service users. She talked to Support Workers but didn’t feel the communications were reported back to her Named Nurse and felt no-one was listening to her when she was trying to explain how she was feeling.  23. All family members advised that the focus of Mental Health Services was on the mother and expressed concerns about the lack of focus on other family members or the risks to the child. They were concerned that the increased contact, supported by Mental Health Services, would only increase the risk to the child. They considered the risk to the child was not focussed on in care planning approach meetings with Mental Health Professionals. Mental Health Professionals were always saying the mother was better therefore contact with the child was good for her. The father asked for advice in respect of the triggers in his wife’s behaviour which could be indicative of a deterioration in her mental health. He was advised just to carry on and no advice was received. All family members could not understand the rationale to why Mental Health Services continued to allow the mother un-supervised leave, despite her lack of improvement.  24. The mother and maternal grandparents expressed grave concerns that the mother could take a very significant overdose whilst on the ward, while Mental Health Services should have been supervising her. She had bought the tablets whilst on unescorted leave. It was the maternal grandfather who then informed the ward of the significant overdose. There was a two-hour delay in accessing further treatment, which they feel could have led to her death.  During this time, she was supported by another service user, rather than the Mental Health Practitioners who were supposed to be caring for her. This remains a serious concern for the maternal grandparents and the mother. This incident has been subject to a separate review by Mental Health Services.  25. The night before the second incident, the mother told her Named Nurse she was feeling suicidal, but that information didn’t seem to have been passed on, so the next day she had to explain it to another Nurse. They thought it would help her to see her child. She didn’t think so and felt pressured to go out. She feels she shouldn’t have been allowed out on the day of the second incident as she had been honest the night before about her feelings.  CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 8 of 53   26. The mother and maternal grandparents could not understand why she was not sectioned under the Mental Health Act prior to the second event, due to the increasing risks. They also expressed concerns about how she was sectioned after the second incident. The mother reported she was dragged out of bed at nearly midnight whilst asleep, having taken her medication. The mother said she was not in a fit state to talk to a Social Worker and it could have waited until the morning or alternatively could have been dealt with earlier that day. She was told that it had to be done before midnight because the previous section was about to expire. The mother felt that unfairly “she was deemed to be uncooperative” and was detained.  27. The mother and maternal grandparents contrasted the care provided after the first event by the local Mental Health Services and after the second event by the Mental Health Unit in the Prison Service and the current provider. The latter two provisions of mental health care have been much more beneficial. Medication regimes were considered not appropriate and changed. Currently the mother’s treatment is different and professionals are listening and trying to help her although she still feels low at times. The mother now feels confident, though it has taken a lot to reveal things about herself but now the work is leading to actions being taken. They feel had she been offered this quality of care after the first event the second event may have been prevented.  28. The father described the structure and design of the Child in Need meetings as too relaxed, unstructured and informal. Key professionals were regularly missing (Constabulary, Mental Health and School Nursing) and information provided to the meetings by Mental Health Services was sometimes inaccurate. The father talked positively about how Education and Children Social Care Professionals refocused meetings to talk about the child. The constant theme in the meetings was promoting contact but not about the risk the mother posed. The father felt it was not appropriate to see the child as a protective factor and the focus should have been on keeping the child safe. The father advised that Children Social Care Professionals were always keen for other professionals to take on the work to support the family. The maternal grandparents could not always attend these meetings. They often received late invites, creating challenges in attendance and regularly meetings were cancelled at short notice.  29. The opportunity for carers assessments by Mental Health Services, were discussed with the father and maternal grandparents. The assessments however were not completed therefore resulting in a lack of support. The maternal grandparents expressed concern the safety of the mother was on their shoulders with no effective or meaningful support by Mental Health Services.  30. After the first event, the father did not want a Child Protection conference to be convened, due to a fear of loss of control of family life and concerns that the quality of support would become a challenge within a bigger panel. This was influential in the Social Care decision not to proceed to a Child Protection conference and will be discussed later in this report. The father advised that following the second event, despite his initial concerns the experience of the Child Protection conference was good. In comparison to the Child in Need meetings it was very well-structured and organised.   31. The family advised that the referral process and access to Children and Adolescent Mental Health Services 7 was challenging to understand. The father still wanted a referral at the time of                                                            7 See glossary for definition of Child and Adolescent Mental Health Services. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 9 of 53  the conversation with the Independent Reviewers. The father and paternal grandparents acknowledge the wishes and feelings work organised by Children’s Social Care was very helpful for the child.  32. The mother wants the panel to know that “the person who carried out the assaults doesn’t feel like the person sitting here being interviewed. That person was not rational about actions and was cut off from all emotions.” The mother wants to tell her child “how sorry she is and these things should not have happened once, never mind twice.”   33. In conclusion, the conversations with the family members provided clarity as to the challenges faced whilst trying to support the mother during her illness whilst balancing the child contact arrangements. There were consensus opinions from all family members who could identify what worked well and areas for improvement especially in relation to managing the risk around contact arrangements. The family participation in this process provided a significant contribution to the learning achieved for the review.    CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 10 of 53  SECTION 2: CHRONOLOGICAL ANALYSIS & LEARNING FROM SAFEGUARDING PRACTICE. 34. The search for information secured all relevant data with no obvious omissions. This data was used to develop a comprehensive multi-agency chronology of service provision. The chronology along with information gained from the conversations at the practitioner event and the individual agency reviews supported the development of this section which critically analyses key events and themes in chronological order. It seeks to identify good practice and areas requiring improvement. Learning points and key practice events are identified. The section is divided into two chapters;   Relevant history up to the first life threatening event in July 2014.   The timeline of practice issues and events between the initial and subsequent life threatening events: July 2014 to February 2015.  2.1 Relevant History Up to the First Life Threatening Event in July 2014.  35. Historical Events.  Historical information and family discussions revealed the mother had experienced a positive childhood, not requiring additional services in respect of her health, educational or social needs. In 1993 she had an acute episode of mental ill health whilst attending University. She sought treatment but did not improve, returning home to be cared for by her parents and General Practitioner. The mother then made a good recovery with no further recurrence, resumed her studies, gained a master’s degree and went on to secure a professional, high profile, senior role.   36. Family Life. Child AB’s parents were reported to be devoted, loving and caring and their child was the focus of family life. Both parents were in full time employment and balanced that with a happy and active home life. The child had positive, supportive family networks as well as extensive social and religious networks. All family members reported the mother to be an organised, enthusiastic adult who was motivated to take on many activities. The family dynamics were viewed to be positive and supportive. Following the first assault the mother reported some tensions at times in the relationship with her step-daughter, who had lived with the family following the death of her own mother. These tensions were mediated by the father. The family were supported by maternal and paternal grandparents. There were no other obvious tensions in family dynamics and all the adults worked cohesively to provide the child with a happy childhood.   37. The Pregnancy, Birth and Postnatal Period. In July 2007, Child AB’s parents were happy to be pregnant with their child. The mother required hospitalisation due to pregnancy complications. The child was delivered prematurely, cared for in the Special Care Baby Unit, made good progress being discharged home after 1 week. Maternity Care provision was in line with the expectations of the service and the mother recovered well from the birth.   38. In the antenatal period, Midwifery Services asked if the mother had a history of psychiatric disorders, emotional concerns or any history of familial mental illness. She did not disclose any previous history. Following the birth, whilst an in-patient she had daily assessments of her emotional health with no identified concerns. Following the birth, universal maternal mental health screening was not undertaken by Health Visiting Services, despite the development of a CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 11 of 53  LSCB safeguarding protocol8 and national guidance.9 Selective screening of mothers was available at that time only if indicators of mental ill health were present. However, the mother did not present with any provoking factors and demonstrated a secure attachment to her child. She was not offered screening which may have provided opportunity for discussion about thoughts and feelings. Whilst there is no evidence that this issue impacted on the mother following the birth, early detection of maternal mental ill-health was and remains critical in safeguarding practice, to reduce the risk of mentally ill mothers harming their infants. Maternal mental ill health can remain hidden, in some cases for many years. Its negative impact on the welfare of children is well documented within many national and local Serious Case Reviews. It is positive that some services across the Local Authority have developed a universal maternal mental health screening process aligned to national guidance.10 The LSCB should be assured that this process is and remains embedded in safeguarding practice for all relevant partner organisations.  39. The child was reviewed regularly and discharged by NHS Paediatric Services, due to prematurity. The child and the mother were seen regularly by the Health Visiting Service both in community clinics and during home visits. Following an initial period of intensive support, the case was de-escalated to receive a core Health Visiting Service, meaning the family were assessed as not having additional needs for support.  40. The mother did not receive screening for domestic abuse through routine enquiry. It is of relevance as following the first assault she repeatedly disclosed to Mental Health Services her experience of emotional abuse within her marital relationship. These disclosures were not investigated. The review has not been able to substantiate these allegations. This issue will be discussed later in this review. It is positive that NHS Maternity and Health Visiting services have now established routine enquiry as a part of the management of domestic abuse but this is not yet embedded into practice by all multiagency services. From April 2014, up to the first event, she was seen regularly in Primary Care, by at least thirteen practitioners, yet the issue did not form a consideration within contact with the mother, despite the clear association between domestic abuse and mental ill health. Creating an environment to enable the disclosure of domestic abuse and ensuring systems are in place to train the workforce should also be central components of the strategy. There is new national guidance for all key professionals recommending the introduction of routine enquiry as a part of the domestic abuse risk management strategy.11 All services should evaluate their systems to ensure routine enquiry is embedded into practice for all multi-agency professionals.   Learning Point 1: The management of disclosure and routine enquiry in respect of domestic abuse and maternal mental health for all women was not in line with practice expectations at the time of Child AB’s birth. (Links to LSCB Recommendation 3)                                                               8 Local Safeguarding Children Board (2006) Safeguarding Protocol for The Identification and Management of Perinatal Maternal Mental Health.  9 NICE Guidelines (2007) Antenatal and Postnatal Mental Health, Clinical Management and Service Guidance, updated and Replaced by NICE Guidance CG192. 10 NICE 2014 Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. NICE Guideline CG192. 11 NICE 2014 Domestic Violence and Abuse: Multi-Agency Working. Nice Guidance PH50 Feb 2014. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 12 of 53  41. Child AB: The Early Years up to the First Event in July 2014. The child enjoyed good health and the parents sought appropriate medical advice. Attendances at the General Practitioner and Accident and Emergency departments were always for genuine reasons and on review not unusual or excessive. In June 2014, the child attended General Practice with a 6-night history of night terrors12. This coincided with the mother’s deteriorating mental health. There are many complex interrelating factors that may cause night terrors however the General Practitioner review did not provide any definitive conclusion as to the significance for the child. The General Practitioner’s Review comments that the assessment of the night terrors should have included a conversation with the child and that the issue was poorly documented within the records. Record keeping practice and assessment including communication with children has been strengthened in the General Practice because of this finding.  42. The evidence provided to the review supports the perspective that up to the sudden and unexpected first assault in July 2014, the child had a stimulating and happy childhood, was nurtured by the parents and had been supported positively by the extended family. The review has not received any evidence of missed risk indicators or that the child had been subjected to previous episodes of abuse or neglect.    43. Maternal Health Prior To The 1st Event. From November 2013, the maternal grandparents were concerned for their daughter’s wellbeing, due to work related stress and witnessing a car accident. In April 2014, the mother attended the General Practitioner’s surgery complaining of anxiety, stress and sleeping difficulties due to pressure at work. She did not disclose thoughts of self-harm or intentions to take her own life and declined a same day appointment. She was seen three days later by a General Practitioner, presenting with work related anxiety rather than depression. Medication was prescribed and a referral for practice based counselling was completed. One week later the mother attended the Practice presenting with increased symptoms including depression and low mood. The medication regime was amended. There was still no discussion regarding intentions to self-harm or intentions to harm others despite the emergence of depressive symptoms. Practitioner conversations highlighted the awkwardness for General Practice in undertaking these types of conversations. Within the practice, it would not be normal practice to enquire about thoughts of self-harm or harm to others, unless the service user presented with depression. This issue has been discussed within another local Serious Case Review 13 and a recommendation made that it would be good practice to ask about self-harm in all cases of mental ill health as well as anxiety and depression. The practice has now introduced this line of questioning into consultations.   Learning Point 2: General Practice did not directly question services users in respect of thoughts to harm others during mental illness consultations and identified the challenges and difficulties in this task. A single agency recommendation has been made to address this; it is recommended this is shared with General Practice across the county. (Links to LSCB Recommendation 3)  44. During a triage telephone conversation 8 days later, the mother disclosed thoughts of serious self-harm. She was promptly seen by a General Practitioner to assess whether an urgent                                                            12 BMJ Kotagal S, Pianosi P (2006), Sleep Disorders in Children and Adolescents, Volume 332, Published 8th April 2006. 13 LSCB, Serious Case Review Child XXXXXX Published. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 13 of 53  specialist mental health consultation was required. She then provided a different perspective to the attending General Practitioner than she had done during the triage conversation. She reported that the medication had begun to help her and stated her thoughts were more about not wanting to wake up than serious self-harm. Unusually the maternal grandmother had two separate communications with the surgery around this time, on consecutive days, without her daughter’s consent, asking if an urgent referral could be made to a private healthcare establishment that offered Mental Health Services. The maternal grandmother said she would re-contact the surgery following further discussion with her daughter but the issue did not progress. It would not be normal practice for the General Practice to follow up such communications. The mother’s conflicting descriptions of her feelings and thoughts regarding serious self-harm together with her own mother’s request for specialist help did not trigger any action to expedite counselling or consult with Specialist Mental Health Services. Consultation opportunities with specialist Mental Health Services were available at that time and may have benefitted the management of this case.  Learning Point 3: Consultation with Specialist Mental Health Services should be made available for all cases that are not improving and consultation should not only be available for high risk mental health cases. (Links to LSCB Recommendation 3)  45. Further follow-up was undertaken by several General Practitioners and two practice based Mental Health Counsellors on ten occasions. Her condition remained unstable showing limited improvement and medication was changed on three occasions due to unpleasant side effects to facilitate improvement in her mental health. The management of mental health is complex and it can often be challenging to find effective medication. The General Practitioner Review identified that it is not unusual in such circumstances to have frequent changes of medication and the prescribing practice was in line with national clinical guidelines.14   46. In May 2014, the child’s mother began counselling sessions, 6 weeks after the initial referral. In June, a risk assessment was undertaken during a counselling session, it was noted she had a low mood however there were no risk factors identified. The assessment omitted to include risk to others. Despite evidence from national serious case reviews 15 there was no consideration of the impact of potential risk to the child because of the mother’s mental health. The risks of extended suicide16 by including others was not an apparent consideration. The mother also completed a patient health questionnaire (PHQ-9), a tested and reliable tool used to detect depression and the score was high.17 She had identified thoughts of “being better off dead or wanting to hurt herself every day”. The practice did not review the PHQ-9 document or compare its content with the findings of the day’s earlier counselling session. The contrast in the two communications may have encouraged further exploration and the high risk identified.   Learning Point 4: This case identified that the PHQ9 self- assessment form was not reviewed or followed up within the General Practice. This point should be shared with Primary Care service across the County. (Links to LSCB Recommendation 3)                                                            14 NICE 2009 Depression in Adults: The Treatment and Management of Depression in Adults, NICE London. 15 Brandon M., Et Al (2012), New Learning from Serious Case Reviews: A Two-Year Report For 2009-2011, Dfe, July. 16 See Glossary for Definition of Extended Suicide.  17 Kroenke K1, Spitzer RL, Williams JB.J Gen Intern Med. 2001 Sep; 16(9):606-13. The PHQ-9: Validity of A Brief Depression Severity Measure. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 14 of 53   47. The Initiation/Consideration of the Common Assessment Framework (CAF) 18 In the 4 months preceding the first assault, the parents and family provided a stable life for the child, whilst trying to balance concerns for the mother’s health. The school recognised the deterioration in the mother’s mental health but did not consider the use of the Common Assessment Framework process (hereinafter known as the CAF). General Practice was in regular contact with the mother but did not consider the impacts of her deteriorating health on the child and the benefits of instigating the CAF. The CAF process was not considered by either agency yet may have promoted improved partnership with the family, multi-agency communication, information sharing and planning for early help. The child presented as a chatty, friendly, enthusiastic and motivated. Further discussion with Education Professionals identified that whilst they were experienced in the instigation of the CAF it was not considered it in this case as the child was not exhibiting signs of harm. General Practice are encouraged to participate in the CAF process although in practice it would not be common for the General Practitioner to instigate the CAF.  48. All practitioners need to be aware that children living in such circumstances may hide their experience, do not always stand out from their peers and often act very normally in school or other environments.19 The initiation of the CAF would have been helpful in assessing the level of need and the need for early intervention for the child. Early intervention through the CAF process should always be considered when working with families who are under stress but in this case, it was not a consideration.  49. In summary, professionals in daily contact with the child were aware of the mother’s ill health. The child did not exhibit any overt physical or emotional indicators that would suggest he was a Child in Need of support or at risk of harm, so professionals did not consider or think to instigate the CAF. The CAF process may have provided an improved framework for an early multi-agency response to support the child and the family. Furthermore, it could have improved communication as the mother’s condition deteriorated prior to the first assault as such should have been considered.   Learning Point 5: The instigation of the CAF was not in professionals’ mindset despite the stress this family was under as Child AB’s mother’s mental health showed no improvement prior to the first event. There should always be consideration of the instigation of the CAF in these situations and the decision-making rationale documented. (Links to LSCB Recommendation 3)   50. The Day of the First Event.  On a morning in July 2015, the mother was found by the child’s half-sister, apparently having just seriously self-harmed. The child was present in the family home. The attending hospital doctor identified the child was watching television at the time the event. However, this is not an accurate picture as the child later clearly articulated the earlier scene in the home to Constabulary. It is crucial that doctors examining mentally ill patients with child care responsibilities demonstrate a healthy sceptism and respectful uncertainty 20 when assessing the circumstances surrounding an event. The description of events by mentally ill patients may                                                            18 See Glossary for Definition of Common Assessment Framework. 19 Brandon M Et Al (2012) New Learning from Serious Case Reviews: A Two-Year Report For 2009-2011. University of East Anglia. Dfe. 20 Laming (2003) The Victoria Climbie Inquiry: Report of An Inquiry by Lord Laming. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 15 of 53  not always be accurate. Service users may attempt to reframe Child Protection events therefore the story should be corroborated when possible. Professionals should always consider the possibility of extended21 suicide involving others when adults present following attempts on their own life.  Professionals need to challenge their own biases and belief systems that harm to a child is a real potential during episodes of serious self-harm.   Learning Point 6: Professional biases may have contributed to the ineffective management of the case during the multi-agency Child Protection /Child in Need interventions. (Links to LSCB Recommendation 1 and 3)  51. The Ambulance service took the mother to the Accident and Emergency Department and by early afternoon she had been transferred to a short stay Psychiatric Unit for assessment. Later that day the father was informed by the half-sister, that the child had disclosed the mother had attempted to seriously harm the child on two occasions that same day. The father informed the Nurse caring for the mother, who then made an immediate Child Protection referral to Children’s Social Care. Due to the timings of the referral being after hours, the initial response was managed jointly by the Emergency Duty team and the Constabulary.  52. The initial assessment of the mother’s health by Adult Mental Health services was robust. She was urgently assessed for care and treatment and Mental Health Services communicated with key agencies (Constabulary, Children’s Social Care and the General Practitioner). The Consultant Psychiatrist advised, following consultation, that the initial trigger for the mental health difficulties had been a minor family argument at her parent’s home between the maternal grandparents and her husband.   53. An initial mental health diagnosis was made. On admission to the ward she was clinically re-assessed and the mental health diagnosis was enhanced. The workplace stressors previously discussed and the minor family argument continued to cause her to experience distress. She was prescribed medication. The review process has clarified Child AB’s mother responded well to medication and that some of the symptoms began to diminish.  54. In conclusion, minor to moderate mental ill health is managed in the community by NHS Primary Care services and necessitates close partnership working with other services and partners, with access to specialist expertise and to a range of secondary care services.22 The mother and her family had very positive relationships with the General Practice. Although she showed no significant improvement, she did not exhibit symptoms of severe mental ill health which would have then have been the indicator for referral or consultation with specialist services. Specialist Mental Health Services were not asked to support the management of this increasingly complex case through consultation. As discussed previously the threshold for expert consultation between Primary Care and specialist Mental Health Services should be reviewed and the model strengthened to ensure the inclusion of such cases. Whilst there was evidence of direct questioning regarding thoughts of self-harm, questioning was not undertaken regarding thoughts about harming others, including her child.  Research is clear that this issue should always be a risk management strategy for all services (Learning point 2). Whilst there were some spheres of practice that could be improved this review has not identified any significant                                                            21 See Glossary for Definition of Extended Suicide. 22 Guidance for Commissioners of Primary Mental Health Care Services: Joint Commissioning Panel for Mental Health Raffertys, Feb 2012. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 16 of 53  deficits in safeguarding practice that may have prevented the initial catastrophic assault on Child AB.  2.2 Practice Issues and Events between the Initial and Second Life Threatening Event.   55. The Initial Child Protection Response.  The Staff Nurse followed procedures and made a timely verbal Child Protection referral to Children’s Social Care.23 The worker was advised that the incident should be reported to the Constabulary. The investigation has been able to clarify that a Child Protection referral with these features would always trigger an immediate joint investigation with the Constabulary and it is not clear why this response was given to the referrer. It has not been routine practice for referrers to duplicate their Child Protection referral to the Constabulary. Further discussion has identified conflicting perspectives, with some agencies advising that practitioners duplicate their referrals whilst multi-agency safeguarding procedures do not advise that practitioners duplicate their referrals. There should be a consistent approach to the referral process by all agencies within the LSCB geographical area to avoid confusion at the point of a referral.   Learning Point 7: This case demonstrates inconsistencies in practice at the point of a Child Protection referral with some referrers being advised to duplicate their referral to the Constabulary and Children’s Social Care. (Links to LSCB Recommendation 3)  56. The Constabulary and Social care convened an immediate strategy discussion to plan the response and a welfare check was undertaken just before midnight. Child AB was seen, looked well and was fast asleep being cared for by the father. There were no welfare concerns. The joint response ensured the immediate safe management of contact arrangements. The mother was not to have contact with the child should she take her own discharge as a voluntary patient. Health staff providing care for the mother was also advised of this point. The father signed a written agreement in concurrence with the request.  57. The agreement was unfortunately written up on an incorrect form, which is considered by Children’s Social Care to be down to a simple error. The use of written agreements, in isolation, cannot effectively support the safeguarding arrangements. The father advised he had a pile of written agreements which changed every day. The Children’s Social Care Review also acknowledged some of the subsequent written agreements were lacking in detail and rigor. The Children’s Social Care review advised that a written agreement should be a working document that needs to be clear and concise, reviewed and amended in appropriate circumstances. The recent inspection 24 has also highlighted this failing; an over-reliance on parents’ compliance with written agreements to keep children safe rather than sound safeguarding practice. Practitioners need to understand and work with non-abusing parents and carers to identify and work with the obstacles they face and the reactions they exhibit during the process.25  Children’s Social Care will make improvements to this system in the post inspection improvement plan.                                                             23 HM Government (2006), What to Do If You’re Worried a Child Is Being Abused, (Now Archived). 24 Ofsted Inspection of Services for Children in Need of Help and Protection, Children Looked After and Care Leavers and Review of The Effectiveness of The Local Safeguarding Children Board. Report Published:XXXXX. 25 Ward H., Brown R., Hyde-Dryden G., (2014) Assessing Parental Capacity to Change When Children Are on The Edge of Care: An Overview of Current Research Evidence, Dfe, June. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 17 of 53  Learning Point 8: The written agreement process during and post the Child Protection investigation was not effectively managed to support safeguarding practice. A piece of paper alone cannot secure a child’s safety. This issue is being managed as part of the Ofsted post- inspection improvement plan. (Links to LSCB Recommendation 3)  58. The father and paternal grandparents commended the Constabulary in the sensitive and efficient way they undertook the achieving best evidence interview 26 with the child the next day. The interview was visually recorded and Child AB gave more detail about the sequence of events from the day of the assault.   59. An early decision was taken by the Constabulary after the assault that the mother would not be arrested until her discharge from hospital and the charge against her would be attempted murder. Her solicitor was notified. This was the right course of action to support her ill-health at the time and in accordance with legislation.27 There were further discussions instigated by the Constabulary with Mental Health Services to determine whether an earlier interview could be undertaken. However Mental Health Services did not provide a clear view as to whether the mother was fit to be interviewed, despite the significant amounts of leave from hospital she was allowed. The delay in the interview process was thought to have contributed to the mother’s anxiety. Specialist Mental Health Services should have offered their opinion to the Constabulary to ensure that mentally ill service users can be interviewed at the earliest point in a criminal investigation, without compromising their health status.  Learning Point 9: The Constabulary were not provided with a clear expert Mental Health Services opinion regarding Child AB’s mother’s fitness to be interviewed despite repeated requests, this contributed to a delay in the criminal proceedings. This is an additional learning point for the Constabulary and Mental Health Services. (Links to LSCB Recommendation 3)  60. In conclusion, the initial response by all the agencies to the assault on Child AB was positive. The risk to the child was recognised, sensitively and effectively managed during the initial response to the Child Protection referral. The review has identified there may be differing perspectives in respect of duplicating the referral process to the Constabulary. This is not an expectation of current multi-agency safeguarding practice and the point should be clarified to ensure consistency across the LSCB geographical area. Specialist Mental Health Services should also provide clear directions to the Constabulary regarding a service users fitness to be interviewed, to enable progress in the criminal investigation and reduce anxiety for the service user.  61. The Child Protection Medical Examination. The Child Protection medical examination is normally undertaken to look for signs that a child has been abused or neglected. It is different from a clinical examination undertaken to establish what is wrong medically with a child and if treatment is necessary.28 The Child Protection medical examination is normally undertaken by an appropriately qualified Paediatrician. The                                                            26 Achieving Best Evidence Interview Is Undertaken in Accordance with Section 17 Youth Justice Criminal Evidence Act 1999. 27 Section 23 Of the Criminal Procedure and Investigation Act 1996. 28 General Medical Council, Carrying Out a Child Protection Examination. Downloaded 20.11.15 Gmc-Uk.Org. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 18 of 53  Constabulary planned for Child AB to be medically examined 29 however the father wanted to minimise the distress to his child, who was not showing any physical indicators of harm requiring hospital attendance. The father did not consent to the examination and advised he would take the child for a medical examination to the General Practitioner. The Constabulary acknowledged this perspective, cancelled the appointment and informed Children’s Social Care. Child Protection procedures were not followed in cancelling this paediatric medical appointment. The investigating team had at that time begun to minimise the seriousness of the event and its impact on the child. Their approach was possibly influenced by perceptions and assumptions regarding the parents’ social class, professional status, high academic qualifications and the attitude of the father towards them. This type of professional bias is well documented in other serious case reviews.30 It is critical that robust supervision and challenge is embedded into practice to avoid this type of professional biases impacting on practice  62. The General Practitioner was rather surprised when the child attended the surgery two days after the event, was not informed of the plans for a Child Protection medical examination by multiagency colleagues and was not aware of the assault. Mental Health Services had completed the notification to inform the General Practice of the mother’s admission, which included the assault on the child. The review has been unable to elicit whether this information had been received. The General Practitioner undertook an examination of the child which was unremarkable.  63. The General Practitioner is certain that communication with Child AB took place during this consultation, although there was no documentary evidence. The practice has now addressed this issue. The General Practitioner advised that no feedback was given or requested from the examination. However, the outcome of the examination was documented in the Constabulary chronology as advised by Children’s Social Care. It is likely that the information was shared by the father who was in regular contact with Children’s Social Care but feedback should have been provided also by the General Practitioner. Communication with General Practice in Child Protection work has been criticised in numerous local and national serious case reviews.31 Changes to practice are necessary to ensure that the General Practice’s ongoing role with families is better understood within multi-agency safeguarding partnerships. This issue is being considered nationally and guidance has been produced.32   Learning Point 10:  This child did not have a Child Protection medical examination by an appropriately qualified Paediatrician despite the life-threatening assault. This is not in line with policy guidance and is not expected practice. (Links to LSCB Recommendation 3)  64. In conclusion, Child AB was subject to a very serious life threatening assault but fortunately did not sustain significant physical injuries requiring treatment, therefore a clinical examination at hospital was not deemed to be in the child’s best interest at the time of this first assault. The General Practitioner was placed in a difficult situation, being asked to undertake an examination without being clear of its purpose. Communication with the General Practice by either the                                                            29 Safeguarding Children Board, Procedures, Practice Guidance: Medical Examinations for Children Suspected of Being Abused, Pan LSCB Procedures online. Com Downloaded 14.11.15. 30 Cheshire East Safeguarding Board (2011). Serious Case Review Child B, C, D, CE001, Feb 2011. 31 NSPCC repository, SCR Baby E, library.nspcc.org.uk, downloaded 23.11.15. 32 RCGP, NSPCC, UCL, University of Surrey (2014) The GP’s Role in Responding to Child Maltreatment: Time for a Re Think, an overview of policy, practice and research. July. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 19 of 53  Constabulary or Children’s Social Care would have clarified the examination purpose and enabled further debate. The decision not to undertake a medical examination by the Constabulary, was possibly influenced by the father, who was unaware of the expectations of policy guidance. However, given the seriousness of the assault, the decision not to follow Child Protection procedures remains difficult to understand. Local policy guidance is robust and provides clear expectations of this process. The Constabulary has acknowledged that professional biases may have influenced their decision in allowing the father to unintentionally subvert their intention to undertake a medical examination and this led to an omission in practice. It would not be normal practice within criminal investigations to omit the medical examination in cases where such significant assaults had taken place.   65. The Strategy Discussions and Meetings. The Constabulary and Children’s Social Care convened a further strategy discussion, the day after the incident however no other agencies were involved. Plans were secured to undertake the achieving best evidence interview 33 with the child and agreement was reached that no contact should occur with the mother pending further assessment. An early strategy multi-agency meeting was not convened and therefore professionals in regular contact with the family were not fully involved in the risk management, assessment or planning processes. The School Nurse advised that she had made repeated attempts to contact Children’s Social Care with no significant response but it seems these attempts were not always recorded in the Social Care records. Mental Health Services were not included in the strategy meeting but separate discussions were held. The decision not to include key partner agencies in the early strategy discussions resulted in the assessment of risk being undertaken without knowledge of family history or the opportunity for professional challenge. This issue has been raised within the recent inspection34 and it being addressed within the Local Authority recovery plan.  66. Social Care had intended to convene a combined strategy/care planning approach meeting, nine days after the initial assault, which was not in line with the Child Protection procedures. The allocated Social Worker was on leave and the meeting was arranged by Mental Health Services. The Social Worker’s team manager was in attendance. It is documented a decision had been taken on the seventh day after the initial assault, not to convene an initial Child Protection conference and the case would be managed as a Child in Need case. This decision was signed off eight weeks later by the management structure. This combined meeting was described as difficult, as the child was expressing wishes to have contact with the mother. The combination of these two meetings should have enabled multi-agency professionals to triangulate information, support the assessment and management of risk, provide the opportunity for constructive discussion and challenge regarding the Social Care decision not to proceed to an initial Child Protection conference. It was an ideal opportunity to develop parallel care and risk management plans for both the child and the mother. However again key professionals with ongoing day to day responsibility were not invited to participate (General Practitioner, Education and School Nurse). Education was on the long summer break but the School Nurse would have been available as a useful conduit for communication with the school.                                                              33 Achieving Best Evidence Interview Is Undertaken in Accordance with Section 17 Youth Justice Criminal Evidence Act 1999. 34 Ofsted Inspection of Services for Children in Need of Help and Protection, Children Looked After and Care Leavers and Review of The Effectiveness of The Local Safeguarding Children Board. Report Published: XXXXX. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 20 of 53  67. Multi-agency Child Protection procedures35 provide professionals with cohesive strategy meeting/discussion guidance, which are fully inclusive of multi-agency partnership arrangements. This review has identified that key professionals with ongoing responsibilities for the family were not included. Practitioner conversations highlighted this as a significant and regular area of concern in practice. This process needs to be reviewed to ensure key professionals sit down and work together at the commencement of all Child Protection investigation. Joint working in this way is the principle of safeguarding work and ensures all agencies agree and understand the risk planning process. This will to avoid confusion and disagreements later in the process and supports the arrangements to safeguard the child. A recent inspection 36 of Children’s Services within the Local Authority has recently highlighted this as an issue for action.  Learning Point 11: Key multi-agency professionals were not invited to participate in strategy discussions or meetings thereby reducing the quality of information sharing and communication throughout the Child Protection investigation. This will be managed through the Ofsted post- inspection improvement plan. (Links to LSCB Recommendation 3) 68. Each new Child Protection investigation builds a new multi-agency team working with the child and family therefore establishing cohesive partnership arrangements early in any investigation. This is critical, to establish a clear understanding of the differing roles and risks to the child. The review has identified that normally there is positive multi-agency partnership in the locality. The allocated Social Worker was very competent although inexperienced having been qualified less than a year and the practice manager was newly recruited which may have impacted on the ability to communicate with other professionals. It is reported the practice manager had received induction into the role. The Children’s Social Care staffing levels were not reported to be a concern however the team capacity was noted not to be at the expected national level. Workforce planning and service transformation is ongoing within Children’s Social Care. There are systems in place for all agencies to notify the LSCB should workforce issues impact on service delivery.   69. Re-instating Contact between Child AB and the Mother. Initially robust directions were provided by the Constabulary and Children’s Social Care that direct contact should not occur between Child AB and the mother, immediately following the incident. However, contact arrangements quickly became a key focus for debate by family members and some professionals, with many dominant opinions primarily in Mental Health Services, that contact should be re-instated. The child was also reportedly requesting to see the mother.    70. The day after admission, Mental Health Services described Child AB as a “protective factor” for the mother. This term is sometimes used in Mental Health Services meaning that a mentally ill vulnerable adult is less likely to take a child’s or other person’s life if they are securely attached. However, it can be misunderstood and in cases when a vulnerable adult has started to seriously self-harm or attempt suicide the child as a protective factor is negated and the risk may become                                                            35 Pan- LSCB Multi-Agency Procedures Downloaded 18.11.15 From Pan lscb.Proceeduresonline.Com. 36 Inspection of Services for Children in Need of Help and Protection, Children Looked After and Care Leavers and Review of The Effectiveness of The Local Safeguarding Children Board Report Published: XXXXXX CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 21 of 53  that filicide-suicide 37 38 39 is planned. This is confusing terminology and is used with a different meaning than is used in Child Protection work. The child may be a protective factor for the adult when assessing the risk of suicide but contact arrangements should always be in the child’s best interest and the risk should be robustly assessed.  The Expert Psychiatric Consultant advised that when patients are suffering with mental health difficulties family members can be protective factors against suicide and self-harm but cases are very complex and there can be no presumption of this safeguard. The use of this term should be avoided in Mental Health Services, the child should always be the central consideration in the management of risk by all services.   Learning Point 12:  The level of awareness amongst practitioners was limited regarding the adult’s mental health presentation and the increased risk of filicide, harm to others, and the risks of viewing the child as a protective factor. (Links to LSCB Recommendation 2 and 3)  71. On the third day, the reviewing Consultant Psychiatrist, suggested that contact should be reinstated and shared this view with the father and Children’s Social Care. The father had spoken to the Consultant who reported that the mother was not having any further thoughts of harming her child. The records stated “we rather encourage good contact and relationship with the child unless there is good reason for not doing so”. This would have been understood as an influential opinion by Children’s Social Care and the father, thereby influencing professional and family discussions to re-instate contact.   72. At this point it seems that many professionals, despite the very recent assault on the child, maintained their belief that contact between the child and the mother would be positive despite the risk that this potentially posed. It seemed that the dominant belief of many professionals and family members was built on the parent-child relationship, formed during the years prior to the first assault. The belief was not focused on the recent assault and new emerging evidence. The Constabulary were very vocal in their opinion that contact should not be reinstated but it seems this critical opinion was not heard or remembered in the quest to re-instate contact. Many professionals were keen to maintain the hypothesis that contact was in the child and the mother’s best interest. This is known as a confirmation bias40 when practitioners tend to maintain their intuitive beliefs when considering evidence that challenges them. Practitioners become attached to their judgements and can employ strategies to ensure that new challenging evidence is not recognised or gathered. The dominant view of the professionals can result in an outlying view being ignored as was evident in this case. In addition, professionals did not provide challenge preferring to leave key decision making and accountability to the lead agency rather that active involvement, known as the bystander effect.                                                              37 See Glossary for Definition of Filicide-Suicide. 38 Hatters Friedman S, Holden CE, Hrouda D Resnick, PJ. (2007) Maternal Filicide and Its Intersection with Suicide (2007) Downloaded 21.10.15 Btci.Stanford.Clockss.Org. 39 Hatters Friedman S, Hrouda D R., Holden C E., Noffsinger S G., Resnick P J., And (2005) MD Filicide-Suicide: Common Factors in Parents Who Kill Their Children and Themselves, American Academy of Psychiatry Law 33:4:496-504. 40  Kirkman E, K Melrose K (2014) Clinical Judgement and Decision-Making in Children’s Social Work: An Analysis of the ‘Front Door’ System, Research Report, April 2014, The Behavioural Insights Team, DFE.  CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 22 of 53  73. Consensus agreement between the Constabulary and Children’s Social Care was reached and supervised telephone contact was further discussed in the first care planning approach/strategy meeting in August 2014. During that meeting, it was highlighted Child AB had said to her "you sound better than when you tried to smother me". The mother was concerned that the father had told the child to say this, indicating communications had already taken place and more robust arrangements for telephone contact were put in place.  74. Initially telephone contact on a loudspeaker was to be supervised at ward level and by maternal grandparents. There is no evidence of assessment to understand the maternal grandparent’s capacity to undertake this supervision given the emerging disclosures by the mother of challenges in family relationships. There was no written agreement formulated with the maternal grandparents to support these arrangements. The agreement was with the father, who despite difficulties in the relationship was expected to communicate with the maternal grandparents in respect of contact arrangements. The communications were to be monitored and restrictions on topics for discussion were applied. However, there was no record made or feedback of these contacts into the ongoing case management records. Most significantly there was no analysis of these communications, to understand their benefit to the child or the mother.   75. In conclusion, Children’s Social Care were placed under pressure by professionals, family and the child to re-introduce contact. There were two hypotheses created; the child and the mother’s previously secure attachment would become disrupted if contact was not re-instated and that the child would be a protective factor for the mother. It is always a challenge to balance the expressed wishes of a child and family to reinstate contact, with the need to assess and manage the risks. However, in this case contact was rushed into without adequate assessment of the risk or assessment of the family members or others in undertaking supervision of the arrangements. The confirmation bias previously described may have contributed to professional behaviours and should be strengthened in LSCB and agency learning events  Learning Point 13: The multi-agency management of contact arrangements was unclear and confused resulting in in-effective support for the maternal grandparents and unclear risk management strategies to protect Child AB. (Links to LSCB Recommendation 3)  76. Child AB: The Threshold for Child Protection versus Child in Need. Early in August, prior to the first combined strategy/care planning meeting, Children’s Social Care had completed the Section 47 investigation. A decision was made not to proceed to a Child Protection conference. The case would be worked under a Child in Need arrangements. At the time concerns relating to the abuse were substantiated but mitigated as the child was then in the care of the father, who had agreed via a written agreement, not to let the child have contact with the mother. However, this scenario was not permanent and would change quickly over the following weeks as contact was re-introduced. The decision to work this case as a Child in Need was a crucial decision yet difficult to understand, as any life-threatening assault against a child is one of the most serious events that could be perpetrated. The risk factors that preceded the first event had not been mitigated therefore the hypothesis should have been that the mother may perpetrate another assault against her child, if provided with the opportunity to do so. This perspective was offered by Expert Psychiatrist offering advice to the case review panel. Practitioners reported that with hindsight they could not understand why they did not challenge the Child Protection decisions.   77. There were several factors that may have contributed to this decision. At the time the Social Worker had sought the perspective of some family members, who held strong views that to CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 23 of 53  proceed into Child Protection proceedings was unnecessary. The Social Worker highlighted that during conversations, the relationship with some family members could be difficult but not because they were unpleasant in any way. They were described as assertive, persistent in putting their views forward and would challenge the worker’s decisions. The Social Work Practitioner felt interrogated, constantly challenged when making decisions and was also concerned as the family regularly asked to speak to line management. The impact of the family’s professional, affluent and middle class status has been a possible issue in this case. It may have influenced the professional behaviours to place too much responsibility and decision making on the father and the maternal grandparents. The perceived assertiveness of family members posed challenges to key professionals who were not used to this level of enquiry. The panel considered that the family’s status may have led to a different safeguarding response and feel it may have contributed to a more guarded approach rather than escalating into Child Protection processes. This has been reflected in other serious case reviews.41  78. Family members were also experiencing a series of life changing events which included accommodating the trauma, concern for the mother, the impacts on family life and the sudden inclusion of statutory services in their lives. This would certainly have been challenging and possibly uncomfortable time resulting in the family feeling the need to protect their family life by challenging and interrogating the process.42 In these circumstances additional supportive contact with the family to support understanding of the system may have been beneficial but it was not considered.   79. The Social Worker’s Practice Manager was aware of the Social Worker’s struggle to develop positive partnership with the family, and tried to support the worker through discussions. The Practice Manager did not undertake joint visits or meetings with the family. The conversations highlighted the supervision processes did not address the emotional context of the work for the Social Worker, which has now been acknowledged as an unintentional omission. Active reflective supervision43 that fully engages practitioners in the process, considers the worker/client relationship and uses observation to identify strengths and weaknesses in practice is the preferred model in safeguarding work. Following the recent inspection Children’s Social Care have plans to strengthen their supervision arrangements.44   80. The initial Section 47 investigation requires that an assessment is undertaken per the Assessment Framework.45 This assessment process is used as a means of gathering and analysing multi-agency information to determine the level of need. Key universal agencies (General Practitioner, Education, School Nurse) had not been asked to contribute to the assessment therefore their professional views did not influence the decision which became the sole responsibility of the inexperienced Social Worker. The probability is that the assessment of needs was based on communications with family members or on professional assumptions that this was a professional, intelligent, articulate, affluent family living in an area of low deprivation,                                                            41  Kingston LSCB, SCR Child A, Dated 18.11.15. 42 Duxbury, J (2000) Difficult Patients, Butterworth Heinemann. 43 Morrison T (2006) Staff Supervision in Social Care: Making A Real Difference for Staff and Service Users, Pavilion. 44 Inspection of Services for Children in Need of Help and Protection, Children Looked After and Care Leavers and Review of The Effectiveness of The Local Safeguarding Children Board Report Published: XXXXXX 45 Framework for The Assessment of Children in Need and Their Families, Department of Health, London, The Stationery Office. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 24 of 53  therefore could adequately manage the child’s needs as well as the risks the mother posed. There was no evidence that the assessment or assumptions about parental capacity were reviewed or challenged, even as the mother’s mental health began to deteriorate and contact with her child began to increase. It seemed that professionals acted as bystanders by not challenging the Social Worker’s decision preferring to stay on the outside of the decision-making process.  81. The Children’s Social Care review has explored the assessment of risk and worryingly there appeared to be no risk assessments regarding the mother’s diagnosis or the risk she posed to Child AB. The risk assessments completed by the Mental Health Services were not always shared and those that were shared were not shared in a way that made then understandable to other services. Some risk issues were discussed within the child and family assessment documentation but this was not sufficient or proportionate to the criminal act. The risk assessment appeared to be based more on the father’s ability to protect his child from any further harm and not on what risk the mother posed to the child or others. In safeguarding practice, the management of risk should be centred on the potential conflict between the child’s interest and those of the main caregivers. There are rights and responsibilities on both sides which need to be given consideration but it is always the child's interest which must be paramount because of the child’s vulnerability.46 The multi-agency arrangements should have jointly assessed and managed the criminal, mental health and Child Protection risks rather than leaving the Social Worker to manage the issues in apparent isolation.  82. The decision after the initial assault not to proceed to a Child Protection conference was agreed by the Social Worker’s manager. At this point, supervised contact between Child AB and the mother had commenced. The mother had been discharged from inpatient Mental Health Services and had begun to exhibit an increase in self-harming behaviour whilst living at her parents. There is no evidence that this was a consideration within the decision-making process. Children’s Social Care have systems in place and managers are expected to seek the opinion and oversight of an Independent Reviewing Officer, in all Section 47 Child Protection cases, that are de-escalated to Child in Need. This service was not accessed which was a missed opportunity for external scrutiny. The recent inspection has highlighted systemic weaknesses in management oversight of this work, with no checkpoints or protocols in place in the cases reviewed.47     83. Whilst it is the responsibility of Children’s Social Care to make the final decision whether to proceed to a Child Protection conference, failure to invite the multi-agency professionals at the beginning of the process reduces the possibility of agency challenge in respect of the decision. Effective Child Protection work necessitates that decisions are informed by multi-agency partners, rather than a single agency as this case identifies. The Constabulary, Education and Mental Health Reviews identified their failures by not challenging this decision in line with Child Protection procedures,48 which provide clear guidance on the management of threshold disagreements. It would seem at the time practitioners had either not understood the risk to the                                                            46 Calder, M & Hackett, (2003), "Assessment in Childcare – Using and Developing Frameworks for Practice".  47   Inspection of Services for Children in Need of Help and Protection, Children Looked After and Care Leavers and Review of The Effectiveness of The Local Safeguarding Children Board Report Published: XXXXX. 48 LSCB Multi-Agency Procedures, Section 8, Resolving Professional Disagreements Downloaded 23.11.15. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 25 of 53  child and or did not disagree with the Social Care decision. It is also noted that multi-agency practitioners did not seek advice or supervision from their agency safeguarding experts, which is another indication that the case was not viewed as complex or at high risk.   84. A Child Protection conference was not convened as would be expected following such a significant and potentially catastrophic assault on a child. There were several issues that could have been more effectively managed including; building relationships between the family and the practitioners involved in the case; failure to challenge the threshold decision not to proceed to Child Protection conference, failure to seek safeguarding expertise, ineffective case management oversight/supervision and agency failure in gathering and triangulating multi-agency information. Ultimately though it would seem that multi-agency professionals were not sufficiently concerned about the initial incident and the decision to not to proceed to Child Protection conference. Even if the outcome was that a Child Protection plan was not deemed to be necessary, the Child in Need process might have been better informed had an initial Child Protection conference been instigated.   85. The balance between considering the wishes of the family and taking Child Protection proceedings forward is difficult. However, Children’s Social Care always has the responsibility to make the decision based on an accurate and ongoing assessment of need and risk. Multi-agency partners have a responsibility to support the assessment process and constructively challenge decisions that they feel are not appropriate to the level of risk. At the beginning of the investigation professionals misunderstood the ongoing risk to the child resulting in the case being managed at a lower level of need, which was incompatible with the high level of risk.  This set the scene for future practice. Children’s Social Care have made recommendations to strengthen this issue which has also been identified in the recent inspection report.49  86. Disclosures of Emotional Abuse. This review does not seek to make a finding on the disclosures of emotional abuse by the mother. It seeks to understand how multi-agency practitioners managed the repeated disclosures, worked to understand her experience and incorporate the issue into her care plan especially when planning for home leave. There was no direct questioning undertaken by professionals and learning points have been identified earlier in this report.   87. The mother continually advised her care team she felt emotionally abused within her marital relationship, a perspective also offered by the maternal grandparents. She also felt that contact with her husband was required to gain supervised access to her child. It was observed that contact with her husband at times lifted her mood. The father was made aware of the disclosures and advised that following the first incident, during child contact, he needed to watch all the time and was ready to intervene if he considered his wife was acting inappropriately towards their child. The father felt his wife interpreted this as him being overly controlling. The paternal grandparents were also made aware of the disclosures and expressed surprise having never observed previously anything more than normal marital disagreements. Education and General Practice had no evidence or concerns that emotional abuse was a factor in the relationship.                                                              49 LSCB Inspection of Services for Children in Need of Help and Protection, Children Looked After and Care Leavers and Review of The Effectiveness of The Local Safeguarding Children Board Report Published: XXXXX CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 26 of 53  88. The Mental Health Review highlights that practitioners did not explore the mother’s disclosures any further. Practitioners did not refer the mother to specialist domestic abuse services or use this information to contribute to planning for home leave or assessment of risk. Home leave was on occasions supervised by the father yet practitioners did not challenge when the mother went on supervised leave with her husband, whom she had made allegations against. The focus of attention was on the clinical management of the mother’s mental health rather than a holistic perspective of contributing factors and risks to the child.   89. The disclosures relating to domestic abuse were made immediately after the initial event and, despite Mental Health Practitioner’s participation in strategy meetings were not shared with the Social Worker until a care planning meeting three weeks later. There are several further references in the chronology but there was no attempt by the Social Worker or Mental Health Services to whom the comments were made, to trigger a domestic abuse assessment.   90. Records indicate the risk to the child was not adequately assessed within the context of allegations of emotional abuse and the focus continued to be the risk the mother posed to herself. This issue was not given due consideration by key practitioners and again conversations have highlighted this as an omission.  Professional optimism is evident as practitioners did not respond to the information even though there were regular disclosures.  Practitioners appeared to filter out and ignore the issue rather than addressing this challenging issue. It appears that staff lacked professional curiosity needed to interrogate the disclosures which contributed to the failings in the assessment process.  91. The LSCB quality assures partner agencies compliance with mandatory training. Self-reporting by agencies indicates uptake is high, so it is surprising that this issue was not adequately managed by Mental Health Services or Children’s Social Care.  However, considering the earlier findings in this review, all agencies should review the effectiveness of their learning opportunities and strengthen the opportunities to interrogate professional belief systems in respect of domestic abuse within supervision and safeguarding practice.  Learning Point 14: Case management oversight through effective, reflective safeguarding supervision was not sufficiently robust leaving an inexperienced front line practitioner isolated in practice when making key safeguarding decisions.  This issue is being managed as a recommendation in the Ofsted post- inspection improvement plan. (Links to LSCB Recommendation 3)  92. The Management of Home Leave. Although the mother was very ill, she had insight at the time of admission agreeing to treatment in hospital rather than in the community. She was admitted as a voluntary patient and was not detained under the Mental Health Act (1983) at any point during her first admission as an in-patient. As a voluntary patient, she could leave hospital at any point. A leave care plan was formulated and within 2 days she had her first period of leave, escorted by her husband whilst her parents cared for Child AB. It was noted that her mood improved following escorted leave with her husband despite the allegations of controlling behaviour as previously discussed.  93. The mother remained an in-patient for 35 days, up to her discharge. Her presentation was sometimes inconsistent i.e. linking home leave with child contact, not always being honest about her feelings to end her life and expressing strong negative feelings when with her husband, child and stepdaughter but not when with her friends or parents. Her presentation continued to vary and she was reported at times to be displaying distressing mental health symptoms which CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 27 of 53  could rapidly change. There was no regular direct discussion of suicidal ideation 50 or plans to include or harm others. She maximised her opportunities for home leave to see her child and the Mental Health Review makes comment “that this made assessments of her mental health status difficult”.  The father and maternal grandparents advised that Mental Health Services did not advise how escorted leave should be supervised.   94. On discharge from hospital, after 35 days, the bail conditions required the mother to reside at her parent’s home. Her parents took on the responsibility to supervise the mother at home but were not offered advice or direction in how to keep her safe, especially as her self-harming behaviours escalated. Her parent’s devised plans and continually searched for items that she may use to harm herself. At one point her parents expressed the challenges when supporting the mother as her mental health was so unpredictable. Mental Health Services reported a carer assessment was offered but the documentation was only partially completed resulting in poor quality of information. Her parents advised that no carers assessment was undertaken and they were left to care for the mother with no practical or expert support.  95. Mental Health Services regularly undertook safety profile risk assessments between the two potentially life threatening assaults, which should have in principle, informed the decisions regarding home leave and other issues. This assessment is routinely completed to identify the risk of suicide, self-harm, self-neglect, risk of harm to others, treatment and/or illness related risks, substance misuse, social circumstances and any risk posed to children. The assessment was reviewed and updated on twenty-seven occasions including on admission, prior to being granted escorted leave and following the Care Programme Approach reviews. There is limited evidence that the findings of these risk assessments were acted on or seen as a continuous assessment of risk. It seems that each assessment was completed with no consideration of the previous assessment, became a tick box exercise and was ineffective in the management of home leave.   96. The Social Worker was not aware of the mother’s diagnosis or of the views of Mental Health Services about the level of risk she posed. There were some discussions throughout the management of the case between the Social Worker and Mental Health Practitioners. However, these discussions did not clearly provide sufficient information to inform a risk assessment. Children’s Social Care did not formally request this information and supervision did not highlight this as significant issue. The Social Work Practitioner was not involved in the discussions regarding home leave despite the possible implications they could have on the welfare of the child.  97. The status of the mother as a voluntary patient meant that she was free to leave hospital at any point for home leave however In-Patient Mental Health Services had a responsibility to accurately assess her mental health to ensure her treatment was adequate and be constantly vigilant of the risk she posed to both herself and others. Despite her inconsistent presentation, there was no apparent consideration to encourage her voluntarily or through statutory powers to spend more time in hospital. This would have enabled her to be assessed more accurately and associated risks to her child. Critically there was no consideration how home leave could be managed effectively whilst also supervising contact arrangements for the family. The two issues should have been considered and managed together so that both issues could have been                                                            50 See glossary for definition of suicidal ideation.  CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 28 of 53  effectively risk assessed. The expectation of family to manage both functions 24 hours a day was unrealistic.  98. The Psychologist’s Intervention and Predictors of Risk. It is positive the Clinical Psychologist 51 was involved in the mental health assessment and the information shows the mother was open and honest about her feelings and thoughts in these consultations. The Psychologist wrote a detailed report based on the two initial consultations with the mother. This interim assessment was completed prior to discharge and provided the most accurate assessment of predictors of risks that that might precipitate another event. It was a commendable, insightful and valuable piece of work however was not shared effectively with multi-agency partners. Therefore, the value of this work remained lost in the safeguarding process.  99. The report highlighted the future uncertainty for the mother in respect of loss of contact with her child, the impending criminal investigation and possible imprisonment, all of which could de-stabilise her condition and increase the risk to others. Mental Health Practitioners were advised to consider these issues, as they would likely impact on her risk-taking behaviours and mental health presentation. Practitioners were advised to maintain regular contact with the mother, whilst keeping a focus on these issues. The Psychologist advised that she was continuing in her marital relationship, although she didn’t want to, to maintain contact with the child. The assessment highlighted the risks for her, in this behaviour, in that if she resumed her place in the relationship she would place herself in the same dynamics that preceded the initial assault.   100. The Psychologist also expressed concerns; about the father’s reaction, the attempt on his child’s life and advised that the father hadn’t yet synthesized the seriousness of the assault. The father was not thought to be focusing upon what had happened with his child at that time and had been noted to be ‘’quite loving and affectionate towards his wife”.  The report outlined that this may have represented that the father was not fully accepting of the significance events, either in relation to the mother’s actions towards her child or the events that led up to this. The Psychologist shared these concerns with Children’s Social Care prior to discharge by telephone although no written assessment was given. The assessment of non-abusing carers or parents is a process, which should happen over time in safeguarding work, with an expectation of some positive shift over time.  It is not uncommon for initial shock or disbelief to exist and this should not form the basis of a complete assessment. The shift in attitude should be assessed on an ongoing basis. The Psychologist felt this should have been a significant consideration in how contact with the child was managed. The Social Worker advised that this would be noted in relation to the case but the social work recordings did not sufficiently explain the discussion and there was no further acknowledgement or assessment of this issue.   Learning Point 15: Specialist Adult Mental Health and the Child Protection services should have been able to unify practice effectively to manage the risk jointly for Child AB and the mother. (Links to LSCB Recommendation 3)  101. The Psychologist’s report provided clear predictors of risk yet its content was either not known or not understood by some multi-agency professionals. Family members were not aware of the assessment and had no knowledge of its content. The LSCB should be assured that in future practice risk predictors identified during a psychologist’s assessment in respect of mentally ill                                                            51 See glossary for definition of Clinical Psychology. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 29 of 53  adults, involved in child safeguarding proceedings, will always be shared in a meaningful form with multi-agency partners and families.   102. Criminal Proceedings.  Some family members feel that the delay in the criminal proceedings was a significant factor, contributing to the mother’s unstable mental health and ultimately contributing to the second potentially life threatening assault. The Psychologist’s report backs up this perspective in identifying that stressful events such as legal proceedings may possibly precipitate a deterioration in the mother’s mental health. The review has analysed this process.   103. Following the first attempt to harm the child there was a delay in the Constabulary interviewing the mother as she was an in-patient and a suggestion by a psychiatrist that she was “too unwell” to be interviewed. The Mental Health Review finds that this decision was inconsistent and questionable as nursing records indicated she was functioning well, meeting her own needs and having frequent periods of leave. There were no factors, excepting medication that may have prevented the initial interview. Due to conflicting messages from Mental Health Services the Constabulary decided to defer the interview until she was fit for discharge, to avoid compromising the investigation and causing her distress. All other witness interviews occurred immediately following the first event except for the ambulance service.  104. In August 2014, the mother was deemed fit to be discharged, plans were made for her to be formally arrested and interviewed. She was arrested on suspicion of attempted murder and interviewed. She was subjected to bail conditions which were reviewed eleven weeks later. The review date was to enable the Constabulary to gather medical notes and Paramedics’ statements. In November, the bail conditions were extended for approximately sixteen weeks (to the day following the second assault on Child AB), pending submission of the file to the Crown Prosecution Service.   105. The formal request for Paramedic statements was delayed for six weeks, due to the Officer being on leave from work for a month (jury service and training). The Ambulance Service requires a formal request to disclose this information, unlike many other NHS organisations, when the disclosure of information is provided quickly as part of multi-agency information sharing agreements. The statements were not received for a further six weeks from the Ambulance Service, following a second request by the Constabulary, which is a significant delay in process. This delay has been explained as being due to operational pressures and staff sickness and the Ambulance Service has now provided operational guidance to the Constabulary should this issue arise again.   106. In December 2014, the Crown Prosecution Service requested the Constabulary appoint a Psychiatrist, to comment on the mother’s ability to form the required intent for the offence of attempted murder. There was a delay in identifying a suitable Psychiatrist and the appointment was sent nearly two weeks later. The mother was assessed, three weeks later and the report was received after one month by the Constabulary and the Crown Prosecution Service.  107. In conclusion, the review agrees with the family in that the delay in progressing criminal proceedings may have contributed negatively to the mother’s deteriorating mental health however the reasons for the delay are multi-factorial and cannot be attributed to a single agency.   108. Bail Conditions and Supervised Contact. Constabulary bail conditions are written to protect victims whilst a decision is made regarding the outcome to proceed with criminal proceedings. Once in place they cannot be altered without CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 30 of 53  the authority of the Custody Officer. Bail conditions were clear. The mother was “not to interfere or have any contact with Child AB apart from telephone contact” or “as directed by Social Services”. On reflection, the Constabulary Review advises this condition was too broad, unspecific and effectively allowed Children’s Social Care autonomy regarding contact arrangements. It has made recommendations to change this practice. The caveat as “directed by Social Services “was a significant factor in the Custody Officer being satisfied the risk to the child was being effectively managed. The Children’s Social Care review explained this can mislead professionals and families into believing that the investigation is of a less serious nature. The Officer managing the bail conditions, was not aware of the agreement that the mother could visit the child in the family home and if known would have made it clear it was against the bail conditions. The Social Worker also misunderstood the process and thought the bail conditions could be amended following a multi-agency decision, without reference to the Constabulary. The Social Worker was placed under undue pressure by the family and multi-agency professionals to increase contact arrangements. There is evidence that the Constabulary who should have had oversight of the bail arrangements, were given very limited information or involved in planning the contact arrangements.   109. All the way through the early stages of the investigation the Constabulary objected to face to face contact unless supervised by a professional and requested that supervised contact by the grandparents should only occur after an assessment had been completed. This assessment was not completed until after the second event. Children’s Social Care agreed in the first Child in Need meeting to discuss the plans for contact with the Constabulary but there is no evidence this conversation took place. In practice the Constabulary normally only attend Child Protection Conferences and are not normally invited to or attend Children in Need Meetings. Therefore, they were not made aware of the predictions contained within the Psychologist’s report. It is probable had the case been worked under the higher threshold and a case conference convened this would have been information available to the Constabulary.   110. The records of the discharge planning meeting identified that it had been agreed contact could be re-instated and supervised initially by professionals. The Care Coordinator would work on a relapse plan with the mother in terms of triggers and signs of a relapse. However, the mother disclosed thoughts of serious self-harm within two days of discharge. The mother contacted the General Practice regarding concerns about her mental health. The General Practice did not liaise with Mental Health Services, leaving the mother to have this discussion. She contacted Mental Health Services, two days later expressing more thoughts of self-harm reported to be due to a lack of contact with her child. Despite this deterioration, she had supervised contact on three occasions, twice in her parents’ home supervised by Community Mental Health Workers and once in school supervised by the Head Teacher. Following the first of these contact sessions, the maternal grandparents disclosed the mother had recently attempted to take her own life. The Care Coordinator was aware of this disclosure but did not follow expected practice and escalate the issue back into the Care Planning Approach process.   111. It has not been routine practice for contact to be supervised by multi-agency professionals other than Children’s Social Care, who normally arrange supervised contact in Child Looked After situations. It is also unusual for the supervision of contact arrangements in Child in Need cases to be supervised by Children’s Social Care. The motivation of professionals to undertake this function was well intentioned and in principle contact arrangements could possibly be supervised by competent multi-agency professionals, although this is not currently normal practice. Legal services in the area had previously advised this is not a function of school staff. No contact planning meetings were held although the issue was briefly discussed in the Child in Need meetings. There were no written recordings of the contact sessions to inform planning or to CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 31 of 53  enable the impact of contact for the child to be accurately recorded, although verbal reports provided positive feedback. In practice this area of safeguarding activity is unclear therefore further guidance is indicated.  Learning Point 13: The multi-agency management of contact arrangements was unclear and confused resulting in ineffective support for the maternal grandparents and unclear risk management strategies to protect Child AB. (Links to LSCB Recommendation 3)  112. In September 2014, during a Child in Need meeting, it was agreed that family members could supervise contact arrangements. The written agreement was signed by the father, agreeing contact between the child and the mother could occur and would be fully supervised by the maternal grandparents, whilst investigations were ongoing. The maternal grandparents did not sign this agreement. No evidence has identified how these decisions were made or what would be requirements of family members. Consideration was not given to the challenges in family dynamics. Contact continued, supervised mostly by the maternal grandparents and the father despite the mother’s deteriorating mental health. Prior to the final event she reported to her care team that contact was difficult as the child would want to play with friends or would ask for the father. She found this overwhelming and difficult to cope with. Mental Health Staff did not see this as an indicator that might precipitate another serious assault.  113. In conclusion, the management of bail conditions and contact arrangements between Child AB and the mother were unclear and confused. The Constabulary have made recommendations for the management of bail conditions arising from this case. Children’s Social Care have limited authority to determine what contact arrangements should be under Child in Need arrangements and multi-agency partners currently have limited involvement in these arrangements. The family was left to manage the contact arrangements with little or no support. The Constabulary who had the accountability for the management of bail conditions was not actively involved in planning the contact arrangements.  Most significantly child contact arrangements and escorted leave were not considered as a single process in practice.  Learning Point 15: Specialist Adult Mental Health and Child Protection Services should have been able to unify practice effectively to manage the risk jointly for Child AB and the mother. (Links to LSCB Recommendation 3)  114. The Effectiveness of Partnership Meetings.  This review has already discussed the strategy meetings convened in the initial stages of the investigation, expressing concern these were not fully inclusive of multi-agency partners. This theme continued into other meetings. Children’s Social Care and the Constabulary requested invites to attend all the Care Planning Approach meetings52 however the Constabulary was only invited to one Care Planning Approach/discharge meeting. During this meeting, when the instigation of contact was under consideration, it is recorded the Constabulary verbally requested the family should never leave the child alone with the mother. Inclusion of the Constabulary in the future meetings could have afforded all agencies the opportunity to reconsider the risks. Risk management in public protection arrangements is a key focus of Constabulary activity and would have added value to the multi-agency skill base. This was also an opportunity for other agencies to provide updates on the case including mental health risk management issues. The Mental Health Review highlights positive evidence to support mental                                                            52 See glossary for Care Planning Approach Meetings  CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 32 of 53  health staff liaison with partner agencies at key stages outside of the meeting but also evidences ‘silo’ working meaning at times multi-agency intervention was not as robust or as effective as it could have been.  115. Child in Need meetings were convened on five occasions separately from the Care Planning Approach meetings. The meetings were not as effective as they should have been and provided no confidence that the risk to the child had been considered in view of the mother’s escalating episodes of serious self-harm and attempts to end her life. The maternal behaviours were not always considered and on one occasion the meeting was cancelled two days after a serious attempt. The recordings of these meetings were not robust and frequently only two agencies, Children’s Social Care and Education, were in attendance, other professionals were not invited or did not attend. Due to the limitations in multi-agency participation information sharing was limited. The father and maternal grandparents advised the meetings were unstructured, unfocused, and poorly managed and family were often invited as an afterthought.   116. The wishes and feelings work with the child was arranged through the requirements of the Child in Need plan and was a commendable intervention. This work commenced within two months of the initial event and remains in place at completion of this review. The worker maintained regular contact with the child and the father and the work is reported to have been of significant benefit as the child accommodates recent events.   117. In conclusion, the meetings should have provided a venue for all multi-agency partners to share relevant information, improve the quality of assessment and manage the risk for the child and the mother. The meetings were not as effective as they could have been resulting in limitations of multi-agency involvement, silo working, poor information sharing resulting in ineffective assessment and risk management. When Adult Mental Health Services and Children’s Social Care are jointly involved in complex cases consideration should be given to the feasibility of a single process to combine the functions of the Care Planning Approach and the Child in Need meetings to more effectively share, assess and manage the information. This may have enabled professionals to more effectively manage the risks to Child AB.  Learning Point 15: Specialist Adult Mental Health and the Child Protection Services should have been able to unify practice effectively to manage the risk jointly for Child AB and the mother. (Links to LSCB Recommendation 3)  118. The Involvement of Children and Adolescent Mental Health Services (CAMHS) Child AB’s father was keen to minimise the psychological consequences on his child’s mental health and was keen to engage early help services. Children’s Social Care contacted the General Practitioner, following discussion with the father, three weeks after the assault. The General Practitioner had not assessed the child psychologically therefore could not be certain a referral to CAHMS was necessary. A referral was made following the discussion with the Social Worker but not accepted by CAMHS because the child was not exhibiting any indicators of psychological distress at that time. A repeat referral was made following the final incident and again the referral was not initially accepted as the child was not outwardly displaying signs of emotional distress. The process for accessing CAHMS expertise was described as confusing by the family and practitioners alike.  119. Further discussions with practitioners highlighted that in practice the service is not normally provided to children who have experienced significant child abuse events unless they are exhibiting symptoms of severe mental ill health. Nationally the NSPCC has been concerned CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 33 of 53  about the issue, discussing that children who have been abused and neglected are often denied treatment because their cases did not meet the "high clinical threshold” required by CAMHS. Specialist trauma services should always be available for these children to prevent the psychological aftermath of child abuse, that may become evident after many years, as the emotional and psychological consequences of the abuse becomes more severe. The commissioning organisation has advised this has been a previous requirement of the service specification and will be strengthened in the review of the CAHMS service specification.   120.  The father and teachers report that Child AB responded positively to the wishes and feelings work provided by the Family Support Worker, employed by Children’s Social Care. They have commended this work saying how much the child looked forward to these sessions. Latterly consultation in respect of this work was offered by CAHMS tier 2 practitioners, who are specialists working in community, in line with the expectations of the service.  121. The provision of CAMHS services were not always understood by professionals or family members trying to access the provision. There was confusion in understanding the thresholds for CAHMS intervention and it was not clear that specialist trauma services would be offered to the child. However, the wishes and feeling work undertaken by the Family Support Worker has been beneficial and supportive to the child and is identified as good practice.  Learning Point 16: The availability of trauma psychological services for Child AB post the initial incident was uncertain leading to some confusion for the family and professionals (Links to LSCB Recommendation 3)  122. Escalating Risk Taking Behaviours and Threats to Harm Others.  This section will provide an overview of the events involving the mother and how the safeguarding systems interacted with the mental health systems in the period between the two assaults. The differing events are referred to in weeks following the first event.  The Mental Health Review explores these issues in greater depth.  123. Attempt 1 (5th week): Within one week of hospital discharge the mother disclosed further thoughts of serious self-harm and contacted her General Practitioner regarding her deteriorating mental health. Following the first contact session in the sixth week with her child, the mother and her parents informed the Care Coordinator that the mother had in the previous week, attempted to take her own life. This was despite intensive support by the Care Coordinator and the Crisis Team. There is no evidence this was shared with other professionals supporting the family or reported to the Mental Health Organisation. It does not seem this issue was considered in final decision made by the Children’s Social Care manager not to proceed into Child Protection Proceedings. Despite this disclosure, the child was still allowed to have contact with the mother, in the home environment. The contact between the child and the mother was perceived as having gone well.   124. Attempt 2 (11th week): The mother’s mental health continued to deteriorate, she began to cancel appointments with her Care Coordinator and there was an over-reliance on her parents to assess their daughter’s wellbeing. The mother made a further attempt to end her life at her parents’ home, 7 weeks after discharge from hospital. The risk to the child was not considered and the exploration of the incident in respect of harm to others was inadequate. All the predictors present prior to the first attempt on the child’s life and contained within the Psychologist’s report were evident but un-recognised. The Constabulary was not notified; the attempt was briefly discussed in a Child in Need meeting, 3 weeks later but not prioritised as a risk.  Her care and treatment CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 34 of 53  was transferred to the Crisis Resolution and Home Treatment Team as she was presenting with increased risk. This is a service that provides intensive support at home as an alternative to an admission to hospital. It was agreed that the team would offer daily visits to monitor and review her mental state and the associated risks. Contact was maintained with Child AB throughout this period and continued to be supervised by the maternal grandparents. Contact continued to be reported as positive although the mother’s mental health showed no improvement.  125. Attempt 3 (19th week): Mental Health Services were notified the mother had been detained by a different cross-boundary Constabulary, under Section 136 of the Mental Health Act, 8 weeks later. She had been located expressing suicidal ideation. Section 136 of the Mental Health Act allows Constabulary officers to detain a person if they are deemed to pose a risk to themselves or others and enables transfer to a place of safety. This section lasts for up to 72 hours, during which time a formal assessment under the Mental Health Act must be convened to determine whether the person requires continued detention. Child AB’s mother was transferred to hospital and agreed to an informal admission. Detention under the Mental Health Act was not deemed necessary due to her agreement regarding a voluntary admission. Supervised contact with the child was again maintained during this period and the opportunity to review the case was lost as the Child in Need meeting was cancelled 2 days after the event.  126. Attempt 4 (21st week):  Two weeks later Child AB’s mother was on leave at the marital home and having contact with her child, escorted by the father. She disclosed to the father her plans to seriously harm him and then take her own life, believing her child would be better off being raised by her parents. The father described this point as a realisation of how poorly his wife was and she was returned to the ward. It is recorded that this information was shared with Children’s Social Care however there is no recorded evidence to indicate this information was shared with the Constabulary despite the mother still being on police bail. Following this incident all escorted leave with the father was suspended to enable the service the opportunity to assess and manage the risk she posed to her husband.  It is surprising and concerning that despite the previous attempt on her child’s life supervised contact continued. The mental health records state this had been agreed by Children’s Social Care but is not recorded in Children’s Social Care records. The mother continued to have escorted leave from the ward for a further 4 weeks and was then granted periods of unescorted leave. Her leave continued to be excessive, making assessment of her mental health difficult and the risk she posed to her child and others apparently remained un-assessed.   127. Attempt 5 (25th week):  When on her first period of unescorted leave the mother bought tablets and on return to the ward took a life-threatening overdose. There was a significant delay in her transfer to the Emergency Department for urgent treatment. This is of significant concern to the maternal grandparents and the mother. The Mental Health Review reports that Child AB’s mother had to be persuaded to have treatment, as she was a voluntary patient.  An assessment under the Mental Health Act was not undertaken, which may have provided the opportunity for statutory intervention in a life-threatening situation. After one week, her physical condition was stabilised and she was transferred back to the mental health ward. She began to openly discuss the challenges in her contact with her child and was more ambivalent about her contact perceiving her child to now be more difficult and challenging. There is no evidence this information was shared or its relevance understood.  128. Escorted leave was re-introduced following this incident and it was stipulated that the leave would need to be facilitated by ‘’people who were fully aware of the history and the risks that she could pose to herself and others’’.  The original Psychologists report was presented and updated. This was agreed within a multi-disciplinary meeting and the Consultant Psychiatrist was fully CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 35 of 53  involved in this decision and sanctioned this arrangement. It was documented that this information was shared with Children’s Social Care but it is not documented. The mother continued to have extended periods of leave and minimal contact with the day staff but engaged well with the night staff, talking freely to staff about her feelings. It is difficult to understand given the fact that reviews took place in the day, how her progress and the risk she posed was accurately assessed. There were plans made after this event for her discharge and potential independent living. The length and frequency of leave and the plans for her discharge may have impacted her parents’ understanding of the severity of her illness.  129. During the 29th week, prior to the second event, despite the provision of multi-agency services to the child and the mother, services failed to understand and manage the obvious risks the mother posed to her child and others. The Child in Need processes did not effectively interact with the Mental Health processes, information was not effectively shared or understood. The Child in Need process was not effectively managed or scrutinised by management and all partners were not fully engaged, resulting in less opportunity for challenge. The risk was not effectively managed to safeguard the child. Professional bias continued throughout the period with a professional perspective that the child was a protective factor for the mother. The risk to the child remained unassessed and misunderstood, even by professionals working in Children’s Services who should have counteracted this perspective. Whilst there was some child focus in the provision of wishes and feelings work for the child, services did not adequately focus on the risk the mother’s behaviour presented to her child.  130. The 2nd Life Threatening Event on Child AB and The Use of Mental Health Legislation. The mother went on leave and had contact with her child on the day of the second event. Her father escorted her and it was noted she hadn’t been feeling well. Mental Health Staff were concerned that leave may not be in her best interest but they didn’t take the opportunity to use their powers to temporarily detain her, pending further assessment. There was no assessment of the risk she posed to herself or others and the father was not informed of the plans for contact with her child, despite the mother’s deteriorating health. The final assault on Child AB as previously described, occurred in her parents’ home. Telephone contact was made by her father to the ward advising she would be returning earlier as she had seriously assaulted her child. On return to the ward she was placed on arm’s length, level 4, observations due to the significant risk she posed to herself and others. This incident was shared with the Constabulary and Children’s Social Care. The Constabulary expressed concern that she remained an informal patient.   131. The mother agreed to remain on the ward and any attempt to leave would have resulted in her being detained under Section 5 of the Mental Health Act. Initially the Consultant Psychiatrist recommended she should be detained but the second Doctor did not agree with the recommendation. The Consultant was then on leave and staff decided to use the least restrictive option as she had agreed to informal admission. There was a delay in using the powers until her Consultant returned from leave, yet the mother was still being subjected to high level restrictive practices but not under a legal framework. The application to section her under the Mental Health Act was completed six days after the event. The Mental Health Review has made several recommendations to strengthen the application of the Mental Health Act in practice.  132. The absence of key professionals such as the Consultant Psychiatrist should not have prevented the use of the Act, which makes provisions for other professionals to undertake this role. During practitioner conversations, it was highlighted that on occasions the ward establishment was covered by low grade and inexperienced Nurses, although they had access to CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 36 of 53  on-call senior staff. This may have been a contributory factor to the Act being ineffectively applied. The organisation has since made improvements to this system.  133. The Mental Health Review provides in depth analysis of the application of the Mental Health Act as opposed to the use of Mental Capacity legislation, which was applied to assess the mother’s capacity to agree to voluntary arrangements. It identifies many opportunities when the Act could have been used to detain and restrict Child AB’s mother’s freedoms. The use of the Act would have provided the opportunity for a more accurate and robust assessment of her mental health and the risk she posed to both herself and others. The inconsistency in the mother’s presentation, the rapid deterioration following discharge into the community post the initial hospital admission, the refusal to be readmitted for in-patient care, the high number of restrictions in place during her leave, the high number of attempts on her own life, the threat to harm others, secreting objects to cause harm and  the level of observations she required as an in-patient were all indicative of the need for Mental Health Services to more effectively consider the application of the Act to manage the risk to others.  134. The mental health recordings do not provide a comprehensive account of the Mental Health Services involvement or actions in the subsequent Child Protection Investigation or Criminal Investigations. The Psychologist provided a detailed account to the investigation detailing the risk issues previously identified in this review, which informed the subsequent Section 47 Inquiry.  135. This review has enabled Mental Health Services to consider their application of this legislation, when their patients have responsibility for children who are at risk of harm. The legislation should have been used more efficiently to support the assessment of the risk the mother posed to herself and others. The voluntary arrangements could have been more insistent on less home leave, to provide the opportunity for a more robust assessment of her mental health condition. If the mother had not agreed to the voluntary arrangements, then restrictions to leave should have been applied for under the Mental Health Act.              CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 37 of 53  SECTION 3: KEY LEARNING FROM PRACTICE.  The review process has highlighted significant learning for safeguarding practice. The learning points contained within the review are tabled below;  1. The management of disclosure and routine enquiry/screening in respect of domestic abuse and maternal mental health was not in line with practice expectations at the time of Child AB’s birth. 2. General Practice did not directly question services users in respect of thoughts to harm others during mental illness consultations and identified the challenges and difficulties in this task. This should be cascaded with General Practice across the area. 3. Consultation with Specialist Mental Health Services should be made available for all cases that are not improving and consultation should not only be available for high risk mental health cases. 4. This case identified that the PHQ9 Self- Assessment form was not reviewed or followed up within the General Practice. This point should be shared with Primary Care Services. 5. The consideration/ instigation of the CAF was not in professionals’ mindset despite the stress this family was under whilst balancing the needs of Child AB whilst the mother’s mental health showed no improvement prior to the first event. There should always be consideration of the instigation of the CAF in these situations and the rationale for decision documented. 6. This case has identified that professional biases may have contributed to the ineffective management of the case during the multi-agency Child Protection /Child in Need interventions. 7. This case demonstrates potential inconsistency in practice at the point of a Child Protection referral with some referrers being advised to duplicate their referral to the Constabulary and Children’s Social Care. 8. The written agreement process during and post the Child Protection investigation was not effectively managed to support safeguarding practice. A piece of paper alone cannot secure a child’s safety. 9. The Constabulary were not provided with an understandable expert Mental Health Services opinion regarding Child AB’s mother’s fitness to be interviewed despite repeated requests this contributed to a delay in the criminal proceedings.  10. This child did not have a Child Protection medical examination by an appropriately qualified Paediatrician despite the life-threatening assault and is not expected practice. 11. Key multi-agency professionals were not invited to participate in strategy discussions or meetings thereby reducing the quality of information sharing and communication throughout the Child Protection investigation. 12. The level of awareness amongst practitioners was limited regarding the adult’s mental health presentation and the increased risk of filicide, harm to others, and the risks of viewing the child as a protective factor. 13. The multi-agency management of contact arrangements was unclear and confused resulting in in-effective support for the maternal grandparents and unclear risk management strategies to protect Child AB. 14. Case management oversight through effective, reflective safeguarding supervision was not sufficiently robust leaving an inexperienced front line practitioner isolated in practice when making key safeguarding decisions.   15. Specialist Adult Mental Health and the Child Protection Services should have been able to unify practice effectively to manage the risk jointly for Child AB and the mother.  16. The availability of Trauma Psychological Services for Child AB post the initial incident was uncertain leading to some confusion for the family and professionals.   CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 38 of 53  136. The management of screening for maternal mental health and domestic abuse including routine enquiry, was not fully embedded into practice despite being a national and local long term priority for safeguarding practice. Practitioners did not seem to understand the relevance of maternal disclosures relating to controlling behaviour and did not effectively understand the impact of the disclosure. The LSCB should be assured that performance measures are in place to monitor the implementation and effectiveness of these systems across the geographical area.  137. Direct questioning in respect of thoughts to harm others and extended suicide was not sufficiently evidenced by the Primary Care Services or Mental Health Services. General Practice expressed the difficulties in undertaking this task and both agencies made recommendations for their respective services. This learning point is relevant for all services across the geographical patch.  138. The opportunity for consultation between Mental Health Services and Primary Care may have benefitted the management of the adult’s mental health prior to the first event but in practice the case would not have met the criteria for consultation. The opportunity for consultation should be made available for all cases showing no or limited improvement and this should be strengthened.  139. Family participation has been a significant benefit to the review process. The family members could clearly articulate the challenges and difficulties they experienced in the provision of services, as the scenario evolved. There is evidence they made repeated attempts to work in partnership with professionals but professionals did not always reciprocate the partnership arrangements. Prior to the 1st event, despite concerns regarding maternal mental health, the instigation of the Common Assessment Framework as a way of working in partnership with the family was not a consideration. There should be consideration to strengthen communications and partnership with families through processes such as family group conferences and the early instigation of the Common Assessment Framework. The voice of Child AB was heard regularly through the wishes and feelings work which is an example of good practice.   140. Child Protection processes were not used effectively despite robust multi-agency procedures being in place. The decision not to invoke Child Protection proceedings, even though the case met the threshold for significant harm, remains difficult to understand given the severity of the initial life threatening event. This decision was made by Children’s Social Care and was taken early in the process, before the first strategy meeting. Multi-agency communication with agencies providing children’s services to the child was not evidenced in decision making. Meetings convened were inconsistent in their membership with key professionals not invited. The oversight of the decision and failsafe mechanisms within Children’s Social Care and multi-agency arrangement were not effective. The decision made by an inexperienced Social Worker, was not seen or challenged by the management structure or by multi-agency partners despite the nature of the assault, the continued concerns for the mother’s mental health and the limitations in the assessment of the maternal risk.   141. The framework used for managing the case under Child in Need arrangements was not as effective as it should have been, the expectations of the process to accurately assess the case and the ongoing risk was ineffective with no evidence of planning or management oversight. Children’s Social Care are reviewing their systems following a recent inspection which has highlighted similar concerns in respect of management Child Protection and Child in Need cases.  142. The multi-agency assessment and management of risk by Adult and Children’s Services was not a joined-up process. Risk assessments were completed by Mental Health Services but were CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 39 of 53  ineffective in supporting the management of risk for the child. The use of numerous contracts to manage the risk to Child AB during contact were also not effective safeguarding practice.    143. The way professional biases and belief systems impacted on the professional judgement is a key learning point for this case. The practitioner event highlighted the affluence and status of this family impacted on professional’s decisions to take certain courses of action against policy.  Professionals maintained their belief that contact should continue irrespective of the emerging risk factors. The child was regularly perceived as a protective factor for the mentally ill adult.  A possible hypothesis was it might have been too difficult for an inexperienced worker, with an outlying opinion to challenge the consensus opinion re contact. Some practitioner conversations highlighted that professionals thought contact should proceed and hadn’t really perceived the risks as significant for Child AB until the practitioner event. The involvement of the Constabulary as the agency most likely to challenge was missing which further compounded the situation. The impact of professional bias in safeguarding work is complex and multifaceted. The issue should be strengthened in learning and development systems as well as case management and supervision systems.   144. In multi-agency practice, there was significant confusion and gaps in understanding of how the supervision of contact arrangements should be managed. The limitations in the oversight by the Constabulary of bail conditions added to this confusion. The management of contact arrangements under the Child in Need framework was not supported by the system.  Practitioners were under the impression that contact arrangements are most frequently managed when a child is supported under the statutory framework used when a child is looked after.  The learning from this case identifies there may be other circumstances when the management and supervision of child contact is necessary. A scoping exercise of the types of situations when supervision of contact should be undertaken. The system should be strengthened and multi-agency roles and responsibilities should be clarified to ensure the process is effectively managed. The expectation that contact should have been supervised 24hrs a day was an unrealistic expectation for family members who were also supervising mother’s home leave. The management of supervised contact was intertwined with the supervision of the mother’s home leave yet the triangulation of information to manage the risk during contact arrangements was ineffective. Even despite maternal disclosure in planning extended suicide by planning to harm her husband, child contact continued although there were significant restrictions being applied for maternal leave purposes. The management of child contact arrangements and home leave for mentally ill service users should be assessed and planned as a single process to manage the risk effectively.  145. The review has highlighted several instances when junior, inexperienced multi-agency professionals were left to manage difficult issues, out of their sphere of experience, with a significant lack of effective management oversight and scrutiny. On occasions, unqualified staff were left having direct contact, with limited involvement by key professionals. The case management and supervision processes including the access to expert advice within all agencies were not effective in highlighting this case.  Agencies have made recommendations in respect of this issue and the recent inspection has also highlighted this as an area for improvement.  146. The rationale for the referral to Child and Adolescent Mental Health Services was misunderstood. The service was required to provide preventative trauma services because of the serious assault however the referral was not accepted as the child did not meet the service access criteria. Eventually the service became involved in a consultative capacity. Practitioner conversations during the process of the review highlighted that trauma services are commissioned locally however this was not known in practice by key services and clinicians CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 40 of 53  SECTION 4: CONCLUSION 147. The review has considered whether the two-attempted life threatening assaults could have been predicted or prevented. The multi-agency service provision and family experience of services has been critically appraised to identify that if information had been effectively and systematically compiled could a prediction of harm have been identified and the risk more effectively managed.  148. Critical reflection of the information prior to the first event highlighted there were no significant dangers, situational or background hazards that could have led professionals to the prediction that the mother would transform so suddenly from being a loving mother to perpetrating the first assault. Whilst there had been no noticeable improvement in her mental health during the preceding 4 months, she was regularly supported by her General Practitioner, planning to return to work and did not present with serious mental health challenges. There were key strengths and protective factors in place (see table 1), the event was sudden, apparently un-planned and could not have been prevented. Table 1: Analysis of interacting risk factors (focusing on factors known at the time of the 1st Event 2014) 53  Background Hazards known at the time Situational Hazards known at the time  Maternal mental health problems 20 years previously effectively managed and no reoccurrence  Work related stress events  Witness car accident  Maternal mental ill health (mild to moderate) not responding to treatment. None evident  Hidden and not appreciated  Challenges in family relationships  Child AB’s mother allegation of feeling emotionally controlled within her relationship Strengths/protective factors known at the time  Dangers known at the time  An articulate, happy, healthy, responsive child, progressing with developmental and educational milestones.  Both parents in full time employment  Residence in an area of low deprivation  Positive relationships within nuclear family.  Consistent attendance at school & nursery  Close supportive extended family network and regular sleepovers  Significant external networks.  None evident   149. Critical reflection of practice during the time span prior to the second event, highlighted many risk factors that should have alerted professionals to the potential risk that a repeat event was high. All hazards and dangers should have been apparent but partnership working was not always effective, information was not effectively compiled, shared or used to manage the risk. The risks documented within a Psychologist report (September 2014) provided key predictors of factors that may increase the risk of further serious events. This information was buried, not effectively shared with multi-agency partners and “lost” to practice.  The mother was not risk assessed in relation to the risks she posed to her child even after she disclosed her intention to                                                            53 Acknowledgement to Ball K (NSPCC) for the use of the Analysis of interrelating risk factors methodology, SCR repository.  CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 41 of 53  harm her husband prior to the second event. The Expert Psychiatric Consultant confirmed the panel’s views that if professionals do not know what risk a mental health patient poses to those around them then it should be assumed that the risk is always high (see table 2). The second event in 2015, was therefore potentially preventable and given the expert advice provided in hindsight potentially predictable.    Table 2: Analysis of interacting risk factors:(focusing on factors known at the time of the 2nd event 2015)54  Background Hazards known at the time Situational Hazards known at the time  No improvement in maternal mental health presentation, limitations in ongoing mental health assessment.  Ineffective use of Mental Health legislation despite risk to individuals.  Lack of control and oversight unescorted/escorted leave by Mental Health Services.  Impending court/criminal proceedings  Intelligent, professional mother, with a proven history of positive attachment /parenting and could maintain this presentation throughout her mental illness  Professionals/family biases and belief systems (not understood at the time)  Silo working vs multi-agency partnership.  Oversight of child contact arrangements ineffective and confused.  Threshold for Child Protection met but de-escalated to Child in Need perceived reduction in risk.  No agency challenge   CAHMS referral declined for assessment  Challenges in family relationship   Repeated allegations of controlling behaviours in marital relationship post 1st event (not proven).  Challenges in supervising child contact and escorted leave of an adult with an unstable mental illness x 24hrs a day at home.  Strengths/protective factors known at the time  Dangers known at the time  Child continued to attend school and support was provided care by the after-school club.  Child had regular support from a key Family Support Worker on wishes and feelings  Positive and child centred relationships with father, sibling and extended family  Risk assessment (psychologist) predicting the risk factors.   No maternal mental health risk assessment relating to risk to others  Escalating maternal risk taking behaviours including suicide and self-harm  Previous potentially life threatening assault attempt and plans to harm others.  Unstable maternal mental health   Challenges for grandparents supervising escorted leave and child contact arrangements.                                                            54 Acknowledgement to Ball K (NSPCC) for the use of the Analysis of interrelating risk factors methodology, SCR repository. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 42 of 53   SECTION 5:   LSCB RECOMMENDATIONS  The LSCB should; 1. Be assured that the content of single and multi-agency learning, supervision and development opportunities strengthens professionals understanding of the negative impacts of professional biases and beliefs in safeguarding practice. (LP6)  2. Review its current procedures to strengthen the understanding around the child as a protective factor, risk of filicide, and harm to others when mentally ill adults have child care responsibilities.  Awareness raising of the issue should be increased within the workforce. (LP 12)  3. Be assured that partner agencies have responded to the relevant learning points contained within the overview report. (LP 1-16)    CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 43 of 53  SECTION 6: APPENDICES   Appendix 1: The Serious Case Review Methodology.  1. The Serious Case Review.  The Serious Case Review (SCR) was commissioned in April 2015.The methodology for the review has been developed in consideration of national guidance55 and advice from the National Serious Case Review Panel.56 The review has not been commissioned with the intention of undertaking a Mental Health Investigation into the provision of Mental Health Services to the mother. The Mental Health Provider has undertaken a post incident review and has made additional recommendations in respect of the provision of services. The post incident review has been shared with the SCR Case Review Panel. A decision has been taken by the Panel to minimise the disclosure of the mother’s confidential medical information within the content of this overview report.  2. Principles. This review follows the principles of national guidance57 which are;  Professionals and organisations will be fully involved and invited to contribute without fear of blamed for practice they took in good faith.  It acknowledges the complexity of multi-agency safeguarding children work and seeks to understand clear timelines, key practice events, issues in the delivery of services and the underlying reached for actions and decisions taken.  It provides opportunities to draw on what works to promote good practice to ensure a continuous culture of learning and improvement is achieved across multi-agency partnerships.  The approach will be proportionate to the scale and complexity of the issues being examined and will be transparent in the way data is collated and critically analysed  The leadership of the review will be undertaken by 2 independent reviewers.  The participation of the family and other relevant persons will be invited to ensure their perspective and experience is heard.  The final report will be submitted to the National Panel and published inclusive of the LSCB’s response to the review findings. It will sensitively consider how to minimise the impact of this publication on Child AB’s and other family members.  3. Process. The LSCB develops a new Case Review Panel for each Serious Case Review and is directly accountable to the LSCB Case Review Sub Group. Eight senior practitioners/managers and two Independent Reviewers were recruited as Panel Members, of which five were agency authors.                                                            55 HM Government (2015) Working Together to Safeguard Children a Guide to Interagency Working to Safeguard and Promote the Welfare of Children. Crown Copyright. Downloaded Www.Gov.Uk 18.10.2015 56 Dfe (2014) First Annual Report National Panel of Independent Experts on Serious Case Reviews, July. 57 HM Government (2015) Working Together to Safeguard Children a Guide to Interagency Working to Safeguard and Promote the Welfare of Children. Crown Copyright. Downloaded Www.Gov. Uk 18.10.2015 CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 44 of 53  The members were supported by the LSCB Business Manager and Administrative Support. All Panel Members were required to demonstrate their independence and nominated a deputy to ensure continuity for the process. Attendance was secured for 3 observers, who later described the process as a positive learning experience which would impact positively on their future safeguarding practice. The panel members were employed by LSCB membership agencies and included;    Designated Nurse and Doctor: Clinical Commissioning Group.  Named General Practitioner: Clinical Commissioning Group.  Named Nurse: Mental Health Foundation Trust.  Local Authority Senior Manager (Education).  Local Authority Team Manager (Children’s Social Care).  LSCB Business Manager and Administration Support.  Named Nurse: Acute and Community Trust.  The Constabulary.   2 Independent Reviewers.  4. Independent Reviewers. Two Independent Reviewers, supported by the LSCB Business Unit, were appointed to co-work, lead and facilitate the review. The tasks were equally divided and the role of chairing the review team and authoring the overview report were allocated. The activities relating to the practitioner events, practitioner conversations, author’s event and conversations with family members were shared between the LSCB Business Manager, Case Review Panel members and the Independent Reviewers.  Independent Reviewer (Chair): Annie Dodd is a qualified Health and Care Professional’s Council (HCPC) registered Social Worker with almost 40 years’ experience in Children’s Social Care services. She holds the qualifications of BA Hons, CQSW and MA (Econ). She has managed assessment, Child Protection and looked after children services and for 10 years was an Assistant Director in a Local Authority. Ms Dodd now works as an Independent Social Work Consultant. Her work includes chairing serious case and domestic homicide reviews, undertaking audits and reviews for LSCBs and Local Authorities, investigating complaints and, until recently, acting as Child Protection advisor to a children’s charity. She has never been employed by any of the organisations involved in the Serious Case Review. Independent Reviewer (Author): Jane Carwardine has recently become an Independent Safeguarding Consultant and this is her initial commission. She holds a MA in Child Care Law and Practice (Keele) and a BA Hons in Health Studies (Bolton) and has had 42 years NHS experience in a range of operational, strategic, provider and commissioning roles. Her relevant safeguarding professional background is 15 years’ activity as a Senior Manager, Designated Nurse for Safeguarding and Head of Safeguarding. She is a qualified Nurse, Midwife (lapsed) and Health Visitor, having 25 years in strategic and operational safeguarding practice. Examples of activity includes work relating to serious case reviews, learning and development, quality effectiveness and strategic board support.  She has been directly involved in the completion of more than twenty serious case reviews/multi-agency learning reviews and has worked intensively to improve the quality effectiveness of the Serious Case Review process. At the time of writing the report Jane was the Royal College of Nursing representative on the Royal College of Paediatrics and Child Health Child Protection Committee. She was previously CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 45 of 53  involved in the work of the LSCB, but has not been employed by any organisation aligned to this review. 5. Structure.  The LSCB determined a hybrid methodology would be used to complete the review, combining several theoretical, tested approaches and techniques. A comprehensive multi-agency chronology was collated highlighting key practice events. The chronology is not included in this document but was critical in the development of a key practice event timeline. Agencies were requested that rapid appraisal was undertaken during the process of the review to ensure that immediate action plans were instigated when system failures were highlighted. The review panel met on five occasions during which information was reviewed and critically appraised to ensure optimum learning would be achieved consistent with practice experience and circumstances. The agency reviews were quality assured and discrepant information was explored and challenged. Mental health expertise was secured via a Consultant Psychiatrist who attended the 3rd review panel meeting. A practitioner event enabled front line multi-agency practitioners to openly consider the case, enrich the information in the timeline and amend the key lines of enquiry. Key practitioner conversations were undertaken by the agency authors and the Independent Reviewers. Agency authors were asked to provide an agency review or report in their preferred format, ensuring that the key lines of enquiry and key practice episodes were a point of focus for analysis and learning. Agency authors requested that a LSCB review format was provided which was circulated. All agencies reviews were quality assured and ratified at executive level.  6. Themes, Key Practice Issues, Key Line of Enquiry. Specific themes were identified and key lines of enquiry highlighted. Agency authors were asked to critically appraise all information and to advise the panel of new and emerging themes or practice events. The panel was keen to conduct the review flexibly to enable new and relevant information to emerge.   The panel was keen to enable themes to develop within the practitioner event however identified the following initial themes, events and key practice episodes for consideration;  i. Relevant historical information prior to the first assault especially from 2013 when Child AB’s mother began to show signs of ill health. ii. Identification of early signs of risk of harm. iii. Reviewing the quality of assessments. iv. Risk assessment and management. v. Constabulary, Crown Prosecution Service, Court, Children’s Social Care Systems, processes and decision making. vi. Nature of child contact and meaning of supervision in Mental Health and Child Care arrangements. vii. Use of legal interventions and voluntary arrangements including the Children Act 1989 and Mental Health legislation. viii. Communication and multi-agency decision making following the first assault in July 2014 and before the second assault in February 2015. ix. The second attempt on Child AB’s life February 2015. x. Access to services post traumatic childhood events including access to Child and Adolescent Mental Health Provision. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 46 of 53    7. The Serious Case Review Completion and Limitations.  The original timescale for completion of the review was 6 months, however an extension of 2 months was agreed by the LSCB chair to attempt to secure communication with the mother.   There were challenges in completion of the review due to several factors. A significant proportion of the Panel Members and Agency Authors were inexperienced. Attendance at the practitioner and authors events was not fully reflective of the multi-agency partnership arrangements with key agencies absent. There was a delay in the completion of the final multi-agency chronology due to late information being received. Most the reviews were of satisfactory quality and critically appraised practice, identifying realistic learning points. The LSCB and its partner agencies are reviewing their systems to ensure they have sustainable processes and expertise to contribute to these reviews. The overview report has been quality assured by the Review Panel and the LSCB.    CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 47 of 53  Appendix 2: Glossary  CAF The Common Assessment Framework (CAF) is a standardised approach to conducting assessments of children’s additional needs and deciding how these needs should be met. It promotes more effective, earlier identification of additional needs, particularly in universal services and aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. CAMHS Child and Adolescent Mental Health Services are specialist services that offer assessment and help when children and young people have emotional, behavioural or mental health difficulties. Child in Need  Section 17 of the Children Act 1989 defines a child as being in need if:  He or she is unlikely to achieve or maintain or to have the opportunity to achieve or maintain a reasonable standard of health or development without provision of services from the Local Authority,  His or her health or development is likely to be significantly impaired, or further impaired, without the provision of services from the Local Authority,  He or she has a disability. The definition includes any child or young person under the age of 18. The service can also be provided to the child’s family or any member of his or her family, so long as the aim is to safeguard and promote the child’s welfare. Support can include providing cash assistance to a family. Local Authorities are under a general duty to safeguard and promote the welfare of all children in need in their area. They must do whatever possible to ensure sufficient services and measures are in place to promote a child being raised within its own family, if it is safe to do so. The authority is obliged to offer the following specific services/support for children in need in their area:  Advice, guidance and counselling;  Occupational, social, cultural and recreational activities;  Home help (including laundry facility);  Facilities or assistance with travel to and from any services provided under the Act or similar service;  Assistance to enable the child and the family to have a holiday. (Downloaded from protectingchildren.org.uk 24.11.15) Child in Need meeting  If Children’s Social Services decide the child is in need they will draw up a plan, setting out what extra help they will provide to the child and their family. This is called a Child in Need plan. The plan should say when and how the plan will be reviewed Clinical Psychology  Clinical Psychology integrates science, theory, and practice to understand, predict and relieve maladjustment, disability, and discomfort. Clinical Psychology also promotes adaption, adjustment and personal development. A Clinical Psychologist concentrates on the intellectual, emotional, biological, psychological, social, and behavioural aspects of human performance throughout a person's life, across varying cultures and socioeconomic levels. In other words, Clinical Psychology is the scientific study and application of psychology to understand, prevent, and alleviate psychologically-caused distress or dysfunction (disability) and CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 48 of 53  promote the patient's well-being and personal development. Psychological assessment and psychotherapy are central to the practice of clinical psychology. However, Clinical Psychologists are often also involved in research, training, forensic testimony, and other areas.  Medical News Today: downloaded medicalnewstoday.com 23.11.15 Core Assessment The Core Assessment provides a structured framework for Social Workers to record information gathered from a variety of sources to provide evidence for their professional judgements, facilitate analysis, decision making and planning. A Core Assessment should be completed within 35 working days of its commencement. A completed record is then used to develop the plan for the child or young person.  Care Programme Approach (CPA) Care Programme Approach (CPA) was developed in 1991 to ensure that people with mental illness have the support and treatment that they need from services. It requires adult care services to arrange and co-ordinate the care and medical treatment that a person requires. When a person is referred to the Community Mental Health Team, an assessment of their needs will take place. When a person has, mental health needs they may need more support through a care coordinator allocated by Mental Health Services. The care coordinator will be the person works most closely with the patient in terms of planning support and will be the contact to discuss issues and concerns. A care plan will be developed as part of the process. Regular meetings will be held under these arrangements.  Further Reading:   Re-think Mental Illness, Fact Sheet, Care Programme Approach (CPA), Downloaded 18.10.15 rethink.org.uk. Extended Suicide  Extended suicide is usually a solitary act. In rare cases, people who are depressed and planning to take their own lives commit what some psychiatrists call “extended suicide.” This usually involves killing family members.  Filicide The potentially life threatening assault of a child up to the age of 18 years committed by his or her parent(s) or parental figure(s) including guardians and step-parents. It is a complicated and multifaceted crime which has a significant historical history and is not a new phenomenon. Recent research and evaluation is beginning to identify trends, traits and characteristics of these cases. There is a growing body of evidence to show that mental illness plays a significant role in filicide and the key to avoiding the devastating effects for both the perpetrator and victim is prevention. Further reading:   West Sara G (2007) An overview of Filicide Psychiatry: Downloaded 20.10.15 ncbi.com   2013 Findings from most in-depth study into UK parents who kill their children Filicide-suicide There is limited research on this issue yet its understanding in the delivery of mental services health is critical. It describes the potentially life threatening assault of a child up to the age of 18 years, committed by his or her parent(s) or parental figure(s) including guardians and step-parents followed by the suicide of the perpetrator. Parental motives for filicide-suicide are complex and include altruistic and acutely psychotic CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 49 of 53  motives for the potentially life threatening assault.  Hospital Order  The courts have the option to make a hospital order if they conclude the defendant needs medical treatment, which must be given in hospital. The courts may do this on conviction for any imprisonable offence except filicide. It is the decision of the court entirely acting on medical evidence. PTSD Post-Traumatic Stress Disorder (PTSD) can affect children as well as adults. Children with PTSD can have similar symptoms to adults, such as having trouble sleeping and upsetting nightmares. Like adults, children with PTSD may also lose interest in activities they used to enjoy and may have physical symptoms such as headaches and stomach aches. However, there are some symptoms that are more specific to children with PTSD, such as:  bedwetting   being unusually anxious about being separated from a parent or another adult   re-enacting the traumatic event(s) through their play   It's normal to experience upsetting and confusing thoughts after a traumatic event, but in most children, these improve naturally over a few weeks. A child should visit the General Practitioner (GP) if problems persist about four weeks after the traumatic experience, or if the symptoms are particularly troublesome. The GP will want to discuss the child’s symptoms in detail and ask whether the child has experienced a traumatic event in the recent or distant past and whether he/she has re-experienced the event through flashbacks or nightmares. The GP can refer the child to Mental Health Specialists if they feel the child would benefit from treatment.  Further reading:   NHS Choices (2015) Post –traumatic stress disorder(PTSD), NHS Choices, downloaded 18.10.15 www.nhs.uk   RCPSYCH (2015) Traumatic stress in children: information for parents, carers and anyone who works with young people, downloaded 18.10.15 rcpsych.ac.uk.  Perry Bruce D. (2007) Stress, Trauma and Post-Traumatic Stress Disorders in Children - an introduction, The Child Trauma Academy, Downloaded 18.10. 2015 from childtrauma.org  Perry Bruce D. (2014) The Cost of Caring, Secondary Traumatic Stress and the Impact of working with High Risk Children and Families, The Child Trauma Academy, Downloaded 18.10.15 from child trauma.org.  Section 8 Orders Section 8 Orders (Children Act 1989) When cases proceed to court, Section 8 of the act provides for the making of three different orders by the courts: child arrangements orders; prohibited steps orders; and specific issue orders. These, along with any order varying or discharging such an order, are referred to in the act as Section 8 orders. Section 8 orders are defined as follows: •  child arrangements order: is an order regulating arrangements concerning with whom a child is to live, spend time or otherwise have contact and when a child is to live, spend time or otherwise have contact CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 50 of 53  with any person.  •  prohibited steps order: is an order that no step which could be taken by a parent in meeting his parental responsibility for a child, and which is of a kind specified in the order, shall be taken by any person without the consent of the court. •  specific issue order: is an order giving directions for the purpose of determining a specific question which has arisen, or which may arise, in  connection with any aspect of parental responsibility for a child.  A section 8 order does not usually extend beyond the child’s 16th birthday and cannot continue beyond the child’s 18th birthday. Further reading:   DFE (2014) Court orders and pre-proceedings for local authorities, April 2014. Section 47 Investigation (Children Act 1989) Section 47 Investigation (Children Act 1989) is also known as a Child Protection investigation which sets out the duty of the Local Authority and other bodies. Children’s Social Services have a legal duty to consider a child's situation if they have information that a child may be at risk of or has suffered significant harm.  Suicide Ideation  Suicidal ideation, also known as suicidal thoughts, concerns thoughts about or an unusual preoccupation with suicide. The range of suicidal ideation varies greatly from fleeting thoughts, to extensive thoughts, to detailed planning, role playing, and incomplete attempts, which may be deliberately constructed to not complete or to be discovered, or may be fully intended to result in death, but the individual survives. Downloaded en.wikipedia.org · 1.1.16    CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 51 of 53  Appendix 3: Single Agency Recommendations contained in Individual Agencies Internal Management Reviews. General Practice 1. It would be good practice to review the PHQ9 forms after they are completed and to contact anyone with a very high score or obvious suicide risks identified for a more in depth discussion as soon as possible. 2. During consultations where there is obvious evidence of self-harm and potential harm to others those opportunities to discuss alone are made available to allow for these discussions and questions to take place. 3. When consultations take place, and patients are clearly articulating self-harm behaviours that questions are asked of their intentions to harm others and this is clearly documented within the records. These questions should also include the patients caring responsibilities.  This links to recommendation 2 4. The mental health records and letters refer to Child AB being a “protective factor” for the mother. This should never happen, rather the child behind the adult should be considered, and risks to the child or children in a family with parental mental health problems should always be considered. This should be discussed at MDT meetings within practices and appropriate action taken to safeguard the children if required. 5. It is very important also to try to get a better level of communication between the Children’s Social Care and GP Practices locally. This case particularly illustrates how important such contact can be to share vital information and enable ongoing assessments to take place involving a good level of input from GPs. 6.  Whilst the benefits for the child and family of family members carrying out the supervised contacts are obvious, relying on family to supervise and to potentially report unsuitable behaviours is something that needs to be debated within the multi- agency forums. The moral and ethical side of such an arrangement needs to be discussed, as well as the practical details. Constabulary 1. When officers are attending incidents where paramedics may be required to later provide statement officers must ensure they obtain their contact details at the time 2. Officers to be reminded of duties under S.47 Children Act to request an ICPCC should CSC not deem this is necessary 3. When officers are dealing with offences where there is a serious risk to children, the bail conditions must be specific and without the caveat ‘as directed by CSC’ 4.  When suspects are on bail for child abuse it must be a condition of their bail they must not visit the house where the child is residing Education 1. Ensure there is a written record following any supervised contact that school may be responsible for facilitating. This needs to be shared with CSC and a copy kept on the child's file in school for future reference.  CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 52 of 53  2. Establish clear guidance on roles, responsibilities and procedures when supervised contact is agreed. 3. Improve communication between the school and CSC by agreeing triggers for communication; e.g. changes in the child's behaviour or further incidents where there are safeguarding concerns. 4. To review the sharing of contact telephone numbers for CSC managers with schools so there are clear lines of communication where there is a need to escalate concerns. 5. Ensure schools are aware of the Safeguarding Children Procedures and the procedure for the escalation of cases where there is a disagreement.   Children’s Social Care  1. To consider supervision tools to allow more critical debate and reflection. Issues to be included:  Quality of assessment  Risk assessment  Triggers for reassessment  Dealing with professional relationships and professional challenge  Dealing with family members  2. To ensure that training is offered with regards to issues identified:  Quality of assessment  Risk assessment  Triggers for reassessment  Dealing with professional relationships and professional challenge  Dealing with family members   From the onset of entering a post with CSC refresher training could also be available. 3. CSC has a system in place to manage cases that meet the threshold of Child Protection, where the concerns that a child has suffered significant harm are substantiated, but the child is not judged to be at continuing risk of significant harm and therefore a decision is made not to convene an Initial Child Protection Conference. In such circumstances, there is a requirement to consult an Independent Reviewing Officer who undertakes independent scrutiny of this decision. Where there is disagreement, the decision is escalated using the line management structure. CSC must ensure that this requirement is adhered to in all applicable cases.  4. To satisfy themselves that the Child in Need process sufficiently deals with issues of risk where cases include the assessment and management of risk. Improved multi-agency communication and information sharing is required at a Child in Need level. CONFIDENTIAL: FINAL VERSION  ANONYMISED FOR PUBLICATION ON NSPCC REPOSITORY  Page 53 of 53  5. To ensure that assessment is rigorous and thorough and proportionate to the concerns whichever system is used to manage cases. 6. To ensure that risk assessments are used which highlight risk rather than risk being incorporated within the Child & Family Assessment. Mental Health Services 1. To ensure the application of the Mental Health Act is strengthened in practice. 2. To consider actions to reduce the possibilities of misjudgement of risk to the service user 3. To consider the use of the Mental Capacity Act vs the Mental Health Act needs by clinical teams when patient’s freedoms are being restricted. 4. To ensure the absence of a consultant should not prevent application of the Mental Health act  5. To ensure the clear arrangements are made in consultant cover arrangements.  6. To improve communications between clinical team members  7. To ensure Forensic Psychiatric Services share comprehensive risk assessment when granting a patient leave from the ward. 8. To consider the whole risk as opposed to the risk posed to one person when leave is suspended 9. To consider the risk to the child when patient’s mental health deteriorates and ensure the focus remains on the child throughout the service involvement.  10. To promote understanding of CPA meetings and the role of the care coordinator.  11. To be aware when a client’s presentation continues to deteriorate the risks should be constantly assessed and managed. 12. To consider the application of the Mental Health Act at each suicide attempt not only for the patient’s own safety but for those of others. This should be considered in the context of the whole picture. 13. To strengthen the management of domestic abuse in respect of the management following disclosures.  14. To always exploration disclosures of controlling behaviours 15. To strengthen risk assessment documentation especially in relation to management of domestic abuse. 16. To always assess the risks posed by a patient throughout the service involvement, the risk to children and others should be regularly assessed and acted upon and shared with relevant agencies.             