Death of Baby J aged 4 weeks in summer 2014 owing to head injuries associated with being shaken. Baby J's father, FJ, was later convicted of manslaughter. Baby J's parents had both received support from mental health services prior to and after Baby J's birth. FJ had a history of domestic abuse with a previous partner and increasingly with Baby J's mother. He was the subject of a Non-Molestation Order in relation to his previous partner and their child. Both parents were homeless and living in separate hostels throughout the pregnancy although Baby J's mother moved to her parents after the birth. An initial assessment was carried out November 2012 and although recommended, a pre-birth risk assessment was not carried out. Findings include: no one agency had a full picture of the parents' history of mental health issues and drug and alcohol misuse; risk assessments did not provide the full picture; the risks posed by domestic abuse and coercive control by perpetrators were not understood; written agreements with families need to be monitored. Recommendations for all agencies included improving information sharing, communication and record keeping in relation to domestic abuse and mental health issues, and involving fathers in risk assessments.
      
 Title:  Serious case review: Baby J. LSCB: Hull Safeguarding Children Board Author: Colleen Murphy and Linda Richardson Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                    Serious Case Review  Baby J        November 2016  Last amendments March 2017  Hull SCR Baby J /Mar 2017 2  Contents  1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews   2. The circumstances which led to this Serious Case Review (SCR)   3. The approach used  4. Scope and Terms of Reference    5. The family’s perspective  6. Agency involvement with the family  7. Analysis  and Findings  ASP 1:  The extent to which potential risks in this family were assessed and well understood by professionals /agencies  ASP 2:  The ways in which professionals communicated and worked collaboratively within a multi-agency context.   ASP 3:  The response of CSC to referrals and contacts from partner agencies  ASP 4:  The response by agencies in Hull to incidents of domestic abuse1       Appendix 1: The Findings and Issues for Hull Safeguarding Children Board   Appendix 2: Actions identified in Agency Learning Reports Appendix 3: Relevant developments in Agencies since the period under review                                                                      1 In Hull, the term domestic abuse is preferred to domestic violence. The Review Team therefore made a decision to use this term wherever possible throughout this report.  However, the recording and reporting systems in some agencies used the term ‘domestic violence’ at the time and this has necessitated its usage in some parts of this report.   Hull SCR Baby J /Mar 2017 3 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs)2 are to co-ordinate and ensure the effectiveness of the work of member agencies to safeguard children. The statutory guidance3 which accompanies legislation and which underpins the work of LSCBs is very clear in its expectation that LSCBs should maintain a local learning and improvement framework so that good practice can be identified and shared.  1.2. In situations where children die, and where abuse or neglect of the child is known or suspected, LSCBs are required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce the risk of future harm to children. There is an expectation that these processes, known as Serious Case Reviews (SCRs), should be transparent with the findings shared publicly.  2. The circumstances which led to this Serious Case Review (SCR) 2.1. Children’s Social Care (CSC) became involved with MJ (mother) and FJ (father) in spring 2013 when they were expecting their first child and there were concerns about the domestic abuse perpetrated by FJ against a previous partner, SS.  CSC remained involved with the family until April 2014 when a decision was taken by CSC to end their involvement.    2.2. The couple’s second child, Baby J, was born to MJ and FJ in summer 2014. Four weeks after the birth, FJ and MJ took Baby J to hospital stating he was unresponsive. Hospital scans revealed significant bleeding inside the brain and eyes and further tests indicated that the baby’s injuries were a result of head trauma, associated with being violently shaken. Baby J died two days after being admitted to hospital. 2.3. Having considered the circumstances surrounding the life and death of Baby J, the Serious Case Review Sub-committee recommended to the Independent Chair of Hull Safeguarding Children Board (HSCB) that the criteria for undertaking a Serious Case Review were met. The Chair agreed with this recommendation and, as soon as the medical opinion about the cause of death was received in May 2015, confirmed that a SCR should be undertaken in respect of Baby J.   2.4. FJ was charged and convicted of manslaughter and received a custodial sentence of 8.5 years in relation to the death of his son. 3. The approach used  3.1. This SCR used a systems methodology to look at not only what happened to Baby J, but also to try and understand some of the factors that influenced why professionals acted as they did or why they did not act at all. Two independent reviewers, both of whom had experience of using a systems methodology, were commissioned to lead the serious case review process. Neither reviewer was employed in any capacity by the agencies involved in the review process, nor did they know the family prior to the review.                                                              2 s14 of the Children Act 2004  3 Working Together to Safeguard Children 2015. HMSO  Hull SCR Baby J /Mar 2017 4 3.2. A Review Team of senior professionals representing the agencies that were or had been involved with the family was established. Their role was to provide a source of high-level strategic information about their own agency and their involvement with Baby J’s family through their contributions to the SCR process and through the submission of an agency learning report. The Review Team gathered and analysed data, appraised practice and agreed the content of this report.  The Review Team consisted of:  Lead Reviewer (Chair)   Colleen Murphy  Independent Consultant4 Lead Reviewer   Linda Richardson  Independent Consultant Business Manager     HSCB Professional Practice Officer    HSCB Child Death Review Coordinator    HSCB Senior Probation Officer     Humberside, Lincolnshire and North Yorkshire          Community Rehabilitation Company (CRC)  Victims Manager / Senior Probation Officer   National Probation Service  Detective Inspector     Lead for Child Protection, Humberside Police Named Midwife for Safeguarding/   Supervisor of Midwives     Hull & East Yorkshire Hospitals NHS Trust Practice Manager     Hostel Accommodation Provider Named Nurse for Safeguarding Children   City Health Care Partnership (CHCP) Designated Nurse for Safeguarding Children   NHS Hull Clinical Commissioning Group (CCG) Principal Social Worker     Children, Young People & Family Services         Hull City Council Named GP       NHS Hull Clinical Commissioning Group (CCG) Domestic Abuse Services Manager    City Safe & Early Intervention  3.3. A Practitioner’s group was also established which consisted of frontline professionals who worked directly with the family or who were known to other adults related to this SCR. Their openness and willingness to reflect on their work with this family contributed to much of the learning which has emerged from this review.  The practitioner’s group consisted of:  Midwives     Hull & East Yorkshire Hospitals NHS Trust Hostel Worker     Hostel Accommodation Provider GP       Local Surgery Police Officer 1 and 2    Humberside Police Health Visitor     City Health Care Partnership (CHCP) Probation Officer 1    National Probation Service Probation Officer 2    Humberside, Lincolnshire and North Yorkshire         Community Rehabilitation Company (CRC) Women’s safety worker (Women’s Safety  worker for period of review)     National Probation Service Social Worker   }   Children, Young People & Family Services Manager  }   Hull City Council Family Practitioner }   Mental Health Nurse    Humber Foundation Trust Manager  }   Hull City Council Family Practitioner }                                                               4 These consultants were independent of all the agencies involved and had prior experience of undertaking SCRs.   Hull SCR Baby J /Mar 2017 5 Mental Health Nurse    Humber Foundation Trust  3.4. Both parents, individually, offered their perspectives about their experiences and their views, together with those offered by the maternal grandfather, were welcome contributions to this report.  4. Scope and Terms of Reference 4.1. The Review Team agreed that the SCR would look at what happened between October 2012, when FJ began a new relationship with MJ, and September 2014 when Baby J died.  Tentative lines of inquiry were centred on agencies’ understanding of, and responses to, domestic abuse, the extent to which agencies communicated with each other and the challenges for frontline practitioners in working with a mother who denies or is unable to acknowledge the abusive behaviours of her partner. The Review Team was also mindful of previous case and serious case reviews, which had taken place locally and nationally.  5. The family’s perspective    FJ 1990  Father of Child SJ and Baby JSS   SS                                        (a previous partner of FJ with whom she had a child) MJ 1992  Mother of Child SJ and Baby J SJ 2013  Sibling of Baby J Baby J 2014  SUBJECT d.2014 MGM and MGF (MGPs) Maternal Grandmother and Maternal Grandfather (Maternal         Grandparents)  The perceptions of FJ 5.1. FJ met with representatives from HSCB who advised him about the SCR and he agreed to meet with the independent reviewers so his views and experiences could be represented in this report. A meeting took place in HMP Hull in June 2016. There were some specific issues highlighted during the conversation, which offer useful insights into work with males suspected or known to be violent towards partners.  5.2. FJ acknowledged the difficulty he had in controlling his emotions, especially his anger and frustration. He felt that police and social workers always saw him as a perpetrator and ‘someone who was violent’ and that because of this he was never given a fair hearing. He believed when he tried to give his version of what had happened between himself and MJ… ‘It was always with MJ, they didn’t bother with me’. FJ said that no one was interested enough to find out more about him or thought to check about whether he was a good father. He said the problem with his ex-partner was directly linked to her refusal to allow him contact with his son and this was the cause of all their arguments. 5.3. There was an acknowledgement by FJ that despite what they told social workers, he and MJ had been living together and not just for the ‘two days a week’ they told social workers. FJ said he didn’t understand why he could stay for two days but not move in and so he and MJ had pretended to go along with the arrangement. FJ also said that on the occasions when social workers called he was often in the bedroom listening to what was being said. He told the reviewers that MJ was struggling  Hull SCR Baby J /Mar 2017 6 to cope and he needed to be there to help her look after Child SJ and then later Baby J. He said that he worried about how she looked after the children as ‘she smoked a lot of weed’. 5.4. FJ said the IDAP5 programme (with which he engaged between September 2013 and March 2014) was just ‘OK’ and although he learnt a few things, most of the input was about physical violence towards women and whilst he had used violence in fights with other males, he did not see himself as a man who was violent towards the women with whom he had been involved. FJ said he would have liked more help to understand and control his emotions, which he linked to the violence he had experienced in his childhood.  The perceptions of MJ  5.5. MJ told the reviewers that she felt bad because she had not been honest with social workers and police officers about her relationship with FJ. She explained that when they first began seeing each other everything was fine and she had believed that it was the behaviour of SS, his previous partner, which made FJ behave as he did. However, once she became pregnant, she said that FJ began to be more controlling and although he ‘slapped’ her a few times, it was his angry outbursts and threats that she feared most.   5.6. MJ said that FJ became more abusive towards her as their relationship progressed especially when he had been drinking. He took her phone and money and threatened her that he would tell social workers that she was a bad mother and they would remove her children. MJ explained that she was unable to tell social workers what was happening, as she really believed that FJ would harm her or their child. MJ said that she knew of another child who had died following an attack by an abusive ex-partner and this had made her fearful about what FJ could do.  5.7. In response to queries by the reviewers, MJ said she didn’t think social workers could have done much more to help as FJ was always listening to what she said and he told her what to say when police came to the door. Referring to a bruise on her eyebrow seen before she gave birth to Baby J, MJ confirmed that this was caused by FJ but said she wouldn’t have admitted this to the midwife, no matter how sensitively she had been asked about it. She said that although she had different social workers visiting, she wasn’t sure if anything would have helped her talk about FJ and what he was like.  5.8.  MGF was present with MJ when she met the reviewers. He expressed his anger that social workers did not do more to help MJ because they ‘knew what he was like’. He said they did not listen to him and his wife when they told them about the arguments. MGF said at first he thought FJ was OK but then he saw him lose his temper with Child SJ when trying to put on his coat and he saw a different side to him. MGF said he believed that FJ could easily dupe people into thinking he was OK and a good father.                                                                5 The Integrated Domestic Abuse Programme (IDAP) is a nationally accredited community-based group work programme designed to reduce re-offending by male domestic abuse offenders.   Hull SCR Baby J /Mar 2017 7 6. Agency involvement with the family Background Information 6.1. FJ had a son with SS, but the relationship ended in March 2012 following several domestic abuse incidents, which were reported to police and children’s social care. FJ continued to harass and threaten SS, and she obtained a Non-Molestation Order to prevent contact. FJ told his probation officer and social workers that his actions were solely in relation to SS preventing him having contact with their child.  6.2. In May 2012, FJ was referred by his GP for a mental health assessment. This assessment concluded that FJ needed help in managing and controlling his emotions, especially his anger. FJ had by then, self-referred to the Strength to Change6 programme, but although he was offered appointments, he did not attend or make further contact with the programme co-ordinators. Towards the end of the summer in 2012, following a breach of the court order, FJ was placed in police custody. As there were concerns about his mental state he was seen by the custody nurse who identified what appeared to be a correlation between FJ’s mental health and alcohol use. FJ declined the subsequent offer of a referral to a specialist service, and acknowledged that he had anger issues which he had experienced for most of his life and that he was discussing an  ‘anger management programme’ with his probation officer.  October 2012 – December 2012 6.3. According to police and probation reports, FJ continued to threaten and harass SS and consequently a DASH7 assessment was undertaken by a DAP8 worker which identified there was a ‘high risk’ 9 to SS from FJ. A referral was consequently made by the same DAP worker to MARAC10 and at a meeting in October 2012, the details of the DASH assessment were shared with the agencies present which included police and CSC. Risk management strategies were agreed to ensure SS and her child would be better protected from future threats or violence from FJ. When it became known that FJ was in a new relationship with MJ and she was pregnant, it was agreed that the DAP representative would make a formal referral to CSC. This action was undertaken and in                                                             6 Strength to Change is a service to males who want to address their abusive behaviours  7 Domestic Abuse, Stalking and Honour based Violence (DASH) is risk assessment tool used by practitioners working with victims of domestic abuse to help them identify those who are at high risk of harm and whose cases should be referred to a Multi-Agency Risk Assessment Conference (MARAC) meeting in order to manage the risk. 8 Domestic Abuse Partnership is a multi-agency team which works to improve the safety of survivors and children in Hull through a coordinated and effective inter-agency response. 9 Risk Assessment Categorisation: Based on the OASys (Offender Assessment System developed by the Prison and Probation Services)  Standard: - Current evidence does not indicate likelihood of causing serious harm.  Medium: - There are identifiable indicators of risk of serious harm. The offender has the potential to cause serious harm but is unlikely to do so unless there is a change in circumstances, for example, failure to take medication, loss of accommodation, relationship breakdown, drug or alcohol misuse.  High - There are identifiable indicators of risk of serious harm. The potential event could happen at any time and the impact would be serious. Risk of serious harm means ‘a risk which is life threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible’. (Home Office 2002 and OASys 2006): 10 A Multi- Agency Risk Assessment Conference (MARAC) is a local, multi-agency victim-focused meeting where information is shared on the highest risk cases of domestic violence and abuse between statutory and voluntary agencies so victim can be better protected.  Hull SCR Baby J /Mar 2017 8 response, CSC took the decision to instigate an initial assessment. At the time MJ and FJ were living in separate hostels.  6.4. The decision by CSC to undertake the initial assessment was based on the information and concerns shared at MARAC - FJ’s domestic abuse, his controlling behaviours and the use of drugs and alcohol which exacerbated feelings of anger towards others. The assessment undertaken by DSW111 included contact with both hostels where MJ and FJ were living, the probation service, DAP, and the midwifery service who confirmed that MJ was pregnant and engaging with antenatal services. MJ was seen on one occasion and a telephone conversation took place with FJ to ascertain his views.  6.5.  In November 2012, following another breach of the Non- Molestation Order, FJ was sentenced to a 24 month community order and was required to attend and complete the Integrated Domestic Abuse Programme (IDAP).  6.6. MJ told DSW1 that she was ‘shocked’ at the suggestion that FJ might pose a risk to her or to her unborn child. She acknowledged that he was hostile towards SS but said this was because he was refused access to his child and SS was to blame for this. Both MJ and FJ were described as being excited about the pregnancy and the assessment stated they ‘indicated a willingness to work with services’. DSW1 completed the initial assessment and recommended that a ‘Pre-Birth Assessment’ be undertaken ‘to ensure that FJ is fully committed to the IDAP and safety measures are in place whilst this is completed’.  6.7. As part of the preparations for FJ attending the IDAP programme, MJ was offered the support of a women’s safety worker and a visit was made to MJ in her hostel just before Christmas 2012. At this visit, MJ made it clear that she did not require any support and said that she thought FJ would attend the programme but only ‘to get it over with’. She told the link worker at the visit that she was pregnant but had not had any recent contact with CSC. The women’s safety worker forwarded a report to FJ’s offender manager (OM1) advising her of MJ’s pregnancy and stating that MJ seemed to have limited understanding of domestic abuse and had refused any further support. January – April 2013 6.8. In January 2013, two months after the initial assessment had been completed, the CSC team manager (TM1) transferred the case to a locality team for ‘further assessments’ to be undertaken. This decision was based on FJ not being allowed contact with his child from a previous relationship because of ‘significant domestic violence’ and because both he and MJ were living in hostels with neither having a permanent address. The case was passed onto the locality team, and although a decision was taken not to allocate a named worker, they were ‘supported by visits and contacts’ through the duty arrangements in place at the time.  6.9. In March 2013, staff in the hostel where FJ was living, contacted CSC to report a domestic abuse incident between the couple. CSC responded promptly and DSW2 contacted the caller and was told that FJ had taken MJ’s phone and keys after an argument and would not return them. DSW2 was also told that FJ and MJ were always arguing and there had been complaints by other residents and as a result MJ had left her hostel to return to live with her parents. MJ had asked staff at the hostel                                                             11 There were several duty officers /social workers involved with the family during the period under review. For ease of reference these practitioners are referred to as duty social workers (DSW 1 – 9).  Hull SCR Baby J /Mar 2017 9 not to report the incident to CSC, as she was worried they would ‘take her baby’. The response to this referral was a visit to MJ at the home of her parents and later, a telephone call to FJ. Both adults were then invited into the office where it was agreed that FJ should continue to work with IDAP, both adults would attend a parenting course and liaise with health professionals and MJ would continue to live with her parents until suitable accommodation was found.  6.10. The health visitor (HV1) saw MJ in the antenatal clinic in early April 2013, where she attended with her mother. HV1 later made a referral to CSC following information from MJ about FJ’s history. Health visiting records indicate that HV1 was informed by CSC that an assessment was to be undertaken. Information was received from CSC on 1.5.2013 and recorded in midwifery records, that a ‘pre-birth assessment’ had been undertaken following concerns about FJ and his ‘domestic violence’ towards a previous partner and a Child’s Plan had been formulated which confirmed that:  When born, Baby J would live with MJ and her parents, there would be no restrictions in respect of FJ and contact with Baby J  FJ would attend an IDAP programme   Both parents would attend a parenting course.  A written agreement specifying the expectations of the local authority would be put in place  6.11. Midwifery services were asked to advise the CSC locality team when Baby SJ was born and discharged with MJ.                                   6.12. At the end of April 2013, DSW2 and a community support team worker made an unannounced visit to see MJ at her parent’s home. As MJ did not have a named social worker, this duty visit was in line with interim arrangements in place at the time. CSC records indicate that FJ was present and said he and MJ saw each other for around 3 hours on a night and he occasionally stayed over with MJ at her parent’s home. FJ was still waiting for a start date to join the IDAP programme. FJ was told that whilst there were no restrictions in place in terms of contact with the baby when born, the local authority did have expectations about both parents’ engaging with professionals and if this did not happen then CSC would ensure any future contact with the baby would be supervised.   6.13. DSW2 returned the following day and the details of a written agreement were discussed and agreed with MJ, FJ, and the maternal grandparents. The agreement specified that FJ would continue to engage with the Probation Service and the IDAP programme; both parents would attend and engage in a nurturing parenting programme; MJ would engage with the women’s safety worker through IDAP; and, the parents would work with CSC and allow access to their baby following the birth.  May – July 2013 6.14. Child SJ was born in May 2013 and discharged to the home of maternal grandparents with MJ, where the baby progressed well and met expected milestones. Visits by duty social workers and practitioners from the community support team were then made on a regular basis, as the case remained unallocated to a named worker.  6.15. Between May and June 2013, there were 4 visits from the health visiting service. As a result of MJ’s postnatal depression, she was offered an enhanced health visiting service, which at the time involved six ‘listening visits’ from the health visitor in addition to seeing the GP for medication if  Hull SCR Baby J /Mar 2017 10 needed. MJ declined the offer of this service but accepted advice and support, which were offered by HV2. Due to other family members being present, HV2 was unable to make routine enquiries about domestic abuse until the third visit when she found MJ at home alone and without FJ being present. MJ denied there was a need for any concern and suggested the arguments between FJ and herself were trivial and she was often to blame. MJ confided that she was feeling low and had visited her GP.   6.16. The MGPs did not raise any concerns with social workers or the health visitor about the care of Child SJ, although records indicate they did describe the heated arguments that sometimes took place between the couple and they were left wondering how the couple would manage if they lived together. The MGPs told DSW3 on one occasion that it was sometimes difficult having their daughter living with them as it could be ‘chaos’ but DSW3 stressed the importance of their support for their daughter until she became more confident as a parent. MJ continued to stress that the arguments were just ‘bickering’ over trivial things and were often caused by her ‘mood swings’.  6.17. FJ told his offender manager (OM1) about the same time that the tensions in the home were between MJ and her parents and were ‘nothing to do with him’. HV1 continued to record that Child SJ was well cared for and thriving. The maternal grandparents moved house again about this time and MJ and Child SJ moved with them. FJ later told OM1 that he could not move in with the family.  6.18. Towards the end of July 2013, staff from FJ’s hostel again contacted the CSC locality team, to advise that the CCTV camera had picked up a worrying incident of MJ and FJ having a heated argument outside the hostel in the presence of Child SJ. An off-duty police officer witnessed the same argument and rang 999 to report the incident. According to police records, officers attended and spoke with both FJ and MJ following which MJ returned home with Child SJ, who had been asleep throughout the incident. The attending officers graded the incident as ‘standard risk’ using SPECSS12 risk assessment tool in place at the time and a Domestic Violence Form was completed. In reviewing the incident, the attending officers recorded that there were no previous incidents on record between the couple although they were aware that FJ did have a Non-Molestation Order in place with a ‘previous partner’. The records further stated that FJ told officers that MJ was struggling to cope with being a new mother and trying to find accommodation. He also said that MJ had postnatal depression but would not seek medical treatment. The Domestic Violence form was forwarded to the domestic violence unit and entered onto the records on 1st August 2013. The incident was not subject to a secondary risk assessment13 or shared with partner agencies.  6.19. DSW4 visited the following day, although the context of the duty arrangements meant that the practitioner had not met the family before so the extent of her knowledge about the family background was limited. MJ and Child SJ were seen and MJ again blamed herself for the argument, stating that she had been very snappy and was starting arguments with FJ over ‘silly things’. She told DSW4 that she was having a break from FJ for a few days and FJ ‘was OK with that’. FJ was not seen on this visit or contacted to discuss the incident.                                                               12 SPECSS: Separation (child contact), Pregnancy (new birth), Escalation, Community isolation, Stalking harassment, Sexual abuse 13 Secondary Risk Assessments were introduced so that any incidents attended by police officers  and identified as  domestic abuse were reviewed by a senior officer taking into account known history and providing an overall risk assessment  Hull SCR Baby J /Mar 2017 11 6.20. DSW4 visited MJ a few days later and again discussed the incident which MJ continued to describe as an argument over little things and linked it to her having ‘baby blues’. She confirmed she had an appointment with her GP. A few days later this visit was followed up by DSW3 and MJ repeated her assertion that the arguments between herself and FJ were her fault and said they were ‘alright’ now. Following this conversation, DSW3 consulted with the team manager (TM2) and subsequently made a referral to DAP; it was also confirmed that CSC would not provide a letter of support for the couple to gain a tenancy if MJ moved out of her parent’s home and that the previous plan - that FJ and MJ should not live together until FJ had completed the IDAP programme and a further assessment had been undertaken – would remain in place. 6.21. In response to the referral made by DSW3, DAP contacted police who confirmed that the recent incident had been a verbal argument and had been assessed as ‘standard risk’ and that they had been informed by MJ that the argument was linked to her ‘struggling with a new baby’. DAP, consequently, took no further action.  6.22. In late July, MJ was allocated a new health visitor, HV3. MJ told DSW5 during a visit that she had completed an application for a property with a [named] housing provider and that she knew FJ was not allowed to move in with her. She said relations between herself, FJ and her parents were good, and the maternal grandmother confirmed this to DSW5. FJ had just begun his IDAP programme and DSW5 advised MJ that in some circumstances when men undertook this programme there was an increased risk to their partners and children. MJ was advised she should report any incident to police and CSC. MJ said she did not think this would be an issue.  6.23. At the end of August 2013, FJ was arrested and charged with an affray following an argument with a family member. He was bailed until October and appears to have been dealt with by a conditional discharge, as there is no reference to a further order or other penalty. OM1 contacted FJ’s key worker in the IDAP programme and was informed that FJ was learning from the programme and finding it useful to manage situations more positively. Probation records state that FJ’s personal goal at this time was to be ‘the best parent he could be.’ MJ had not, however, responded to overtures from the women’s safety worker and, consequently, no work was undertaken with her.  September – December 2013 6.24. Reports of FJ’s attendance at IDAP during September 2013 continue to suggest he was gaining insights into his behaviour and was making progress. This information was shared with CSC by OM1 at the end of October 2013.   6.25. Between September and October 2013, FJ made several visits to his GP and records and recall by the GP indicate that FJ said he had been in prison for the past year and he described his low mood, his history of domestic violence, and the situation with MJ and his past partner. He also indicated he did not live with MJ and his child. The records indicate that FJ told his GP that his ‘children were his only protective factor’. He was prescribed anti-depressant medication and referred to mental health services but did not keep the appointments offered.  6.26. A named social worker, DSW6 was allocated to the family during this period but only one visit took place with MJ and FJ before the worker took a lengthy period of sick leave, resulting in the family again being supported under duty arrangements. DSW7 visited the family mid-October and FJ self-reported he was making good progress on the IDAP programme. MJ said she had been offered her  Hull SCR Baby J /Mar 2017 12 own property. Towards the end of October, MJ moved, with Child SJ, into this property and DSW8 made an unannounced visit the following day when MJ, FJ, and Child SJ were seen. The parents advised DSW8 that they wanted to live together and said that the written agreement did not state this could not happen. They said that FJ was spending two nights at the property and visiting every day to ‘help’. MJ said that FJ had unsupervised access to Child SJ whom he sometimes took to stay at his mother or sister’s house. DSW8 agreed to return to the office and check on details. 6.27. Following this visit, DSW8 referred back to the team manager’s decisions recorded in April 2013 and confirmed with TM2 that, although there  were no contact restrictions in place, it was clearly stated that FJ should not move in until the IDAP programme had been completed. The couple had, however, stated that FJ was already staying over for two or three nights each week and FJ occasionally had sole responsibility for Child SJ. DSW8 made contact with HV3 who confirmed that she had no concerns about the care of Child SJ whilst MJ had been living with her parents and had been well supported by them. Contact was also made with OM1 who expressed no concerns and indicated that FJ was ‘progressing’. It is to be assumed that neither practitioner highlighted concerns about the couple’s ‘new’ living arrangements  6.28. In October 2013, MJ was prescribed anti-depressants by her GP and was referred to Single Point of Access14 (SPA) by her GP who was concerned about her weight loss and possible Post Natal Depression (PND). MJ met with a mental health practitioner but denied any problems with coping or depression and insisted the referral was due only to her weight loss. The contradiction between the GP’s referral and MJ’s presentation led the clinician to refer MJ for a mental health assessment, which took place in November 2013. However, the triage15 assessment appears to have focused only on the physical element of weight loss and did not explore any mental health concerns in relation to PND.  6.29. In November 2013, during a supervision session with DSW9, the team manager (TM3) in CSC determined that a core assessment (1) was required for this family, given that MJ was no longer living with her parents and had obtained a tenancy in her own right. DSW9 undertook the core assessment (1) and made a number of visits to the family. The assessment was completed in December 2013 and led to a decision by TM3 that, before CSC could close this case, a multi-agency core group16 should be convened. At this time, FJ had another 2 months before he completed his IDAP programme.   January- March 2014 6.30. In January 2014, CSC implemented a new model for the delivery of social work services. The new structure consisted of small social work teams known as ‘Pods’; each led by a consultant social worker (CSW). DSW9 had supervision with CSW1 in January and the supervision records refer to the positive core assessment (1) that had recently been completed and noted that no worries or concerns had been raised by other agencies. The decision to convene a core group was also noted.                                                             14 The Single Point of Access (SPA) service for Humberside provides a first point of contact for people aged 18 and over who have been referred to mental health services. 15 Mental health triage is a process which aims to assess and categorise the urgency of mental health related problems. 16 A core group is a meeting of relevant professionals and family members who come together to ensure that child in need or child protection plans are properly implemented and progress is regularly monitored and reviewed.   Hull SCR Baby J /Mar 2017 13 By this time, however, it was known that MJ was pregnant with her second child and CSW1 requested DSW9 to complete a second core assessment (2) in respect of unborn Baby J.  6.31. The first core group meeting was held at the end of January 2014 and was attended by both parents, DSW9 and HV3. Probation had been invited but could not attend. The record of the core group meeting would suggest that the respective GPs and midwifery services were not invited, nor were they asked to contribute to the meeting. There were no concerns identified in relation to Child SJ’s health or development, and MJ’s family were described as being supportive. The only actions to emerge from this meeting were that MJ should continue with health appointments for herself and Child SJ, and FJ should continue with the IDAP programme.  6.32. In early March 2014, a reflective discussion about the family was held in the Pod team, led by CSW2. Drug and alcohol use were noted to be a feature in this family, but the discussion concluded that there was no evidence that these were impacting on family life. A decision was taken that, following further checks with the police and the IDAP programme, a final core group meeting should be held and, if all agencies agreed, CSC would close the case.  6.33. On the same day this discussion took place, police received an abandoned 999 call from the couple’s home address. Police officers attended the address and spoke to MJ and FJ. Both adults were described as being calm, and they confirmed there had been an argument but would not disclose to police what it had been about. The attending officers graded the incident as ‘standard risk’ and a domestic violence form was completed. Consent was provided by the couple for the information to be shared with other agencies. There is no record of whether Child SJ was seen by the officers, but police records indicate that FJ left the property. The domestic violence form was forwarded to the domestic violence unit the same day and entered onto the domestic violence recording system on the following day (5th March 2014). According to Police records, the incident was shared with CSC on the same day but this is not recorded in CSC case files and did not lead to a duty visit.   6.34. When MJ attended an antenatal appointment in March 2014, she advised the midwife that CSC were ‘closing the case’ and the midwife contacted the CSC social worker based at the hospital to confirm this information. She was advised that, although they were aware of MJ’s pregnancy, FJ had completed his IDAP programme, and as there had been no domestic abuse incidents, the case was in the process of being closed to CSC. The risks that FJ posed to others however remained unchanged and were still assessed as ‘medium’.    6.35. The women’s safety worker had attempted again to contact MJ to inform her about FJ’s progress in the IDAP programme and to obtain any feedback but there was no response to her efforts and the case was closed, as per usual practice.  6.36. Information was received by Probation mid-March 2014 that FJ had again been arrested for a breach of the Non-Molestation Order in respect of his previous partner. Later that month, a second core group meeting was held attended by DSW9, the health visitor, and the probation officer. According to the record of the meeting midwifery services were not asked to attend or to contribute to the meeting and, although FJ was present, MJ did not attend but the record of the meeting did not refer to her absence or the reason for it. Child SJ was again reported to be well. The information about FJ’s arrest was shared by OM1 at this meeting and FJ gave his own account  Hull SCR Baby J /Mar 2017 14 of the incident, and said this had occurred as a result of a misunderstanding and he was required to attend the police station to explain what had happened. OM1 reported that there had been a ‘stabilisation of FJ’s emotional management’ over the last year and he had now completed the IDAP programme, and although he was required to undertake further work on a one to one basis with OM1 around anger and understanding the emotions of others, OM1 said that on completion of IDAP programmes ‘no-one comes away with no recommendations’.  6.37. The professionals who attended the core group agreed that CSC would close the case, pending the outcome of FJ attending the police station in respect of the reported incident. Those present, apart from FJ, were unaware of the abandoned 999 call and FJ did not share this information. He said that his use of cannabis had subsided and he did not often drink any more. Following this meeting, DSW9 made two further home visits; during the last visit FJ informed her that the police were to take no further action in relation to the incident which had led to his arrest.  CSC closed the case on their records at the end of March 2014. 6.38. In April 2014, FJ’s case was transferred as part of a bulk transfer of cases from Humberside Probation Trust to the Community Rehabilitation Company, as the Probation Trust was being spilt into two separate agencies – The National Probation Service and the Community Rehabilitation Company (CRC). The management of FJ was consequently transferred from OM1 to a new offender manager (OM2).  6.39. Police arrested FJ for producing and possessing a controlled drug in May 2014, – this related to a small quantity of cannabis buds and cuttings. FJ admitted to possession of these substances and attended court the following month where he received a fine.  6.40. Two related incidents occurred between MJ and FJ in July 2014. The first was dealt with by two police community support officers who observed a heated argument in the community between the couple and intervened. MJ and FJ eventually agreed to go their separate ways and FJ agreed to take Child SJ and look after him for the evening. A second incident was later captured by CCTV operators during which both adults were again seen to be arguing in the street. Police officers attended the incident; FJ informed officers that he had just returned Child SJ to MJ as he had changed his mind about looking after the child and this had resulted in a further argument. Both adults stated they would stay with their respective families for the evening.   6.41. Both incidents were recorded on one domestic violence form and the form was finalised by the officer dealing with the second incident. The incidents were graded as ‘standard risk’. The record shows that the police were informed that although the parents were in a relationship they lived at separate addresses. The records also show that Child SJ was seen during these incidents and ‘appeared to be well.’ The domestic violence form was forwarded to the domestic violence unit and entered onto police systems on 29th July 2014. The incidents were not subject to a secondary risk assessment or shared with partner agencies. 6.42. On the 28 July 2014, the day before these incidents were recorded on the police system, an incident was reported to the police by a member of the public who stated that a female was shouting inside a property ‘he’s taking my baby’. Police officers attended the address and spoke with both MJ and FJ. Child SJ was noted to be present at the address. There is limited information on the incident log, which recorded the incident as a ‘verbal argument’ between the adults, both of  Hull SCR Baby J /Mar 2017 15 whom lived separately. The officers gave advice and graded the incident as ‘standard risk’. A domestic violence form was again completed. The only information recorded on the risk assessment is in relation to Child SJ, which states that the couple have one child who lives with MJ and that she is currently pregnant and due to have her second child in six weeks. The domestic violence form was completed and forwarded to the domestic violence unit and entered onto police systems on 7th August 2014. The incident was not subject to a secondary risk assessment and was not shared with partner agencies. The record shows that a DAP booklet was posted to MJ which she later returned insisting she was ‘not a victim’. 6.43. Baby J was born at the end of August 2014 and discharged to MJ’s care. MW2 visited and noted that Baby J appeared well. After three unsuccessful attempts to visit the family, MW2 eventually gained access to the family again, 3 days later. Child SJ and FJ were present. Baby J woke up and despite crying ‘inconsolably’, FJ picked him up only after being encouraged to do so by the midwife. MW2 was concerned that the family needed support and left a message with the duty health visitor as HV3 was on leave.  6.44. MJ attended for a postnatal check 5 days later and MW3 noticed a bruise to MJ’s left eyebrow. Records indicate that the midwife decided not to ask about the bruise directly as MJ appeared ‘withdrawn and reluctant to talk’ and she thought MJ might be more forthcoming in response to more routine questions about domestic abuse. MJ simply replied ‘No, never’ to the questions asked about possible domestic abuse. She said she was feeling unwell and dizzy and was therefore referred by MW3 to her GP. No concerns were noted in respect of Baby J who appeared well. MJ advised MW3 that she had been taking cannabis the night before and this had left her feeling unwell.  MJ did not keep her appointment with the GP and later suggested there was some confusion over the appointment time.  6.45. There were two related incidents reported to the police on 17.9.2014. The first of these was reported by an anonymous caller ringing 999 just after midnight and stating there had been shouting at a flat since 20.30 hours and they had heard a woman shouting – ‘You f… woman beater’. The caller believed that young children were living in the property as they heard crying but they had no details of who the children or occupants were. The caller said this was a regular occurrence and they had reported it to their housing provider who had advised them to keep a diary, which they had done since March 2014. 6.46. Police attended a block of flats about 15 minutes later but had no means of identifying which property within the 3-storey block the caller had been referring to. Although some windows were open in the block there was no sound of shouting or any disturbance. There were no means of the police entering the block of flats other than to force entry or ring individual flats for more information. Neither action was considered appropriate as all was quiet and there were no sounds of a disturbance taking place. 6.47. Completion of the incident log was delayed for welfare enquiries to be undertaken later that morning. However, at 02.30 hrs, police received a call from FJ stating that his girlfriend was shouting and screaming in the street; during the contact, a female could be heard shouting and crying in the background. FJ informed police they had a new-born baby in the house, police officers attended the property and gained access where they spoke with both FJ and MJ. The attending officers graded the incident as ‘standard risk’. The risk assessment records state that the couple  Hull SCR Baby J /Mar 2017 16 argued on a regular basis, possibly due to them having two very young children close in age and they were tired from lack of sleep. The records state that the couple had been in a relationship for two years and, whilst there had been no physical assaults, MJ had said she felt angry towards FJ because he was always criticising her for being a bad mother.   6.48. The risk assessment showed that the attending officers saw both children. Child SJ was asleep on the living room settee and Baby J was asleep in the pram in the living room, and although they had been present when both parents were arguing, they were described as being fast asleep when officers arrived and it was concluded that they had been ‘unaffected’ by the arguing. The domestic violence form was forwarded to the domestic violence unit and was recorded on police systems on 24th September 2014.  6.49. On the 23 September 2014, Baby J was found unresponsive by FJ and was taken to hospital. Baby J died two days later.   7. Analysis and Findings 7.1. This analysis is based on discussions in the Review Team and with practitioners, the individual agency contributions to the Review and research information accessed by the lead reviewers. The analysis also takes into account learning from local and national SCRs and the recently published triennial  analysis of SCRs. 17  7.2. The examination of single and multi-agency working leading up to the death of Baby J has identified several areas of learning for agencies, together with some reflections about how judgments were applied at key points of interventions. The analysis is structured around four areas of significant practice (ASPs), which lead to the findings and identification of common thematic issues. The ASPs are listed below and further details follow.  ASP 1:  The extent to which potential risks in this family were assessed and well understood by professionals /agencies  ASP 2:  The ways in which professionals communicated and worked collaboratively within a multi-agency context.   ASP 3:  The response of CSC to referrals and contacts from partner agencies  ASP 4:  The response by agencies in Hull to incidents of domestic abuse     7.3. ASP 1: To what extent were potential risks in this family assessed and understood by professionals /agencies No one agency held the full picture of FJ’s history, or that of MJ, so important information about the parents’ mental health and use of drugs and alcohol was not shared and, consequently, these aspects were not considered alongside concerns about domestic abuse. This left potential risks to the children unexplored. Professionals viewed FJ’s attendance and completion of the IDAP as a significant safety measure and concluded when the programme had been completed that risks were reduced. The prediction of future harm is highly complex and the assessment in this case would have                                                             17 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: Final report May 2016.Peter Sidebotham, Marian Brandon et al.  Hull SCR Baby J /Mar 2017 17 been enhanced by the use of risk assessment tools by the practitioners working with the adults in the family. Had assessments been more robust, the risks associated with FJ’s behaviour and MJ’s minimisation of those risks might have been better understood and the need for safety plans for Baby J recognised and acted upon.     Assessing Risk 7.3.1 There is an extensive body of evidence that shows how parental problems such as domestic abuse, substance misuse and mental health problems can undermine parenting capability and increase the likelihood of significant harm to children. Research18 continues to emphasise the importance of understanding and acting on concerns about children’s safety and welfare when they are living in households where these parental problems are present. Although such problems in families do not preclude caring and effective parenting, research suggests that it is where these multiple problems interlock and interact as a ‘toxic trio’ that there is a substantially increased risk that children will be exposed to maltreatment and suffer significant harm.  7.3.2 FJ was referred to in agency records as a perpetrator of domestic abuse. He was discussed at a MARAC meeting which, by definition, identified the risk he posed to SS, his previous partner, as ‘high’. At the time, FJ was also on remand having repeatedly breached a Non-Molestation Order in respect of SS.  7.3.3 Munro (2008) writes the ‘best guide to future behaviour is past behaviour’ and suggests that without evidence of different dynamics or changed behaviour in families, professionals should always consider the likelihood that past behaviours will re-emerge under certain circumstances. The Review Team was told by most practitioners that, as far as they were aware, FJ’s behaviour was changing as a result of the IDAP programme and not only had there been no ‘domestic abuse’ incidents reported between the couple, MJ had also described their arguments as ‘trivial ‘and ‘silly’ and said that abuse was not a factor in their relationship.  7.3.4 Research studies 19 suggest, whilst individuals may change, where domestic abuse is concerned change is probably the exception rather than the rule: it takes time, and in itself is not always easy to recognise or measure. Women may also minimise the risks experienced by themselves in response to threats and coercion from their partner, or as a means of ensuring that their children are not removed from their care by statutory agencies. In its ‘Practice briefing for social workers and family support workers’ in relation to the learning about domestic abuse from serious case reviews, Research in Practice states that: ‘many mothers suffer[ed] cumulative harm that made it difficult for them to disclose the abuse, access services, leave a violent man or protect their children. Assurances that a violent man has changed or does not present a risk to children should be treated with scepticism; violence does not usually stop without intervention’. (2016)                                                              18  Brandon, M., Bailey, S. and Belderson, P. (2010) Building on the learning from serious case reviews: Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence (2011)Cleaver, Unell and Aldgate;  19 Research in Practice is a charity which brings research and practitioner expertise to build the sector’s capacity for evidence- informed practice.  Hull SCR Baby J /Mar 2017 18 7.3.5 The Review Team was of the view that FJ’s attendance and completion of the IDAP programme was very much regarded as a ‘safety measure’ and, by default, viewed as a form of ‘intervention’. IDAP is a cognitive-behavioural programme, which challenges convicted offenders’ attitudes and beliefs in order to change their behaviour. Men are referred to the programme on the basis of a pre-sentence report recommendation but the programme is not considered suitable for all those with relevant convictions. An offender manager assesses suitability on the basis of a risk assessment, age, level of drug and/or alcohol dependency, literacy, and crucially, the level of motivation. It is not, however, a programme designed to improve parental capacity. Whilst it touches on issues of responsible parenting, it does not equip offenders with the skills required for safe and responsive parenting. The core group’s assumption that FJ’s compliance with the IDAP programme equated with safety measures for both Child SJ and Baby J obscured and minimised the risks which, had they been known and fully assessed, were evident both before and after the birth of Baby J. 7.3.6 Health and CSC practitioners told the Review Team that they were unfamiliar with IDAP but believed that FJ’s compliance and completion of the programme was a strength within the family. Whilst right to view FJ’s commitment as a strength, the assumption that completion of the course meant FJ was less of a risk to his children was mistaken and was neither tested nor measured. Significantly, no actual ‘work’ or ‘intervention’ was undertaken with the parents during this period so professionals were left with a misplaced confidence that the IDAP programme, together with the (required) separation of the couple, were adequate safety measures to address the perceived risks from FJ.  7.3.7 The emphasis on the parents not living together whilst the IDAP was being undertaken was regarded as an additional safeguard. However, enforced separations do not take into consideration the emotional and psychological aspects of a relationship and without any additional work with parents, such ‘ties’ were left unassessed and the couple, perhaps inevitably, sought ways to be together because they did not understand why they should live apart. The Review Team was of the view that the decision to require the couple to live separately was not a safety measure, but it did provide a degree of reassurance to social workers. In effect, the couple began living together when MJ moved into her own accommodation and both parents admitted independently that they deliberately gave the impression of living separately, but remained puzzled by the fact that CSC said they could not live together as a family yet it was acceptable for FJ to stay over for two or three nights a week.   7.3.8 Munro 20states that making ‘decisions in conditions of uncertainty’ (i.e. risk taking) is a core requirement for professionals working with children. The challenge of assessments, however, is predicting the likelihood of risk where both risk and uncertainty are key features. Given his past history, it should have been predicted that FJ would be ‘more likely than not’ to continue with his abusive behaviour in a new relationship; the extent to which the IDAP would help him to manage his emotions and behave differently was certainly far less predictable, yet this was accepted as a given. Had this issue been raised and explored in any depth, the limitations of this programme as a                                                             20 The Munro Review of Child Protection: Final Report: A child-centred system 2011 DfE   Hull SCR Baby J /Mar 2017 19 safety measure might have been better understood.  The Review Team was also of the view that, had the core group been more curious about FJ and sought more detailed information from key professionals who knew him, it is highly likely that the emergent chronology would have highlighted incidents and significant patterns of behavior, which would have better informed their subsequent decision-making.  7.3.9 FJ was a known domestic abuse perpetrator; both parents had been referred to mental health services; and both were open about cannabis use. FJ was also known to drink heavily at times which was known to adversely impact on his behaviour. These features are viewed as indicators of increased risk of harm to children and young people but the extent to which all three features were present in this family was not known and this impacted upon the assessment and quality of decision-making.   7.3.10 ‘Healthy scepticism’, ‘professional curiosity’ and ‘respectful uncertainty’ are all phrases associated with good quality child protection work. The absence of any ‘healthy scepticism’ prevented practitioners from seeking out ‘missing’ information to confirm their views or what they had been told by FJ and MJ. Critical and analytical thinking encourages practitioners to process information rigorously and methodically and to question the reliability of both sources and content. This is an essential component of risk assessments but it did not happen in work with this family and the Review Team learnt from practitioners that this view was linked to the parent’s apparent co-operation and the absence of any concerns about Child SJ, together with a pre-conceived view as to what ‘domestic abuse’ looked like. The context, content and concerns of the original referral to CSC through MARAC were lost as professionals worked independently and assessed risk only in terms of their own perspective.  Finding 1: Without a clear system for linking MARAC assessments to police call-outs and family work, the risks posed by perpetrators of domestic abuse may not be well understood.   Understanding the nature of Domestic Abuse 7.3.11 There are conflicting recorded accounts as to whether FJ was physically violent towards his previous partner and MJ said that FJ had never, and would never, physically assault her. She also insisted to the DAP worker that she ‘was not a victim’. There was, however, evidence of FJ’s controlling and coercive behaviours towards MJ, which research suggests is not only ‘the most common context in which women are abused, it is also the most dangerous.’21 The Review Team found that the absence of any evidence to suggest that FJ was physically violent towards MJ, together with her denial that it occurred, led practitioners who knew about FJ’s background to underestimate the risk of domestic abuse as a factor in their relationship.  7.3.12 Practitioners confirmed in discussions that had MJ presented with bruises and injuries, agency responses might well have been different. Police confirmed that their response would also have been different if signs of physical injuries had been seen and confirmed that at that time, officers handled verbal arguments differently to incidents of physical violence. The probation officer recorded that there was no evidence of physical violence towards previous partners and that FJ demonstrated ‘mainly controlling behaviours within his relationships’. The records also state ‘there                                                             21 Evan Stark (2007),’ Coercive Control. How Men Entrap Women in Personal Life.’ Oxford University Press  Hull SCR Baby J /Mar 2017 20 was no domestic violence between FJ and MJ’, a view repeated in CSC assessments which referred to FJ’s past behaviours but which did not take into account MJ’s self- blaming comments or those made by hostel workers which suggested that FJ was controlling and coercive in his relations with MJ. It was not recognised by these professionals at the time that this, in itself, was a form of domestic abuse and without the sharing of information in a multi -agency context the extent, the nature and potential impact of FJ’s behaviour remained unassessed. 7.3.13 New legislation22 now protects victims by criminalising patterns of coercive and controlling behaviour that amounts to psychological and emotional abuse, even where there is no evidence of physical violence. Difficulties, of course, can arise in determining at what point marital arguments and disagreements are classed as abusive, but in terms of safeguarding children, professionals need to broaden their understanding of what constitutes abuse where behaviours are observed to be intimidating and controlling. 7.3.14 It is now more widely recognised that coercive control is a core part of domestic abuse and this recognition has been a significant and influential factor in changing the terminology used from domestic violence to domestic abuse. The Review Team would suggest that certainly more could be done in Hull to encourage greater use of the term ‘domestic abuse’ and eliminate and discourage the term ‘domestic violence’. The Review Team was informed that training and increased awareness is beginning to make a difference as patterns of behaviour and a couple’s history are now assessed in much more detail, placing even more emphasis on the importance of good recording and information sharing and succinct chronologies so emerging patterns can be more easily recognised.   Finding 2: Coercive control is subtle, circumstantial, and highly nuanced; professionals are more likely to recognise controlling and coercive behaviours as domestic abuse when they are well trained and where there are good records, succinct chronologies and opportunities to share and analyse information and concerns within a multi-agency context.   Drug and Alcohol Issues  7.3.15 The Review Team was unable to evidence any consideration by professionals related to the hidden harm and risks associated with drug and alcohol misuse. Examination of agency records indicates that FJ was a known cannabis user and was convicted for the possession of cannabis in 2014. The Offender Assessment System (OASys23) made reference to FJ previously being in receipt of prescribed anti-depressants and yet, when he self-disclosed taking his mother’s Tramadol tablets, this information was not addressed by his offender manager and neither was it shared with other agencies. FJ was also noted to recognise the relationship between alcohol and his unpredictable behaviours but this did not trigger the need for a further discussion with other agencies. 7.3.16 MJ was also known to have used cannabis since her early teens and remarked to her GP that she ‘liked taking Tramadol’. The Review Team considered it an unlikely coincidence that both parties independently referred to this prescribed drug, but a lack of communication and collaboration between agencies meant the significance of these remarks went unnoticed and information, which may have been significant, was lost. The link, therefore, between substance misuse and potential                                                             22 The Serious Crimes Act 2015 became law in December 2015 23 OASYs Offender Assessment System measures the risks and needs of criminal offenders under their supervision.  Hull SCR Baby J /Mar 2017 21 harm was not made or evidenced in any agency records and neither were they considered as risk factors in the CSC assessments or the two core groups, which took place.  Mental Health of Parents 7.3.17 FJ made several visits to his GP in relation to feeling ‘low’ for which he was prescribed anti- depressants. He also talked about suicide and told his GP that his children were his ‘protective factor’. He did not, however, engage with mental health services after being referred, although it appears that his GP was unaware of this. When he was taken in to custody in August 2012, FJ was referred to the custody nurse where he was noted to be calm and engaging. Notes from the assessment highlighted naivety and immaturity and a lack of emotional resilience; FJ also scored high on an alcohol assessment and notes suggest that alcohol played a significant part in his violent outbursts. FJ said he had struggled with anger issues all his life, but he declined any further support. FJ had a difficult childhood and was known to have witnessed and experienced significant domestic abuse as a child; this, coupled with a struggle to manage his emotions, left FJ as not only a vulnerable adult but also a very volatile one. In the absence of any contact with his GP, the duty social workers and health visitor were unaware of his mental health issues and the impact that alcohol was known to have on his behaviour.  7.3.18 The mental health assessment carried out in November 2013 for MJ focused just on weight loss and the disparity between the details of the GP referral and MJ’s presentation was not picked up by the mental health practitioner or addressed with the GP. Neither was there any exploration of drug and alcohol use in the assessment, although CSC records suggest MJ had been using cannabis since she was a young teenager. The mental health practitioner reflected on her assessment during the review and acknowledged that it would have been helpful to liaise with other practitioners involved with the family so that important information could be shared and discussed. The Review Team was advised that further work has since been undertaken by that agency and all assessments are now monitored and regularly reviewed.  7.3.19 The decision by the core group to close the case in the early stages of MJ’s pregnancy with Baby J was made on the basis of incomplete and missing information, both in terms of the extent of drug and alcohol use within the family and, importantly, the mental health of both parents. Had information been sought from all the various professionals involved with the family and specifically from their GPs, and hostel staff, the additional risk factors around vulnerabilities may have emerged and the need for a pre-birth assessment considered. The problems of making decisions on the basis of incomplete information are well documented24 and, whilst it cannot be assumed that the decision to close the case would have been different, even had they considered any of the above factors, there would, however, have been far greater evidence to support their professional judgment and subsequent decision-making.  The responses of MJ   7.3.20 According to agency records, the bruise seen by MW3 was the only time any injuries were noted on MJ. The bruise, observed by the midwife soon after the birth of Baby J, led her to ask a routine                                                             24 DePanfilis, D. & Girvin, H. (2005) Investigating child maltreatment in out-of- home care: Barriers to good decision-making  Hull SCR Baby J /Mar 2017 22 question about domestic abuse to which MJ replied ‘no, never’. Had MW3 been more aware of what was happening in the family, if, for example, midwifery services had been invited to the earlier core group meetings; it might have encouraged her to ask more directly about the bruise. However, MJ told the reviewers that no matter how sensitively she had been asked, she would not have admitted what was happening because she was so fearful of what FJ might do and this fear was greater than the belief that she and her children would be kept safe if she told anyone about FJ’s behaviour. MJ also told reviewers that FJ controlled what she did and where she went and she was frequently told by him that she was a useless parent and could not look after her children. She was threatened with exposure and losing her children if she spoke out about what was happening. 7.3.21 MJ’s experience is mirrored by Stark’s research 25 which illustrates the concept of coercive control in his description of women who live with aggressively controlling men, who would ‘isolate these women, impose restrictions on them, and control many aspects of their lives. The women would behave in ways that highlighted the fear within which they lived, but often would not disclose the abuse they were experiencing from their partners’  7.3.22 If the context of coercion and control presents significant barriers to women disclosing what is happening in their lives, it also creates particular difficulties for   professionals trying to ensure the safety and welfare of children in the family whilst also seeking to support the non-abusing partner, even assuming the woman is ready both psychologically and physically to confront what might be happening. Where there is past or present evidence of domestic abuse, professionals need to approach work with a family with a degree of scepticism if told that that abuse is no longer a feature of that relationship. Whilst the need for challenge to the abusing partner is essential, there is an equal and paramount need for sensitivity in providing repeated and ongoing opportunities for women to disclose so they can be supported and helped to voice their concerns.  7.3.23 There was evidence of a lack of recognition of the ongoing vulnerability of MJ to FJ’s controlling behaviours as professionals who knew FJ’s history believed the risks he posed were being addressed through the behaviour change programme. They were also reassured by MJ’s assertion that he was not an abusive partner. The implications of MJ failing to engage or acknowledge the reasons why FJ was attending the IDAP programme were not addressed by social workers or those who attended the core group. Had the women’s safety worker been invited to attend the core group meetings, this information may have alerted professionals of the need to consider if MJ’s refusal to engage with DAP impacted upon her ability to protect her children and was in any way influenced by FJ.    The use of tools to aid professional judgment 7.3.24 In effect, there were a number of risk indicators evident in this family which, had they been known and considered in greater depth, would have alerted professionals to consider the need for more robust safety plans for Child SJ and Baby J.  The Review Team found that without the use of any risk assessment tools to inform their professional judgment, together with the lack of a comprehensive multi-agency view, CSC professionals were left to rely upon their professional view to determine risks and the likelihood of harm to children in the family. It is important to acknowledge that a practitioner’s intuitively based feelings and responses have been identified as an important source                                                             25 Stark, E. (2007). Coercive Control: The Entrapment of Women in Personal Life. New York: Oxford University Press  Hull SCR Baby J /Mar 2017 23 of data in assessments. However, the dangers of reliance upon intuition, because of its potential as a source of bias, are also well researched and highlight that intuition needs to be tempered with critical and analytic thinking in any assessment process. 26  7.3.25 Where decisions have been based largely on intuition, it is important that professionals consciously check and review their judgments, using objective evidence where possible, in order to detect any errors even if they are confident about the accuracy of their decision.27 There are many tools that can help make reasoning more explicit, informed, and systematic but none of these were used in work with this family. The Review Team was told that the use of such tools is not commonplace in CSC or in other agencies locally and there is little evidence that supervisors or managers encouraged their use. 7.3.26 Research studies28 suggest that ‘without the use of tools to assess risk, professional judgment can too often be flawed, with assessments being ‘only slightly better than guessing’. The assessments undertaken by CSC did not use any specific risk assessment tools, such as the DASH29 assessment, which may have informed the analysis of risk, or tools such as Prochaska and Diclemente’s model30 to ascertain the extent to which both parents were actually able and motivated to change their behaviours to keep their children safe.  Even a tool as simple as a multi-agency plan to determine and measure progress was not in evidence. The challenge for professionals, of course, is to know which tools to use and when and this is where guidance from line managers and the safeguarding board becomes essential. Finding 3: The reliability of practitioners’ judgments concerning the assessment of risk and harm; could be significantly improved if information is collected and analysed using integrated chronologies, evidence-based tools and standardised measures to inform structured professional decision- making.  Finding 4: A range of safety measures are required to protect children in families where domestic abuse is a concern, but a reliance on the physical separation of family members and/or perpetrator change programmes, in the absence of a wider multi-agency plan, may leave children vulnerable and without effective help. There are also particular challenges for professionals where women deny or are unable to accept the risks posed to their children from their partners and this requires persistent ongoing work in relation to safety planning for all parties.  Risk indicators for abusive head trauma 7.3.27 Research undertaken by Ofsted in 201131 summarised some key findings from 482 SCR’s evaluated between April 2007 and March 2011. 35% of children considered by these reviews were under the age of one year and the study found that information sharing between professionals was often inadequate, that parents’ own needs and the fragility and vulnerability of very young infants were                                                             26 Judgements or Assumptions? The Role of Analysis in Assessing Children and Young People's Needs. Helm 2011 British Journal of Social Work.  27 Thinking Fast and Slow Kahneman, 2011; 28 Systemic Review of Models of Analysing Significant Harm  DFE RR199 Barlow 29 Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) is a checklist for identifying and assessing risk used by police and partner agencies across the UK. , 30 Prochaska and Diclemente: Stages of Change (2009) 31 Age of Concern. Ofsted 2011  Hull SCR Baby J /Mar 2017 24 underestimated, and that pre-birth assessments were not undertaken or, where they did occur, they were insufficiently detailed or analytical to identify risk and plan support for parents.  7.3.28 Additional research32 highlights how parental stress, anxiety and relationship problems can also impact on a parent’s ability to respond calmly to their babies’ crying, leading to some parents   ‘shaking’ their babies and causing head trauma. In the UK, nearly 200 babies suffer from these injuries each year with infants who are under six months old being at greatest risk of non-accidental head injury. Both parents were informed of these risks by midwives and by HV3 but they were not considered in the assessment process. The same research suggests that, whilst there is a growing awareness about the causes of head trauma injuries, it is not only parents who need to be educated about how to respond to a baby’s crying, social work professionals also need to be aware of the triggers which can lead to such injuries in babies and be mindful of these in their work with all families.  7.4. ASP 2:  The ways in which professionals communicated and worked collaboratively within a multi-agency context Examining the integrated chronology, it is clear that in work with this family, each agency held pieces of information which, had they been shared with partners, would have contributed to a better understanding of potential risks within this family. The information that was shared was not analysed in any depth and this left individual professionals in contact with parents without access to shared hypotheses or multi-agency plans. The Review Team considered that in relation to Child SJ and Baby J, individual agencies were working independently of each other and so missed opportunities to work collaboratively to ensure the safety and well-being of children within the family.   7.4.1 The importance of an integrated professional group being accountable for safeguarding children rather than confining the responsibility to children’s social care was stressed in Munro’s33 first two reports on the child protection system. A collaborative approach is meant to ensure that not only are parents recognised as having needs in their own right, but also the impact of those needs on their children becomes part of a multi-agency response. National policy and guidance supports these principles and research34 confirms that the value of inter-agency collaboration is widely accepted by professionals, including those working in adult services, who are now more likely to regard themselves as part of the child well-being system. Nevertheless, continued work is required to ensure that these principles are embedded and reflected in local practice. By its very nature, joint working brings together professionals with different roles and responsibilities as well as divergent professional cultures and these differences can act as barriers to effective joint working. Understanding the roles and responsibilities of colleagues from different disciplines and respecting their expertise is critical to the success of joint working.                                                              32 lr Med J. 2010 Apr;103(4):102-5. Medical, social and societal issues in infants with abusive head trauma, Koe S, Price B, May S, Kyne L, Keenan P, McKay M, Nicholson AJ.   33 The Munro Review of Child Protection: Part 1: A Systems Analysis, 2010; Part 2:The Child’s Journey 2011 34 Children’s needs – Parenting capacity Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence DFE 2011  Hull SCR Baby J /Mar 2017 25 7.4.2 During the review process practitioners helpfully explored the question ‘why did we not know ‘ [certain pieces of information]. The Review Team were told that it is not uncommon for professionals from partner agencies to hold the view that social workers ‘must know best’ and it was assumed CSC would automatically share information relating to any risks and issues of concern, as they were the key agency ‘working’ with the family. The fact that no multi-agency meetings were called until early January 2014 was attributed, in the practitioners’ meetings, to CSC decisions that none were needed, yet GPs, probation and the staff from the hostels each had significant bits of information not known to, or asked for, by CSC when undertaking their assessments.  7.4.3 The significance of the combination of factors was, therefore, not recognised by practitioners as they each focused on their own discipline and area of expertise within their respective services. It would, for example, have been helpful for the GP to liaise with CSC; given the knowledge that FJ was a parent, had mental health issues, was struggling with drugs and alcohol, and had a history of domestic abuse. These factors – the toxic trio - are common features in families where harm to children has occurred but the GP was of the view that, as FJ did not live with his family at the time, any risks to the children were minimal. Even if contact with CSC had not taken place, a conversation with HV2 would have been of benefit. Similarly, when MJ was referred to mental health services, a conversation with HV3, given there was a baby in the family, may well have alerted her GP to the vulnerabilities in this family. 7.4.4 The staff at the hostels where MJ and FJ were living held a significant amount of information, not only about FJ but also about the couple’s relationship and MJ’s reluctance to acknowledge FJ’s abusive behaviours towards herself and others. When staff at the hostels contacted CSC, they were informed that they were waiting for the outcome of an assessment and they should call back for updates – this was a missed opportunity for practitioners to learn more about FJ and MJ and how they were coping and highlights a lack of understanding about the work of the hostel and the services provided by that charity.   7.4.5 National guidance emphasises that ‘safeguarding is everybody’s business’ and that effective safeguarding requires the input of all professionals in collaborative multi-agency working. In discussions with both practitioners and the Review Team, it became apparent that professionals’ determination of need and risk were not consistent and were significantly influenced by what is described in research35 as ‘subtle hierarchies’ within the system. This led to information being ‘weighted differently’ dependent upon the source and the perceived ‘expertise’ of that source. The concept of these ‘hierarchies’ also helps to understand the tendency for some practitioners across professions to ‘defer safeguarding responsibility to social workers’ or to assume that  ‘social workers, or the police for example, know best’. The concerns held by hostel staff, which they attempted to share with CSC, for example, were not seen by duty social workers as significant, despite their considerable involvement with FJ and MJ and the fact that the hostel workers in question were also qualified social workers. This left hostel staff feeling devalued and that their concerns were not ‘heard’ or well understood.                                                                 35 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: Final report May 2016.Peter Sidebotham, Marian Brandon et al.  Hull SCR Baby J /Mar 2017 26 7.4.6 A recent study 36 of health organisations offers useful insights to the broader issues of multi-agency working and, perhaps not surprisingly, concludes that workplace cultures are more influential in shaping such behaviours as opposed to being an inherently human way of working. The research suggests that ‘subtle hierarchies’ are more a result of the structures and entrenched cultures in organisations which, despite the clear need for effective teamwork, can create professional silos and a reluctance or hesitancy to work more collaboratively. Professor Braithwaite, the author of the study, suggested that strengthening inter-professional teamwork would be enabled by paying more attention to the characteristics of the context in which teams operate, and the encouragement of more joint activities, shared decision-making and mutual responsibilities, but  this in itself requires ‘effort on the part of managers and leaders, and the [professionals] themselves’.  The Review Team were told by practitioners during this review that they would welcome more opportunities for joint training and case discussions with colleagues from other agencies but also stressed that competing demands on their time severely limited such opportunities.  7.4.7 Issues about data protection and sharing information with voluntary organisations were discussed in the practitioners group and, although it was acknowledged that colleagues working in the voluntary and private sectors are partners when safeguarding and child protection issues are explored, the Review Team was told by the hostel manager that he did not feel this to be the case. He expressed frustration that accessing information or attempting to pass on information to CSC was not always easy and, although the charity often held important information, they were too often not regarded as an ‘agency partner’. The point was made in the practitioner’s meetings that many professionals do not know the extent of the services offered by accommodation providers or, in some cases, by partner agencies and especially those who work within adult settings. Certainly, better collaboration and more curiosity between adult services and children’s services may well have highlighted the different perspectives about what might be happening in this family. 7.4.8  CSC did not establish a core group until early 2014, but no agency had identified the need for a multi-agency meeting before then: the issue of FJ’s ‘domestic abuse’, known to all agencies, was located only within his previous relationship and each agency held only their own piece of the ‘jigsaw’. Without creating opportunities to share and analyse information, a holistic picture of the family did not emerge.  7.4.9 Although various studies show that the development of joint protocols and information-sharing procedures support collaborative working between children’s and adults’ services, there was evidence from this review that, in terms of working in families where domestic abuse is a concern, recourse to multi-agency meetings was seen more as an option than a necessity. A process which requires initial multi-agency meetings, so that information can be shared when domestic abuse has been identified, would be a step forward, although the sheer number of reported incidents presents as a not -  insignificant barrier to this approach. For unborn babies, that process should always lead to a pre-birth assessment although, even in this family, that process was overlooked, in part because the domestic abuse related to a past partner.                                                               36 BMJ Health services research. The basis of clinical tribalism, hierarchy and stereotyping: a laboratory-controlled teamwork experiment Jeffrey Braithwaite et al 1  Hull SCR Baby J /Mar 2017 27 7.4.10 Time, capacity, and workload pressures were all offered as explanations as to why there was limited recourse to multi-agency working. It was suggested that unless CSC called a multi-agency meeting, it was less likely to happen, partly because of the perceived status of that agency but also because other agencies were not confident that other professionals would attend if they were not invited by CSC. The hostel manager said he had not had much success in trying to call various meetings for those reasons.  7.4.11 In order to make a full and comprehensive risk assessment and subsequent risk management plans, it is important for all agencies to be pro-active in seeking out information when domestic abuse is or has been known to be a feature in a family. As such, it would have been good practice, even without multi-agency meetings, for practitioners working with this family to make regular checks and have regular liaison with other agencies known to be involved with the family. There were many examples of where better communication between agencies would have enhanced professional understanding of this family; between CSC and OM1, between midwifery and health visiting and between GPs and CSC, for example, but clearly the most effective way of supporting good communication are opportunities for professionals to discuss, reflect and challenge views and perceptions within a multi-agency setting. It is well known that joint working results in a more proactive and integrated approach to the delivery of relevant and timely services for families where domestic abuse is a concern but this requires joined-up service provision and specific attention given to creating robust professional links between children’s and adults’ services in both statutory and voluntary sectors.  7.4.12 Effective multi-agency working is a significant challenge - just because it is a good idea does not make it happen naturally- it is time-consuming and can engender tensions and conflict between professionals. In this review each agency had their own source of information relating to FJ and MJ and there was insufficient collaboration so information was not shared in a purposeful way and the need for plans to address risk or secure the safety of the children did not emerge.  7.4.13 The lessons about agency involvement with the parents are not just about risk factors arising from the parents’ background and lifestyle; the lessons are also about the practitioners’ assessment of their parenting capacity. There was limited curiosity or understanding by professionals of the impact of the parents’ own experience of being parented and how this could impact on how they cared for their own children.  7.4.14 Greater priority should also have been given to collaboration and inter-agency working between the organisations providing services for adults (such as domestic violence, substance misuse, and mental illness) and those working with children. The Review Team concluded that the reason this did not happen was linked to the view that the couple were working with agencies and co-operating well and risks were considered minimal. In effect, professionals demonstrated a degree of over-optimism which, together with the couple’s disguised compliance, meant that potential risks in the family remained largely unexplored. As there were no perceived imperatives to collaborate or have recourse to multi-agency meetings, professionals continued to work in ‘silos’ and to their own agendas and the significance of FJ’s mental health and past behaviours, and MJ’s struggle to accept what was happening, were not seen in the context of risk to either Child SJ or to Baby J.  Hull SCR Baby J /Mar 2017 28 7.4.15 The evidence provided to the Munro review in 2011 found ‘mixed experiences and absence of consensus about how well professionals understand one another’s roles and work together’ and she argued for ‘thoughtfully designed local agreements between professionals about how best to communicate with each other about their work with a family...’ The Review Team concluded that so much more could have been achieved had there been better collaboration and a clearer understanding of how different agencies were working with both parents.  Finding 5: There was insufficient collaboration between agencies, and between children and adults’ services and the expertise of practitioners in specialist services was not used effectively to inform assessments, judgments, and plans. Without information being sought, shared, and analysed, agencies did not have a holistic picture of the family needs and vulnerabilities did not emerge.  7.5. ASP 3:  The response of CSC to referrals and contacts from partner agencies  There were three assessments undertaken by CSC during the period under review; an Initial Assessment was undertaken in October 2012 but the organisational context of locality duty arrangements meant that contact with the family between January and November 2013 lacked consistency and planning. Although the potential risks to Child SJ were recognised, and practitioners worked to ensure that there was contact with the family and Child SJ was seen on a regular basis, there was no child’s plan and no further assessment until the core assessment (1) in December 2013 for Child SJ, and the core assessment (2) for Baby J. Even though risks had been recognised, neither pregnancy led to a pre-birth assessment and, consequently, the risks posed from the parents’ own needs relating to drug and alcohol misuse, abuse FJ suffered during childhood and being a perpetrator/victim of domestic violence as an adult, were significantly underestimated. There were occasional contacts by CSC with other professionals, particularly the health visitor for Child SJ, but the absence of a multi-agency core group (until Jan 2014) or other framework for involvement meant that multi- agency assessment and planning was limited.   7.5.1. The Initial Assessment undertaken by DSW1 in October 2012, included contact with the hostels where MJ and FJ were living at the time, the probation service, DAP and the midwifery service. MJ was seen on one occasion and a telephone conversation took place with FJ to ascertain his views. The Review Team considered that, given the concerns highlighted by DAP, a meeting with FJ, rather than a telephone call, would have been expected practice, even accepting Initial Assessments were meant to be quick assessments of need. There are significant limitations in making any assessment only on a telephone conversation and there is considerable research, which stresses the importance of working with fathers as well as mothers in families. Whilst the Review Team acknowledged that FJ did occasionally talk with social workers, this was not in response to any specific or purposeful plan and, to this extent, there was no direct work undertaken with FJ to determine or assess his parenting abilities. 7.5.2. Significantly, FJ told the Reviewers that he believed that he wasn’t seen as an individual in his own right and professionals saw him as a potential perpetrator rather than as a parent. Although he admitted that there were occasions when he was hiding in a bedroom when social workers visited, he said this was because the couple were fearful of what would happen if social workers found out he and MJ were actually living together. FJ said that social workers were more interested in MJ …  ‘always MJ’   and never discussed with him issues about the care of Child SJ or Baby J. This limited engagement with FJ as a parent was acknowledged by practitioners and was thought to be influenced by the knowledge that he was ‘seen’ regularly by other workers  - OM1 and the key worker on the IDAP programme.   Hull SCR Baby J /Mar 2017 29 7.5.3. Although DSW1 did not meet FJ as part of the Initial Assessment, she nevertheless concluded that, due to the knowledge about his background and the heightened risk related to MJ’s (first) pregnancy, a ‘full Pre- Birth Assessment’37 was required. Pre-birth assessments differ from Initial Assessments in that key professionals are brought together from the outset so that potential risks can be explored from a multi-agency perspective and plans agreed. CSC procedures at the time stated that the criteria for undertaking pre-birth assessments included concerns about actual or potential domestic violence in the family use of drugs, or any parental issues, which could place an unborn baby at risk. These factors were identified by DSW1 in the initial assessment and the recommendation for a pre- birth assessment was both timely and appropriate.  7.5.4. Although the initial assessment was concluded in November 2012, with the recommendation for a pre-birth assessment, it was not until January 2013 that a decision was taken by the team manager to transfer the case to a locality team. The Review Team was informed that this was due to the volume of work and the organisational structures in place at the time, arrangements that were later replaced when a revised organisational structure was introduced in January 2014. 7.5.5. The decision to pass on the case to the locality team, although out of timescales, was appropriate. However, at the point of transfer, the language significantly shifted from the need for a ‘pre-birth assessment; to ‘further assessments’, and it is not clear from records whether the need for a ‘full pre-birth assessment’ was well understood, but the absence of such a timely assessment was a significant missed opportunity to gather and assess information from a multi-disciplinary perspective, especially in relation to the sharing of background information about FJ. When agencies are able to anticipate safeguarding risks for an unborn baby, such concerns should be addressed through a pre-birth assessment, the aim of which is to make sure that the risks are identified as early as possible, to take any action to protect the baby, and to support parents in caring for the baby safely.  7.5.6. It is important to highlight that midwifery services received notification from the CSC social worker based at the hospital in May 2013, informing them that a pre-birth assessment had been undertaken and providing details of the ‘child’s plan’. Whilst a challenge to not being involved in such a process would have been appropriate, the midwives nevertheless recorded this information on their records. The Review Team were unable to ascertain why the hospital social worker believed a pre-birth assessment had taken place and she was unable to recall the specific conversation or access any records related to it. It is possible that, upon being told about the ‘child’s plan’, the hospital social worker assumed that a pre-birth assessment had been undertaken. The long established systems of informal communication with health staff, which relies on the hospital social worker, appears  to  have provided the conditions for  this misunderstanding, which was exacerbated by the fact that knowledge of the family within children’s social care had been fragmented by the duty social work arrangements.  On this basis, the Review Team concluded that there could be benefit in exploring the role as it currently operates within the re-modelled health and social care systems to establish whether the role and function in relation to safeguarding processes and inter-agency communication is effective and well understood.                                                              37 A Pre Birth Risk Assessment is a formal process of multi-disciplinary collation, and analysis of information regarding the circumstances of an unborn child, which will identify the potential risks to the child following the birth   Hull SCR Baby J /Mar 2017 30 7.5.7. Further enquiries confirmed that the CSC duty arrangements in place at the time led to the need for a pre-birth assessment being overlooked, highlighting the importance of managerial oversight to check that actions and decisions are followed through, especially in times of transition if families in need are without a named social worker.  7.5.8. At that time, the role of the Central Duty team was to act as a single point of contact for referrals and to make an initial assessment of need only. The system was designed so that the workflow between the two teams was more rapid, with the locality teams having responsibility for the completion of more detailed assessments where these were required. However, the decision to transfer cases for ‘more detailed’ assessments led to a high volume of new cases in locality teams, not all of which could immediately be allocated to a named worker.  7.5.9. In order to manage this system as safely as possible, a management decision was taken to support some families through duty arrangements. In effect, this meant that for some families, visits were planned by a duty co-ordinator and allocated on a rota basis to duty social workers and/or community support team workers who then visited the family and reported on any emerging issues of concern or risk. It was acknowledged that this was not an ideal situation. Practitioners found the arrangements not only challenging, in terms of their impact on the development of meaningful relationships, but also anxiety- provoking, as they were not working to any specific plans or goal-related work. Not all practitioners were qualified social workers, and this added a further layer of challenge in terms of the confidence felt by some practitioners in relation to the complexity of the family’s needs. In terms of this review, there was further impact in that most practitioners had only minimal contact with the family and, without a comprehensive assessment of the family, the purpose of the visits was simply to check all was well and respond to any emerging issues.  7.5.10. Given the challenges of responding to increasingly higher numbers of referrals and significant capacity issues, these arrangements were an attempt by senior managers to safely manage challenges within the authority during a critical period. The Review Team was informed that data (about unallocated cases) was regularly collected and monitored at senior leadership level, but questioned to what extent decisions were informed by a sufficiently thorough analysis of risk given the length of time this family, for example, was without an allocated worker or a multi-agency plan.38.  7.5.11. The organisational context of the duty arrangements, however, meant that contact with the family lacked consistency and planning. Although some of the potential risks to Child SJ were recognised and there were attempts to ensure contact with the family, the absence of any child’s plan or multi-agency core group resulted in social workers visiting the family without any clear goals or multi- agency remit.   The use of written agreements  7.5.12. The decision taken in May 2013, that there would be no restrictions on FJ’s contact with his child when born, was in stark contrast to the CSC decision that FJ was not allowed contact with his son from his previous relationship. The Review Team was informed that, in relation to unborn Child SJ, there was no evidence that there was any domestic abuse by FJ towards MJ and she was living with                                                             38 These ‘holding’ arrangements were discontinued in January 2014 when  Social Work Pods were created; each led by a Consultant Social Worker who ensured that all cases were allocated to named workers  Hull SCR Baby J /Mar 2017 31 her parents who were seen as a supportive and protective influence and all parties had discussed and accepted a written agreement.  7.5.13. There is, however, little to evidence that this agreement was used constructively during any of the visits by duty workers, the only time the agreement was reviewed appears to have been in response to a challenge by both parents about their living arrangements. The agreement did not specify that the couple could not live together although this was the advice given to both adults then and on later visits. The agreement was forwarded appropriately to HV2, probation, and midwifery services but was not forwarded by probation to the women’s safety worker linked to the IDAP programme. This could, perhaps, have made MJ’s cooperation with the support worker more likely. This does highlight the importance of key professionals being kept well informed of the involvement of other agencies working with family members. 7.5.14. Planning and intervention in work with families is a core social work task, requiring a solid grasp about what needs to change and how to know whether progress is being made. The duty arrangements in place at the time, together with the absence of any plan, other than the written agreement, was undoubtedly a challenge for the different workers who visited the family and this clearly made it difficult for visiting workers to undertake any ‘change work’ with either parent. The use of written agreements was described as common practice in Hull at the time and they were used as a means of responding to ‘lower’ levels of concern by clarifying and stipulating the expectations of the local authority. The Review Team considered that the use of these ‘written agreements’ could too easily become practice that protects the agency rather than as part of a working plan aimed to protect children. Research39 suggests that such agreements or letters are ineffective in reducing domestic abuse incidents, may actually increase risks for some victims and, in themselves, do not keep children safe. In addition, more recent research40 suggests that there can be an over reliance on ‘working agreements ‘ and it can also create uncertainty for both parents and professionals if they lack rigour and clarity about what is expected and how this can be achieved. 7.5.15. The Review Team is aware that ‘written agreements’ in CSC were replaced at the end of  2013 by ‘Family Plans’ but are of the view that these are not significantly different from written agreements. The Review Team suggested the use of ‘safety plans’ for children would be more appropriate given these agreements are intended to manage threats to a child’s safety and rely upon a parent’s awareness and acknowledgement of these and their acceptance and willingness for the plan to be implemented.  Finding 6: Written agreements or family plans can be valid tools for helping a family to change, to solve problems and, in some cases, to remove the risks that would otherwise make the children unsafe at home. However, without a process by which an agreement is monitored and reviewed as part of a multi-agency plan, these ‘agreements’ do not, in themselves, constitute a plan or keep children safe but may give the impression of doing so.   7.5.16. There was a timely response by CSC to the referral from the hostel in July 2013 but there is no record of any liaison with other agencies or a consideration of a core group meeting, then or later                                                             39 NSPCC Children and Families experiencing Domestic Abuse  (2010) 40 Pathways to Harm op cit  Hull SCR Baby J /Mar 2017 32 when it became apparent that MJ had moved into her property and FJ was staying over ‘a couple of nights’ every week. The Probation service and the hostel were key agencies in terms of their relationship with FJ, and had knowledge not just of the risks he presented but also about his vulnerabilities but the absence of any multi-agency forum meant that this knowledge was not shared. The Review Team acknowledged the difficulties for the different CSC professionals to have oversight of the complexity of issues and see the family from a holistic viewpoint, but it is here where managerial oversight should have made a difference. The absence of not only multi-agency meetings but also of a working plan meant there was no focus or direction in work with the parents.  7.5.17. Partnership practice with parents and building relationships is an important part of the assessment process, as parents are often experts in what is happening in their family. However, as previously discussed, it is critical that professionals maintain a level of ‘healthy scepticism’ about what they are told. This is an active process of triangulating the information from different sources, and establishing whether there are discrepancies and what those discrepancies might mean for the child.  7.5.18. Fish41 suggests that professionals need to take active steps to work against ‘our human tendency to seek only the information that we wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on work with a family without question or challenge. She goes on to state  ‘one of the most common, problematic tendencies in human cognition ... is our failure to review judgments and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’ The Review Team concluded that there was evidence of such professional bias in both core assessments and, whilst it is possible that this was a result of the fragmented knowledge of the family due to the duty arrangements, the outcome was influenced by a lack of managerial oversight and challenge.  7.5.19. The decision to undertake the first core assessment in November 2013 was taken by TM3 almost a year after the initial assessment had been completed and was in response to a review/audit of cases as part of the implementation of the ‘pod’ model. The family were allocated a named social worker at the same time. When MJ’s second pregnancy was confirmed, a decision was taken to undertake a second core assessment in relation to unborn Baby J. The Review Team was unable to establish why this was not a pre-birth assessment.  7.5.20. Core assessments are in-depth assessments, which address the central or most important aspects of the needs of a child and the capacity of his or her parents or carers to respond appropriately to these needs within the wider family and community context. The core assessments completed by children’s social care were, therefore, key documents that defined and guided the work of children’s services. As key tools, these should have provided a structured framework for children’s social care to record information gathered from a variety of sources to provide evidence for their professional judgments, facilitate analysis, decision making and safety planning. Although the Review Team were informed that risk issues were discussed in supervision, these were not articulated in either of the core assessments.                                                              41 SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews  Hull SCR Baby J /Mar 2017 33 7.5.21. The two assessments were, not surprisingly, similar in content and had a significant degree of repetition. MJ was described as a mature young woman well able to protect her children and this, together with FJ’s attendance at IDAP, were regarded as strengths within the family. The risks of domestic abuse were referenced only in relation to FJ’s previous relationship; there was no reference to drug or alcohol issues or any reference to the mental health of either parent. When Child SJ was born, MJ was living with her parents and was considered to have a significant level of support.  Whilst practitioners acknowledged this support in the early months of Child SJ’s life, it was also clearly evident that there were tensions within the family and the grandparents expressed their concern about the couple actually living together but this was not explored at all.  7.5.22. In contrast to the strengths identified, MJ was described as minimising FJ’s previous behaviour, but again this was not explored, nor is there any consideration of the fact that MJ did not engage with the women’s safety worker as part of IDAP, which had been a requirement of the original written agreement. The assessments, in this respect, focussed on the very recent period of involvement by CSC and there was minimal reference to background history or any evidence on which to make a confident assessment of change/risk reduction.  7.5.23. There was no contact with any worker or agency involved with SS, FJ’s previous partner, and no reference to any information which explained why FJ was ‘not allowed’ to see the child of that relationship. Probation records simply stated that CSC would ‘not permit child contact’. The Review Team was curious about why there was not greater effort by CSC to find out more from colleagues in their own agency about what had happened between SS and FJ and why FJ was not permitted any contact with his child from that relationship but no further information or explanations came to light during conversations with practitioners. This suggested evidence of professional ‘availability bias’ in which a decision maker relies upon knowledge that is readily available rather than examine other alternatives or explanations.  7.5.24. Telephone contact was made with the probation service at the end of January 2014 in relation to the assessment. However, that service was not invited to provide a written contribution to the assessment, which would have been good practice given the weight attached to FJ’s engagement in the IDAP programme. The information given by FJ about the outcome of a court appearance in January 2014, following an altercation with his brother in 2013, could have been helpfully discussed with the probation service. FJ received a restraining order and a 24-hour training course in respect of drugs and alcohol, but this issue was also not explored or acknowledged, despite the original referral in October 2012 stating that FJ’s behaviour was thought to be more violent when he was under the influence of drugs. This risk factor should have been considered in depth.  7.5.25. The completion of the first core assessment led to the decision to convene a core group. Whilst acknowledging the importance of multi-agency meetings, the Review Team was of the view that the convening of this meeting appeared to be more in response to the need to close the case rather than an attempt to plan for a child  in need. The first core group meeting was held in early February and was attended by DSW9, the parents, and HV3. FJ’s offender manager, although invited, could not attend, yet given the contact this professional had with FJ, her attendance at the meeting was crucial. There is no evidence to suggest any consideration was given to inviting midwifery services or the women’s safety worker who had been trying to engage MJ.   Hull SCR Baby J /Mar 2017 34 7.5.26.  The GPs for both parents were not invited to the meeting and neither were they asked to contribute any information, yet both had specific information relating to the mental health of the parents and this could have had a bearing on the decision taken to close the case. The Review Team recognised that the timing of such meetings can be problematic for GPs but are of the view that their contributions are immensely important and should always be sought as a matter of good practice.  7.5.27. FJ, DSW9, the health visitor, and the probation officer attended the second core group meeting 6 weeks later. MJ did not attend. Again, neither the GPs nor midwifery services were invited, despite MJ’s current pregnancy. Notes from the meeting indicate that FJ’s engagement with IDAP was positive and there were no concerns about the care and development of Child SJ. An agreement was reached by all agencies that CSC should close the case, pending the outcome of FJ attending the police station in respect of the incident in the street involving his brother’s girlfriend.  7.5.28. It is important to understand the context in which this decision was made. As far as the core group were concerned, there had been no reported incidents of any physical violence between the couple and both parents were considered to be working with agencies as per the written agreement made in May 2013, despite the fact that the ‘agreement’ was not actually used as an ongoing contract. There were no concerns about the care and development of Child SJ who was reported to be progressing well. The core group was not, however, in possession of all the relevant information, partly because, as already outlined, key professionals were not invited to attend or to contribute to the meeting and partly because the core group did not ask themselves whether they were in receipt of enough information to make an informed decision about the level of risk in the family.   7.5.29. Munro’s research suggests that professionals need to take active steps to work against “our human tendency to seek only the information that we wish to find”, and confirms the dangers of a tendency to “stick to what we think we know” and carry on with plans without question or challenge. Munro argues that professionals should always take time to step back and question the assumptions, which underpin actions and decision-making, a form of reflection she describes as  ‘double loop learning‘, although creating the ‘space’ for this is easier said than done, and relies upon access to good quality, consistent ‘reflective supervision’ and ‘reflective case discussion’. 7.5.30.  The Review Team considered that the  ‘reflective discussion’ which took place in CSC in early March would certainly have benefited from a more critical and challenging analysis of the actual and potential risks in this family and  a consideration of how the birth of the baby later in the year could impact on relationships in the family. Importantly, although FJ was just completing the IDAP programme, it had been identified that further work was needed and was to be undertaken with the offender manager.  7.5.31. This ‘further’ work is significant and should have been carefully considered when making the decision to withdraw services from the family, especially given that MJ was pregnant. The notes from the core group would suggest a degree of minimisation about the work FJ was required to undertake. It was said, and accepted, that ‘no-one comes away (from IDAP) with no recommendations’. The work was, however, to address three specific areas: Victim awareness: – for FJ to recognise that actions have consequences and to increase his awareness of the impact of these on the individual and the wider community; Victim empathy: look at things from a different perspective, to include looking at the triggers to his behaviour and how he can better respond in  Hull SCR Baby J /Mar 2017 35 the future and finally, Victim safety: to develop his understanding of the harm he can cause to others if confronted and the impact this can have on himself and to others around him. There was no discussion in the core group as to whether the assessed need for this additional work had a bearing upon FJ’s role as a father or how it could impact on his relationship with his pregnant partner. 7.5.32. CSC closed the case in early April 2014 without confirming the detail of the incident with police, but relying on FJ self-reporting that the incident was closed. Had contact been made directly with the police, CSC may have been alerted to the abandoned 999 call which came from the couple’s home address earlier that month. According to police records, this was forwarded to CSC via the ‘domestic violence form’ but there was no record of this abandoned call on CSC files and it was not, therefore, considered at the core group meeting held in March 2014. No arrangements were made to ‘step down’ support from CSC to targeted services, which, given that MJ was pregnant, would have been appropriate. The Review Team was informed that the early help services at that time were in the early stages of development and were not at that time being used ‘as expected.’ 7.5.33. The contact by DAP with the Access and Assessment Team on 5th August 2014 was triggered by MJ herself who had attended the DAP offices to ask that all references to her being a victim be removed from records. This information was shared with CSC but was recorded as ‘information sharing’ only. Whilst there was reference to the three reports to the police from neighbours about verbal arguments at the family home, it also indicates that the police had not referred these incidents to DAP under the domestic violence information sharing arrangements. This appears to have influenced the decision that there was no role for CSC, despite MJ’s current pregnancy.  Finding 7: Assessments underpinned by good analysis and shared critical thinking support better decision–making, but this requires access to integrated chronologies and full social histories. Without these, professionals are more likely to base their decision-making on ‘here and now’ observations which do not include a thorough analysis of past behaviours and actual/potential capacity for change.  7.6. ASP 4:  The response by agencies in Hull to incidents of domestic abuse  Hester (2011)42 uses the term ‘planets’ to describe the very different and separate professional and practice worlds of those involved in domestic abuse work. Whilst practitioners from  the hostel were highly concerned about FJ’s behaviours, these were not seen in the same light by health and social care professionals or, indeed, by probation and police. Agencies clearly have different priorities shaping their work with families, and when there are a number of agencies involved, careful co-ordination and joined up working is required to ensure that the safety needs of children are being met and risks are being identified and addressed. However, the monitoring of known high risk domestic abuse perpetrators, if they have a history of perpetrating domestic abuse in more than one intimate relationship, is extremely important in terms of understanding patterns of previous behaviour and how this can impact on current risk factors. The approach to domestic abuse in this family was incident based and, consequently, the repeating pattern of coercive control was not recognised.                                                              42 British Journal of Social Work Volume 41 Issue 5.   Hull SCR Baby J /Mar 2017 36 7.6.1. Evidence from serious case reviews continues to highlight domestic abuse as a characteristic in families where children die or are subject to a serious incident. Of the many risk factors identified in the backgrounds of parents, the most prominent in these reviews is the ongoing risk posed by situations of domestic abuse and the risks to children under the age of 5 and, particularly, those under one. 7.6.2. Police responded to seven separate ‘domestic abuse incidents’ during the 14 months prior to the death of Baby J. On each occasion, the attending officers completed a risk assessment based on that specific incident, some of which were recorded as a ‘verbal argument’ between the adults. The incident details and the risk assessment were recorded on the Force’s DA form and submitted to the DA unit in line with force policy. All of the incidents were graded as ‘standard’ risk.   7.6.3. Only one of the domestic abuse incidents (March 2014) was shared with CSC prior to the death of Baby J; however, CSC have no record of this incident. The domestic abuse incident in September 2014 was not shared until after the death of Baby J. CSC should have been notified of all of the domestic abuse incidents, due to the age of Child SJ and the fact that MJ was noted at these incidents to be pregnant. The information sharing policy in place at the time required the Police DA team to send a summary and risk assessment via email to CSC for review and appropriate action.    7.6.4. The response of CSC to information from the hostel or the police when informed about these incidents usually led to a visit by a duty officer, but these were also dealt with on an incident-by-incident basis and, therefore, the ongoing controlling nature of FJ’s behaviour was not recognised. This, alongside the absence of any multi-agency working, militated against a more complete, shared understanding of risks being built up over time. 7.6.5. Working within an incident-focused model carries the risk of harm to children continuing unabated for long periods, and ignores the huge damage that will already have been done to victims by the time any action is taken. As Stark (2007) comments, ‘A growing consensus favours intervention in relationships where there is extreme violence, stalking, or an injury to a child. But by the time abuse reaches this point, coercive control is likely to have severely eroded a woman’s personhood from the inside out, the way carpenter ants devour a house.’ Research suggests that assessments can too easily focus on the immediate or presenting issue while failing to consider the case history. Incidents need to be considered in context; concerns need to be connected in order to build up a fuller picture of what might be happening in a child’s life. There was little to evidence in this review that police or CSC, in response to reported domestic abuse incidents, took time to carefully sift through the family’s case history, a process that is integral to any assessment process.  7.6.6. Humberside Police introduced secondary risk assessments following SPECCS and DASH Assessments to support better decision-making around incidents of domestic abuse. These secondary risk assessments were completed by domestic abuse co-ordinators (police officers and/or police staff) who had undertaken additional training in risk assessing in order to undertake the role. The process involved the domestic abuse co-ordinator undertaking a review of the incident that had occurred as well as reviewing any previous domestic abuse history in the relationship and providing an overall risk assessment on the case.   7.6.7. Over time, this process of secondary risk assessing each case created substantial backlogs in the number of domestic abuse cases that, firstly, needed to be implemented onto police systems and  Hull SCR Baby J /Mar 2017 37 then, secondly, made subject to a secondary risk assessment. In order to address this backlog, a number of temporary solutions were put in place including the decision not to undertake secondary risk assessments on incidents that had initially been risk assessed by the attending officer as ‘standard’. The outcome of this decision led to cases being entered onto the police system with no overall review of the domestic violence situation, increasing risk levels and the need to share information with partner agencies. To provide some context, there are nearly 16,000 domestic violence incidents per year across the Force area, all of which required manually inputting onto police systems.  7.6.8. The temporary solution described above has, subsequently, been reviewed and additional safeguards and improvements made. All frontline police officers have recently received domestic abuse training and staff inputting cases onto the police systems have received awareness training to enable them to raise any concerns with a domestic abuse coordinator. There is a triage system in place which ensures that all domestic abuse incidents which involve households with children or where there is a pregnant woman, are immediately notified to children’s social care, irrespective of their assessed ‘risk level’. An information sharing agreement is also in place with City Health Care Partnership for those cases where young children are living in the household or the female is pregnant.  Secondary risk assessments are still undertaken, and the backlog has reduced, but this process does not delay information sharing. Nevertheless, despite these strengthened arrangements, the Board needs to assure itself that the multi-agency capacity is in place to consider the history, circumstances and nature of the abusive incident, to identify patterns and ensure that current and future risks are not overlooked.  7.6.9. Given the prevalence of domestic abuse in Hull and other cities, it is likely that one of the largest cohorts of children requiring early help will be those experiencing and witnessing domestic abuse. The role and remit of LSCBs has been expanded to ensure the effectiveness of early help for children and the LSCB has been assured that the new Early Help and Safeguarding Hub in Hull will benefit families in these situations by drawing in more elements and facilitating purposeful meetings with significant practitioners/agencies.  7.6.10. The learning from this review, however, highlights the need for a step-change in terms of how professionals, agencies, and society as a whole understand and respond to domestic abuse. There needs to be a move away from incident-based models of intervention to a deeper understanding of the ongoing nature of coercive control and its impact on women and children. Whilst there is substantial research43 to back up such a shift, the challenge should not be underestimated and it remains the responsibility of all agencies to ensure that professionals continue to respond to evidence of domestic abuse and not leave it to potentially vulnerable victims to act for their own or their children’s protection.  Finding 8: Clarity of terms and definitions in relation to the recognition and assessment of risk in domestic abuse situations is required to support effective multi-agency safeguarding processes. The language and definitions used around risk in domestic abuse situations can determine processes and outcomes and impact on decisions to act or not to act. This can leave some families without access to effective help.                                                             43 Domestic Abuse and Safeguarding Children: Focus, Response and Intervention. Cathy Humphreys and  Caroline Bradbury Jones 2015 ,   Hull SCR Baby J /Mar 2017 38  Finding 9 Where the systems in place for the assessment and reporting of domestic incidents are under such considerable pressure, there are consequent and predictable issues around oversight and consistency and these create increased opportunities for human error.   7.7. Additional Areas of Learning:  7.7.1. The police and CSC were not the only agencies experiencing structural changes during the period under review. In April 2014, FJ’s case was transferred as part of a bulk transfer of cases from Humberside Probation Trust to the Community Rehabilitation Company, as the Probation Trust was being spilt into two separate agencies – The National Probation Service and the Community Rehabilitation Company (CRC). The management of FJ was, consequently, transferred from OM1 to a new offender manager (OM2). At this point, case management responsibilities of FJ transferred between offender managers, a full case handover meeting should have taken place but this did not happen. Such a meeting would have fully appraised the new offender manager of areas of risks including those related to re-offending and safeguarding concerns and would have confirmed the outstanding interventions that needed to be undertaken with FJ.  7.7.2. The Review Team was told that the staffing restructure and subsequent significant caseload reassignment process meant that the need for this handover meeting was overlooked. There is certainly very little evidence to suggest any of the required work   with FJ was undertaken after he had completed the IDAP programme; the focus of supervision was on his welfare and social issues. At times of such significant change it is especially important that there is good communication between colleagues in order to fully ensure no issues or actions are overlooked. It would have been useful, for example, in the absence of such a meeting for OM2 to undertake and record an administrative review of the case and risk issues involved.  Finding 10: When organisations undergo structural changes, safeguarding agencies need to be alert to the risks that transitions can have on decision-making and professional practice. Without strong managerial oversight, the risks posed to some children and families may be overlooked.        Hull SCR Baby J /Mar 2017 39 Appendix 1 Findings and Issues for Hull Safeguarding Children Board The findings from this review have been grouped under 6 themes. Progress and developments since the period under review are included in Appendix 2.   Using tools to assess risk and inform quality assessments   Finding 3: The reliability of practitioners’ judgments concerning the assessment of risk and harm could be improved. Judgments based on experience and intuitive thinking should be supported but not replaced by information  collected and analysed through  evidence-based tools and standardised measures to inform structured professional  decision- making.  Finding 6: Written agreements or family plans can be valid tools for helping a family to change, to solve problems and in some cases to remove the risks that would otherwise make the children unsafe at home. However, without a process by which an agreement is monitored and reviewed and shared with other agencies, these ‘plans’ do not in themselves keep children safe but may give the impression of doing so.   Finding 7:  Assessments which do not include a full social history and detailed chronologies make it difficult to support critical and analytical thinking, and, consequently, professionals are more likely to base their decision-making on ‘here and now’ observations which do not include a thorough analysis of past behaviours and actual/potential capacity for change.    Issues for the Board   a) How can the Board address the issue of the use of ‘risk assessment tools’ in relation to domestic abuse to achieve a better understanding of risk and a shared ‘common language’? Which agencies should use which tools? b) How can the Board be assured that practice in the use of ‘family plans’ has been strengthened, so that their use is more effective as a clear, explicit and shared ‘safety plan’ for children, which is monitored and reviewed?   Hull SCR Baby J /Mar 2017 40  Recognising and understanding domestic abuse in all its forms   Finding 1: Without a clear system for linking MARAC assessments to police call-outs and family work, the risks posed by perpetrators of domestic abuse may not be well understood.   Finding 2: Coercive control is subtle, circumstantial, and highly nuanced; professionals are more likely to recognise controlling and coercive behaviours as domestic abuse, where there are good records, succinct chronologies and opportunities to share and analyse information and concerns.     Issues for the Board   a) How well do practitioners in Hull have a shared understanding about risk and the impact on children and unborn babies in domestic abuse situations?  b) How does this understanding extend beyond a recognition of ‘violence’ to an understanding of coercive control? c) How can the Board help to facilitate a better shared understanding about the role and impact of ‘behaviour change’ programmes in reducing the risk to women and children from domestic abuse?  Hull SCR Baby J /Mar 2017 41  Working with parents where there are concerns about domestic abuse  Finding 4:  A range of safety measures are required to protect children in families where domestic abuse is a concern but a reliance on the physical separation of family members or perpetrator change programmes, in the absence of a wider multi agency plan, may leave children vulnerable and without effective help. There are also particular challenges for professionals where women deny or are unable to accept the risks posed to their children from their partners and this requires persistent ongoing work in relation to safety planning for all parties.    Issues for the Board  a) How are practitioners supported to work effectively with men where domestic abuse is known or suspected? b) Is the Board confident that the strategy for meeting the needs of children living in families where domestic abuse occurs but which fail to meet the threshold for statutory intervention is robust and effective? c) There are a growing number of SCRs published nationally which relate to the death or injury of young babies from abusive head traumas. Has the Board considered how it might address this issue, both in term of prevention and improved understanding by professionals, about the triggers which can lead to such injuries?  Hull SCR Baby J /Mar 2017 42  Supervision and Managerial oversight  Finding 9 Where the systems in place for the assessment and reporting of domestic incidents are under such considerable pressure, there are consequent and predictable issues around oversight and consistency and increased opportunities for flawed decision-making.   Finding 10: When organisations undergo structural changes, safeguarding agencies need to be alert to the risks that transitions can have on decision-making and professional practice. Without strong managerial oversight, the risks posed to some children and families may be overlooked.     Issues for the Board  a) Within agencies, how do we ensure that opportunities for ‘reflection’ are a consistent feature of work with children and families?  b) Is the Board confident that the quality of initial police assessment of domestic abuse reports is improving? c) Are the police systems for ‘triage’ and secondary risk assessment stronger now? d) How is the Board assured that agencies routinely and randomly quality assure the quality of assessments and the learning from this activity is fed back to the Board?   Hull SCR Baby J /Mar 2017 43 Working collaboratively in a multi-agency context  Finding 5: There was insufficient collaboration between agencies, and between children and adults’ services and the expertise of practitioners in specialist services was not used effectively to inform assessments, judgments, and plans. Without opportunities to share information across agencies, a holistic picture of the family needs and vulnerabilities did not emerge  Finding 8: Clarity of terms and definitions in relation to the recognition and assessment of risk in domestic abuse situations is required to support effective multi agency safeguarding processes. The language and definitions used around risk in domestic abuse situations can determine processes and outcomes and impact on decisions to act or not to act. This can leave some families without access to effective help.  Issues for the Board a) Is the Board confident that the arrangements for multi-agency consideration of ‘standard’ risk domestic abuse incidents ensure that history and patterns (chronologies) are properly considered? b) How does the Board ensure opportunities for reflection in a multi-agency context? c) Is the Board confident that local systems do not militate against an ‘incident-focused approach’ to domestic abuse? d) Are there any mechanisms the Board can strengthen or put in place   to build better teamwork across disciplines so that keeping children safe is always “everyone’s business”?    Hull SCR Baby J /Mar 2017 44 Wider Implications   Finding 8 Where the systems in place for the assessment and reporting of domestic incidents are under such considerable pressure, there are consequent and predictable issues around oversight and consistency and these create increased opportunities for human error.   Finding 9: When organisations undergo structural changes, safeguarding agencies need to be alert to the risks that transitions can have on decision-making and professional practice and without strong managerial oversight, the risks posed to some children and families may be overlooked.    Issue for the Board to consider   a) Where key agencies are undergoing significant organisational change, how does the Board ensure that risks to existing safeguarding practices and processes have been assessed and are being managed? b) Is the Board confident that Hull’s Domestic Abuse Strategy has emerged following a thorough and deep analysis of both the external environment and the internal capacities of key agencies?  c) What actions does the Board take to ensure that the wider issues around domestic abuse are raised beyond the safeguarding community?     End/  Hull SCR Baby J /Mar 2017 45 Appendix 2   Actions identified in Agency Learning Reports    City Health Care Partnership CIC   1. To ensure all CHCP staff are aware of the importance of sharing information regarding Domestic Abuse.  2. Improvement of the process of record keeping and assessment to be undertaken following receipt of DV 913 forms.   Hull Children’s Social Care  1. Working group will be established to review guidance on the use of Family Plans specifically in relation to the work of the Early Help and Safeguarding Hub. 2. Audit of sample of Family Plans will be undertaken between May and July 2016. 3. The views of men are clearly reflected in social care assessments together with analysis of their strengths and any risks identified in relation to their role in family life.   4. The Systemic Leadership Team will clarify next steps /agency policy in relation to current model and practice for individual supervision.  5. Reports to be made available to managers in relation to the proportion of cases subject to Reflective Pod discussions. 6. Review of CSW development programme, to include content on systemic supervision. 7. Review to assess opportunities for the rollout of training session on systemic supervision for all CSWs, Team managers, and other managers.  Hull & East Yorkshire Hospital NHS Trust  1. Increase awareness of the referral process to CSC to all midwives and ensure the process is utilized correctly.  2. Midwives to become more confident in having difficult conversations.  3. Postnatal care and record keeping to be consolidated.  4. Routine enquiries guidance will be amended to include information about who attended with woman at appointment.  Humber Foundation NHS TRUST  1. All practitioners working with families in MH assessment services to undertake advanced SG Children training in line with intercollegiate document. 2. Safeguarding Supervision model to be rolled out into MH assessment services to ensure staff work in a “think family” way and can access appropriate safeguarding supervision. 3. HFT will deliver the planned 2016/17 refresh ‘Think Family’ campaign across the Trust. 4. Adult MH Caregroup will provide updates on access to anger management programmes.  Hull SCR Baby J /Mar 2017 46 5. All staff undertaking mental health assessments within the police custody suite will communicate the relevant findings from the assessment to appropriate partner agency practitioners. 6. In the delivery of the refreshed `Think Family` campaign, a bespoke IG package will be delivered focussed on information sharing. This will reinforce the data-sharing concordat.  Humberside Police  1. A pilot has been introduced within Hull for the sharing of domestic violence incidents with health and, if successful, this will be rolled out across the force area.  CRC Probation Service  1.  A greater inter-agency understanding of the purpose, content, and outcomes (potential and actual) of domestic abuse programmes, and the need for post programme consolidation learning.  2. Improved evidence of liaison and joint working with children’s social care, and improved awareness of and confidence to use the LSCB escalation process.  3. Improved evidence of inter-agency communications and collaborative working.  NHS Hull Clinical Commissioning Group (CCG)  [GP Practice] No actions identified    Hostel   1.  To develop strengthened working relationships with other agencies and to make better use of the LSCB escalation process to resolve professional differences.         Hull SCR Baby J /Mar 2017 47 Appendix 3   Developments in Agencies since the period under review  1. Children’s Social Care:   a) In January 2014, children’s social care implemented a new model for the delivery of social work services in Hull. b) Increase in the staffing of the Access and Assessment Team in recognition of the high volume of contacts made with children’s social care. c) A new children’s social care single assessment was introduced at the same to replace the Initial and Core Assessments referred to in this review.  d) There is improved managerial oversight in place following an increase in staffing levels.  e) Regular reports of those cases with a child’s plan in place are now available to managers, with the most recent report (April 2017) showing only a very small number of children without a current plan.  f) There is an Early Help Hub based in each locality, which works alongside three early help social workers in the Access and Assessment Team, to offer a range of support and interventions to those children and families who do not meet the threshold for referral to children’s social care.  g) An Early Help and Safeguarding consultant social worker has been appointed to provide additional safeguarding support and oversight to early help arrangements.  h) The ‘Strengthening Families’ approach has been adopted in Hull. This is an inclusive evidence-based parenting programme, designed to promote protective factors which are associated with good parenting and better outcomes for children. i) The Early Help and Safeguarding Hub is due to ‘go live’ in June. This will enhance information sharing at every level, including early help. j) The role of the hospital social worker has been reviewed and is now based within the Access and Assessment Team with clearer arrangements for management support and oversight. k) CSC has commissioned a replacement ICS system (Liquidlogic) which will ‘go live’ before the end of May 2017: this will facilitate better storing, organisation and sharing of information and create a direct information link between CSC and early help. l) Quality audits (as part of the Board’s joint evaluation of cases) have shown mostly good quality social work assessments, which have shown good evidence of direct engagement with men, good joint working and effective core groups.  2. Police Service  a) The Force’s policy in relation to the sharing of domestic violence incidents with children’s social care has been updated (May 2015 & July 2015).  b) Further work has been undertaken with  the local authority in relation to sharing of domestic violence incidents that do not meet a safeguarding threshold but require intervention by early help and a process for these referrals in now in place (July 2015).   Hull SCR Baby J /Mar 2017 48 c) A pilot was introduced within Hull for the sharing of domestic violence incidents with the health community. This is now embedded. d) Since February 2015, Humberside Police have provided a further training programme for all front line police staff and supervisors across Communities, Operations and Specialist Commands. ‘Domestic Abuse Matters’ was delivered by external trainers and included a bespoke focus on coercive control. (Humberside Police has subsequently had a successful ‘victimless’ prosecution using the new law on coercive control) e) The current Domestic Violence Form (F913) is in the process of being amended. The new version of the form will ask attending officers to record whether a child has been seen and spoken to, including the demeanour of the child in relation to the incident.   f) The Force has introduced a dedicated team within its Incident Handling Centre, led by an Inspector. This team is responsible for reviewing incident logs where a potential safeguarding need is identified. The team undertakes relevant checks of police and partner agency systems, records these within an incident log and so ensures that officers attending incidents have up-to-date safeguarding information to inform their decision-making. g) All domestic abuse incidents are reviewed by a supervisor. This includes 913 forms and the rationale for risk classification made by the attending officer. ‘High’ risk cases are quickly identified and appropriate safeguarding action taken. Cases involving children in households are identified, leading to early notification of partners. h) A recent audit of ‘medium risk’ assessed DA cases showed that the strengthened triage process is now more robust. i) Humberside Police has taken a lead role in developing the EHaSH (Early Help and Safeguarding Hub) in Hull. This is due to ‘go live’ in June 2017. j) The force is one of three taking part in a national pilot of a revised DASH assessment tool. This is being led by the College of Policing and will report in the autumn of 2017. k) The force is implementing a new IT system – CONNECT – in June 2017. This will allow direct inputting of DA incidents and will enable DA specialist staff more time to focus on triage, secondary risk assessment and domestic violence prevention notices. l) The force is making increased use of safeguarding mechanisms (disclosure) under Clare’s Law. m) Improved processes are in place which identify (highlight) any repeat domestic abuse incidents – this allows for better recognition of patterns.    3. CRC Probation Service a) An Integrated Quality Assurance Model (IQAM) has been operating within the CRC since Sept 2014. This has recently been updated and remodelled. Safeguarding is a ‘thread’ that runs throughout the audit tool. The first full audit (using the new model) took place in April 2017 with outcomes expected shortly. IQAM audits will take place quarterly and will inform improvement plans. b) A guidance document has been provided to all staff which includes information on quality indicators across all phases of offender management. c) All Hull-based CRC staff have completed (HSCB) refresher level 1 safeguarding children training within the last 6 months.  Hull SCR Baby J /Mar 2017 49 d) An update to BBR (‘Building better relationships’ which has replaced IDAP) post-programme reports will be completed by end June 2017. This includes guidance to programme staff in respect of how success and outcomes are measured. e) Guidance for non-probation practitioners about BBR, what is aims to achieve, how it works, what ‘success’ looks like and what that means in terms of risk management will be completed by end of June 2017.     4. Hull and East Yorkshire Hospitals   a) A new electronic referral process (referrals to CSC) in line with the new Strengthening Families approach, commenced in February 2016 and has improved communication between agencies. b) The guideline for ‘Supporting Women with Complex Social Needs’ has been developed (2016) This includes assessment for risk factors and vulnerabilities at booking, during pregnancy at 16 and 32 weeks, and post-natally prior to discharge from maternity services.  c) Midwives are using the locally developed ‘vulnerability toolkit’ and the developed pre-birth vulnerability pathway. d) All midwives were informed of the new processes in 2016 and this is reinforced on ‘caring for vulnerable women’ training and other mandatory training.  e) Guidelines have been strengthened to ensure that when midwives receive new or changed information this is always reported to the health visitor. f) Systems for regularly updating contact lists have been designed so all staff working with women have easier access to community contacts. This includes improved links with housing and hostels. g) A tracking system is now in place to ensure that midwives have access to key information in maternity records prior to antenatal and postnatal appointments. This also enables midwives to more easily identify women who are not attending during the post-natal period, to better facilitate timely and appropriate follow-up. h) The induction process for new midwives has been strengthened and includes safeguarding session with the Named Midwife, ensuring that new midwives have knowledge of the trust’s safeguarding processes and how to access safeguarding supervision and support. i)  Antenatal day unit paperwork has been revised to offer more support to midwives asking routine questions about domestic abuse. The most recent routine enquiry audit showed 95% compliance.  j) A new system has also been introduced which offers women the opportunity to alert midwives if they wish to talk about domestic abuse.   5. Humber Foundation NHS Trust  a) A process of assessments of the practitioner is now in place.  Hull SCR Baby J /Mar 2017 50 b) Progress has been made in ensuring that all practitioners working with families in mental health assessment services undertake advanced safeguarding children training. c) HFT delivered a refresh ‘Think Family’ campaign across the trust in 2016/17. d) Processes are in place to ensure that the findings from mental health assessments in police custody are communicated to appropriate partner agency staff.  e) A revised safeguarding supervision model has been rolled out into mental health services to ensure that staff are working to a “think family” model.     6. City Health Care Partnership CIC (CHCP)  a) CHCP acts as the ‘single point of contact’ for Police domestic abuse (913) forms for the local health community. This was established on a pilot basis initially and has now been embedded b) An audit of 913 DV213 forms was undertaken and this had led to improved systems for circulating this information to the wider health community. c) A second audit has been completed leading to further improvements. d) The system is now firmly embedded. 913 (domestic abuse) reports are now circulated to all relevant staff in CHCP, as well as GP’s, midwifery services and staff in Humber NHS Trust within 48 hours of receipt. e) In 2016, all family nurse practitioners received DASH training. The training evaluated very well. This has led to referral (using DASH) to MARAC from FNP. f) There is a planned roll-out of DASH training to all health visitors and school nurses. Six dates have been established for this. g) All staff working in (CHCP) children’s services, including minor injuries units and sexual health services, have received ‘routine enquiry’ training, which is refreshed every three years.  7. The Hostel  a) These issues have been discussed at staff meetings with an agreement to ensure staff coordinate and work alongside statutory and other agencies to ensure appropriate information is shared and is a two-way process. b) Other agencies have been invited to staff meetings on a regular basis to share information about their respective agencies and to discuss partnership working. The Hostel Manager has also attended a CSC management meeting to give a presentation about the work of the hostel and working in partnership.  c) The hostel is now more confident in calling, and in some cases chairing, multi-agency meetings.     8. Hull Safeguarding Children Board a) Held a ‘deep dive’ day for the full Board in July 2016 in order to explore current issues and extent of domestic abuse in Hull and the impact on children. This included consideration of  Hull SCR Baby J /Mar 2017 51 the emerging learning from this SCR and others, locally and nationally, an audit of cases involving practitioners and a review of MARAC. b) Revisited ‘domestic abuse’ at the Board day in March 2017 to assess improvement. c) Influenced the establishment of a new cross-partnership strategic steering group on domestic abuse, with a focus on developing new approaches in tackling the issue locally, given the continuing rise in incidence. d) Continues to provide domestic abuse training to all partners, including a two-day course which was provided on nine occasions in 2016/17 and new training on routine enquiry to Children’s Centre staff. e) Developed, launched and implemented a pre-birth vulnerability pathway to strengthen joint work where potential risk is identified to unborn babies. f) Has had continual oversight of the developments in early help and progress towards implementing the Early Help and Safeguarding Hub (now due to ‘go live’ in June 2017. g) Reviewed arrangements at the ‘front door’ (of CSC) and early help at the Board day in November 2016. h) Used domestic abuse as the theme for the joint evaluation (multi-agency audit) of cases between January – March 2017 and provided a summary of learning to the Board in March 2017. i) Has influenced the wider use of DASH across the partnership – FNP have been trained and are using the tool; briefings have been provided for social workers, with more planned; health visitors and school nurses are being trained in 2017. j) Has agreed a ‘whole partnership’ review of domestic abuse training to commence in June 2017. k) Is leading on work across the partnership on ‘engaging men and fathers’ in work with families at all levels and contexts. This includes a focus on engaging men who are known to be violent.  