Death of a 20-month-old girl in December 2019, caused by a combination of starvation and influenza, after being left alone for six days. Learning themes include: decisions about assessment of risk and safety planning; the child's lived experience; the impact of housing need within assessments; the impact of a young parent being not in education, employment or training (NEET); significance of family history and the impact of trauma and exploitation on an adolescent parent; adultification of an adolescent parent; and issues around facilitating a child focused service for children of parents who are looked after children or care leavers. Recommendations to the Partnership include: review assessment guidance so that holistic multi-agency assessments take place prior to making significant changes to a child's plan, except when emergency action is required, and include an explicit section to address risks and any necessary risk management plan; assessments of adolescent parents should always include a specific focus on the child's vulnerable child, especially if they do not have their own social worker; assessments should include all family members who will be involved with child-care; ensure staff are aware of the allocations policy enabling senior managers within children's social care to nominate a family for housing transfers when there is a need to keep a family together; consider practitioners training needs on the long-term impacts of trauma for children; clarify which social worker is the lead professional when there are different social workers in a family; consider what systems need to be in place to meet the needs of children NEET; and the local authority should address the range of potential accommodation needs for young parents to be able to provide a range of support provision.
      
 Title:  Local child safeguarding practice review: Child Delta. LSCB: Brighton and Hove Safeguarding Children Partnership Author: Edina Carmi Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1    Brighton & Hove  Safeguarding Children Partnership   LOCAL CHILD SAFEGUARDING PRACTICE REVIEW  CHILD DELTA   Independent Reviewer: Edina Carmi     02.11.22   This report is strictly confidential and must not be disclosed to third parties without discussion and  agreement with Brighton and Hove Safeguarding Children Partnership prior to publication.    2   CONTENTS  1 Introduction ............................................................................................................... 4 1.1 Context of review .................................................................................................................... 4 1.2 Case Synopsis .......................................................................................................................... 4 1.3 Review process ........................................................................................................................ 6 1.4 Family involvement ................................................................................................................. 7 1.5 Practitioner involvement ......................................................................................................... 8 1.6 Foster Carers ........................................................................................................................... 8 1.7 Limitations to the review ........................................................................................................ 8 1.8 Structure of report .................................................................................................................. 8 2 Summary of agency involvement ............................................................................... 9 2.1 Introduction ............................................................................................................................. 9 2.2 Relevant background prior to the timeframe under review ................................................... 9 2.3 September 2017 – December 2017: Mother living in LA4 .................................................... 11 2.4 February – July 2018: Mother and baby specialist foster carer placement; Mother and Delta ‘looked after’ and Delta subject to child protection plan ................................................................. 12 2.5 August 2018 – December 2018: Mother and Baby living with MGM, Delta subject to a child protection and then a child in need plan .......................................................................................... 14 2.6 January – August 2019: Mother and Delta in MGM home ................................................... 15 2.7 September – December 2019 ............................................................................................... 16 3 Family: structure and views ...................................................................................... 19 3.1 Family composition ............................................................................................................... 19 3.2 Views of family members ...................................................................................................... 19 4 Thematic analysis 1: How were decisions about assessment of risk and safety planning made by practitioners in relation to Delta? ..................................................................... 25 4.1 Introduction ........................................................................................................................... 25 4.2 Pre-birth assessment & planning (September 2017 – February 2018) ................................. 26 4.3 Assessments leading to the move of Delta to MGM, ending of legal planning for Delta and discharge of Mother from s.20 accommodation (March – July 2018) .............................................. 26 I. Positive Early Parenting Assessment Programme (EPAP) assessment ................................. 27 II. Positive viability assessment of MGM ................................................................................... 28 III. Positive health assessment ............................................................................................... 30 IV. Lack of assessment of MGM’s complaint and cause of tensions in home ........................ 31 V. Carer’s reports not fully integrated into assessment and decision making .......................... 34 VI. Ending of legal processes for Delta ................................................................................... 36  3   4.4 Ending of Delta’s child protection plan ................................................................................. 37 4.5 Ending of Delta’s Child in Need plan: October – December 2018 ........................................ 38 4.6 The decision to move Delta and Mother to supported accommodation: January - September 2019 without further assessment of Mother and Delta’s needs and the risks to each from such changed circumstances .................................................................................................... 42 4.7 Responses to emerging concerns and re-referral of Delta to CSC in October 2019 ............. 47 5 Thematic Analysis 2: Terms of Reference 2 - 7 .......................................................... 53 5.1 Introduction ........................................................................................................................... 53 5.2 What was practitioner’s understanding of Delta’s lived experience? .................................. 53 5.3 What was known and understood about the impact of Mother’s education experience on Delta’s welfare? ................................................................................................................................. 59 5.4 How were accommodation services used and understood by other agencies to support Mother and Delta? ............................................................................................................................ 61 5.5 How was Mother understood and supported by practitioners? .......................................... 66 5.6 What was known and understood about Mother’s experience of exploitation (including CSE or other forms of exploitation) and the impact on her? ................................................................... 70 5.7 What was known about or understood regarding Delta’s father and how was this addressed by practitioners in terms of safety planning? .................................................................. 72 5.8 Systemic and organisational issues ....................................................................................... 73 6 Conclusions, Findings and Recommendations ........................................................... 76 6.1 Conclusions ............................................................................................................................ 76 6.2 Findings & Recommendations ............................................................................................... 78  4   1  Introduction  1.1 Context of review 1.1.1 Brighton and Hove Safeguarding Children Partnership (BHSCP) commissioned this Local Child Safeguarding Practice Review (LCSPR) following the tragic death of a 20-month-old girl in December 2019. The post-mortem found that her death was caused by a combination of starvation ketoacidosis1 and influenza. Her mother pleaded guilty to a charge of manslaughter and was subsequently sentenced to a substantial prison term in 2021. The death occurred when the mother left her young daughter alone in their flat for 6 days, whilst she was with friends in London and elsewhere in England.  1.1.2 BHSCP use names from the Greek alphabet to provide anonymity to children and their families in Local Child Safeguarding Practice Reviews. This review is titled ‘Delta’ in accordance with BHSCP convention. The toddler, who is the subject of this review, is called Delta in this report, and all family members are referred to by their relationship to her. Practitioners are referred to by their occupational role. See Section 3 for details of family and abbreviations used in the report. 1.2 Case Synopsis 1.2.1 Delta’s mother [referred to as ‘Mother’ in this report] moved from London with her mother and her younger sibling in 2015, aged 14. Mother’s elder siblings and wider family remained in London.  1.2.2 During 2016/ 2017, 15 year old Mother was missing from her home for extended periods and was suspected to have been sexually exploited by unknown adults in London. For this reason, she was accommodated2 in August 2017 and placed in an emergency children’s home placement, some distance away from London and her home in Brighton. Subsequently it was discovered, she was pregnant.  1.2.3 Delta was born in March 2018, after Mother moved to a mother and baby foster care placement in Brighton & Hove. They moved to maternal grandmother’s (MGM’s) home in July 2018, before moving into supported independent accommodation in September 2019. It was here that Delta was left alone for 6 days in December 2019 and died at the age of 20 months. Following her death, the criminal investigation established that she had been left alone 6 times previously. This was unknown by either the practitioners supporting the family or by MGM.     1 Starvation ketoacidosis happens when a person has undergone an extended period of fasting. 2 Under section 20 of the Children Act 1989, a child or young person may be accommodated by the local authority where there is agreement to this arrangement by those with Parental Responsibility. The child becomes Looked After under a section 20 arrangement.   5   1.2.4 Delta was a much-loved baby in her close family and was (and remains) the first and only child of her generation. Since Delta’s birth, Mother’s parenting ability and skills were perceived (and assessed to be) as excellent, albeit the foster carers identified that Mother was not consistently putting Delta’s needs as priority over her own. However, Mother was aged only 16, a child herself, and given her youth this was not unexpected.  1.2.5 Within 3 months of returning home to MGM, tensions emerged, due to overcrowding: with only 2 bedrooms, MGM slept in the lounge, leaving her bedroom for Mother and Delta, and enabling Delta’s younger aunt to keep her own room. 1.2.6 An application for supported accommodation was made for Mother (with Delta) in January 2019. In the subsequent 9 months, whilst waiting for her own flat, Mother and Delta frequently stayed in London, understood by social workers to be staying with family members, with MGM’s agreement. Neither Mother nor Delta were Looked After at this point, nor subject to a Child Protection3 or Child in Need4 Plan.  1.2.7 In 2019, whilst there were some missed health appointments for both Delta and Mother, overall Mother attended many appointments or cancelled or re-arranged others, because, she reported, she was or had been in London with named relatives.  1.2.8 During this time there were emerging recognitions about Delta’s possible delayed development. She was observed variously by the health visitor, MGM and subsequently staff at the supported accommodation (from October 2019) as being passive, slow to explore her environment, wary of strangers and avoiding eye contact. However, this was not consistently observed by practitioners and at times Delta was more alert and seen to be exploring her environment. Unsuccessful attempts were made to provide additional support to Delta via the involvement of a nursery nurse and baby groups, but Mother did not make use of this service. 1.2.9 Mother and Delta moved into their own flat, within supported accommodation, at the end of September 2019. Within a few weeks practitioners became aware of an occasion when Mother’s social life involved drinking alcohol with friends who were visiting her prior to them all going out together. Critically, it was discovered Delta was left alone in the flat for short periods whilst Mother went outside to smoke. The issues were addressed with Mother, and a monitor supplied to enable Mother to ‘pop’ out to smoke and empty rubbish, whilst keeping an eye on Delta.      3 A Child Protection Plan (CPP) is made when a child is judged to be at risk of significant harm, significant harm being a level of harm that affects the health, welfare and development of a child. The Plan will say what the specific risks are to the child and the actions that will be needed to keep the child safe. 4 Children in Need (CIN) Plan - A CIN Plan is drawn up following a Single Assessment which identifies the child as having complex needs and where a coordinated response is needed in order that the child's needs can be met.  6   1.2.10 By this point, the continuing concerns around Delta’s developmental delay led to a paediatric referral for assessment, along with the health visitor convening a multi-agency Team Around the Family (TAF) meeting in December and commencing a Strengthening Families Early Help Plan. 1.2.11 The possibility that Mother would ever leave Delta alone for any time, other than briefly, to empty rubbish or have a cigarette, was inconceivable to any of the practitioners. The discovery during the criminal prosecution that Mother had previously neglected Delta by leaving her home alone was never suspected by any practitioners.  Her ability to deceive and manipulate others (family, friends and practitioners) only emerged during the criminal investigation. 1.2.12 This review aims to understand how, despite the high level of service provision, the practitioners did not identify the risk for Delta, and the lessons to be learnt from this. In particular, the lessons in relation to: the complexities when both Mother and baby are children, with their at times different or even conflicting needs; how to balance the long term effects of trauma on a child, even when that child, as a parent, appears to be a good parent; and the Mother’s ability to deceive everyone in her life. 1.3 Review process 1.3.1 BHSCP concluded early in 2020 that a LCSPR would be commissioned, in recognition of the potential to identify learning regarding the way that agencies work together in Brighton and Hove to safeguard children. The national Child Safeguarding Practice Review Panel agreed with that decision.  1.3.2 The timeframe for the review was from September 2017, the date of known pregnancy with Delta, to December 2019, following the death of Delta. Some earlier history is included so as to provide a context for the period under analysis. 1.3.3 The first reviewer was appointed on 16.12.20, after the Mother entered a guilty plea to a charge of manslaughter.  In early 2022 the BHSCP concluded that a fresh approach was needed in order to ensure the terms of reference were fulfilled with the rigour required, and so a second reviewer was appointed. The author of this report, Edina Carmi, commenced work on 14.03.22. So as to avoid confusion in the report, the original reviewer is referred to as ‘first reviewer’ and Edina Carmi is referred to as the ‘author’ or ‘I’ or ‘myself’. 1.3.4 The terms of reference (see appendix 1) provide the focus of analysis of this review. These were identified as the critical issues for learning from the outset of the review and initially formulated with the first reviewer and review panel. They were subsequently reviewed and slightly amended at a panel meeting on 24.03.22 with the author of this report. Additionally, I have broadened the term of reference relating to commissioning of housing provision (5.4) from ‘How were commissioned independent accommodation support services used and understood by other agencies to support Mother and Delta? to cover wider housing issues relevant to the welfare of Delta and her mother i.e. ‘housing and accommodation support services’.   7   1.3.5 The author was provided with • reports and relevant documents from agencies which had involvement with Delta and / or Mother (see appendix 2 for list of agencies participating in this review) • witness statements provided by the coroner to the author, with the agreement of the witnesses  • a draft report by the previous reviewer and notes of some, but not all, of that author’s virtual meetings or telephone conversations with family and foster carers. 1.4 Family involvement 1.4.1 Delta’s mother had 2 virtual meetings with the first reviewer, and I have been provided with notes made at one of the meetings, undertaken in conjunction with a member of the review panel, who is also Brighton & Hove Council’s anti-racist lead practitioner5. The BHSCP’s Business Manager had great difficulty arranging a visit to Mother in prison for the anti-racist lead practitioner and I, due to obstacles in making such arrangements with the prison / Home office. Finally, we saw her in October 2022, when Mother provided thoughtful contributions to the review and how she might have been able to be more effectively helped (see section 3).  1.4.2 MGM had a telephone conversation with the first reviewer, but no notes were available for this. MGM met with Brighton & Hove’s anti-racist lead practitioner and myself in August and provided a thoughtful and perceptive contribution to this review.  1.4.3 Delta’s father was written to and contacted via the police, but there was no response to this invitation to participate in the review.  1.4.4 Maternal grandfather [MGF] was also contacted and invited to participate but did not respond.   1.4.5 I had hoped to meet with Delta’s elder maternal aunt, with whom Delta spent a great deal of time in 2019. The invitation to participate was made via MGM (aunt’s address is unknown to the local authority) but there has been no response to options of a meeting in London/ Brighton, or a virtual meeting or if preferable an opportunity for her to write her views on the services her family received.  1.4.6 Section 3 provides information on family structure and their perspectives as provided to the first reviewer and/or myself.      5 This anti-racist practice lead role came as a result of Brighton & Hove’s 2019 ‘Being a fair and inclusive council’ report, and the anti-racist project in children’s social work services.  8   1.5 Practitioner involvement 1.5.1 The first reviewer held 3 virtual learning events with front line practitioners in 2021 to better understand their perspective and identify emerging learning. These sessions were for practitioners from LA4 (where the children’s home was located), local Brighton & Hove front-line practitioners and separately their managers. There were no notes from these meetings nor from follow up conversations held with some practitioners, albeit the first reviewer will have included relevant material in their draft report. 1.5.2 The individual management reviews (see appendix 2) involved interviews with some relevant practitioners and their views were in the agency reports. 1.5.3 Additional meetings with practitioners were undertaken in July and August 2022 by the BHSCP Partnership Manager, Safeguarding and Quality Assurance Unit, and myself, focusing initially on those who did not participate in the first review and subsequently those able to assist with specific queries.  1.6 Foster Carers 1.6.1 The first reviewer met with the foster carers, who cared for Delta with her Mother in 2018. The notes of this meeting were provided to the author of this report.  1.7 Limitations to the review 1.7.1 The lack of notes of all meetings and interviews of the first author with family members and practitioners was a limitation. For this reason, BHSCP agreed additional meetings with family members and practitioners be arranged as described above (see 1.5).  1.7.2 Delta’s last social worker, who ended the child in need plan in December 2018, now lives abroad and was not able to be contacted. The ending of social work which specifically focused on Delta’s welfare was a critical decision, but I was able to speak with both her manager and Mother’s social worker at the time, to obtain some understanding of this decision making. All 3 have now left Brighton & Hove CSC’s employment.   1.7.3 Delta’s first health visitor had retired and her whereabouts were unknown to her agency. She was therefore unable to participate in either the agency management review or to meet with the first reviewer or myself. 1.8 Structure of report 1.8.1 The report is structured as follows: • Section 2: summary of agency involvement •  Section 3: family structure and perspectives • Section 4: thematic analysis with regard to terms of reference 1 Assessment • Section 5: thematic analysis with regard to remaining terms of reference  • Section 6:  provides the conclusions, findings, and recommendations  • Glossary of terms and abbreviations • Appendix 1: Terms of Reference • Appendix 2: Contributing agencies  9   2 Summary of agency involvement 2.1 Introduction 2.1.1 Section 2 provides a brief summary of what is known or understood to have happened and the engagement of the different agencies and practitioners. It is divided into the following periods: • 2.2 provides a brief summary of what is known about Mother’s family’s contact with agencies prior to the period under review, so as to give a context to subsequent events. In London she lived in LA1, before moving to LA2 outside of London and then to LA3, Brighton & Hove. • 2.3: September 2017 – January 2018: Mother living in a children’s home in LA4 • 2.4: February – July 2018: Mother and baby specialist foster carer placement; Mother ‘looked after’ and Delta subject to child protection plan: Mother returned to LA4, Brighton & Hove • 2.5 August 2018 – December 2018: Mother and baby living with MGM, Delta subject to a child protection and then a child in need plan, living in Brighton & Hove • 2.6: January – August 2019: Mother and Delta in MGM home: no co-ordinated professional support or involvement with Delta, living in Brighton & Hove • 2.7 September 2019 – December 2019: Mother’s whereabouts unclear during the first weeks of the month, prior to moving into a supported flat in Brighton & Hove 2.1.2 The family perspective of this, as explained in their contact with the first reviewer is explained in section 3. The analysis of what happened, in accordance with the terms of reference (see appendix 1) is provided in Sections 4 and 5. 2.2 Relevant background prior to the timeframe under review  2.2.1 Mother, aged 14 moved to the Brighton and Hove area with MGM and younger half sibling in 2015 from LA1 in London. Mother’s older siblings, MGF and large extended family remained in various locations in London.  Family trauma 2.2.2 Prior to this move the family had suffered trauma. MGM’s own childhood history involved much tragedy with her parents dying in the genocide in Rwanda, where they had gone to see family members.  2.2.3 The family experienced domestic abuse whilst living in London [LA1]. LA1’s records refer to 2 incidents, one in 2006 and one in 2010.  10   2.2.4 The 2006 incident was described as ‘severe’, with MGM telling police she was punched, kicked, and pulled by her throat and 5-year-old Mother witnessed this. MGM and Mother attended hospital, where Mother made unsubstantiated allegations of a burglar inflicting bruises on her and having to go to hospital and of her stepfather having ‘thrown her in the road’. These allegations were thought to be associated with the trauma of witnessing her mother being subjected to domestic abuse. The police charged MGM’s partner with common assault, but MGM subsequently declined to support the investigation. Also in this investigation, children’s social care records refer to an unspecified earlier involvement of a women’s refuge.  2.2.5  In 2010 there was another incident of domestic abuse with a partner, when MGM alleged, he was outside her house harassing her.  2.2.6 This background of domestic abuse was explained slightly differently by MGM in information provided to the social worker as part of an assessment6 (see 4.2.13-14). 2.2.7 The couple subsequently parted. MGM, Mother and younger maternal aunt then moved to LA2.  2.2.8 The Early Parenting Assessment Programme (EPAP) report refers to Mother speaking of a traumatic period from the age of 11, when first her cousin was murdered, followed by the loss of two close family friends, one of whom was also murdered and the other committed suicide. MGM confirmed to me that these tragic events did occur.  2.2.9 Also, prior to moving to LA2, Mother and a friend were the victim of an adult male allegedly sexually abusing them online. Mother provided information to the police about this incident.  Schools 2.2.10 The family describe LA1’s School 1 as being a positive experience, although records note some disruptive behaviour at school by Mother, concerns over her involvement with older children and an incident when another pupil used a racist word towards Mother (and after staff intervention, the other pupil apologised to her). 2.2.11 Following the move to LA2, Mother attended School 2 for a year with good attendance. It is understood that in the summer of 2016, a YouTube video about Mother (made by an older sibling) was shared widely on social media, and subsequently Mother says she struggled to return to school. Mother has also subsequently referred to being bullied and racially abused by peers at this school, but this was not identified by staff at the time.  2.2.12 Following the family moving house to LA3 (Brighton & Hove) in October 2016, 14 year old Mother started at School 3. This move coincided with increasing episodes of Mother going missing from November 2016 and again in early December 2016, when she was 15 years old. The education chronology refers to the school declining her subsequent return to School 3 because she was alleged to have made threats on social media to another child at the school.   11   2.2.13 Mother started School 4, in May 2017, and her attendance was 100% for 4 weeks, prior to going missing again.  There was involvement of the Metropolitan Police Service (MPS) during this period, following an allegation that a friend of hers was raped when Mother took some friends to London one weekend. Mother denied any involvement in or knowledge of this incident or of being a victim of child sexual exploitation (CSE) herself.  Mother missing from home  2.2.14 Mother’s periods of missing from home significantly increased from late 2016 to summer 2017 (when aged 14 and 15), with 8 separate episodes. Police were informed and children’s social care (CSC) notified. Mother often contacted MGM and stated she was staying with extended family in London, but family members were said to be unaware of her whereabouts.  2.2.15  In August 2017, when 15 year old Mother was missing for 9 weeks and with concerns of her being a victim of exploitation escalating, an application was made for a Secure Accommodation Order7. Before the application was heard, Mother was located by police, who used police powers of protection 8 to ensure her safety. 2.2.16 With the agreement of MGM, Mother became Looked After under s.209 Children Act, 1989 and placed in a residential home in LA4 in August 2017.  Although an emergency placement, the residential staff had experience of children going missing and exploitation; the strategy was to place Mother away from London or Brighton, for her own safety.  2.3 September 2017 – December 2017: Mother living in LA4 2.3.1 In September 2017, Mother disclosed her pregnancy soon after she was placed in a children’s home in LA4.  2.3.2 During the 6 months Mother lived at LA4 children’s home there were no concerns about her behaviour, no missing episodes (albeit a wish to go to London) and no concerns of her being exploited.     6 Viability assessment of MGM dated 01.06.18: this assessment was undertaken to help decide if mother and baby Delta should live with MGM 7 The order allows children's services to place a looked after child under the age of 16 in secure accommodation on welfare grounds if the child has a history of running away or the child is likely to injure himself or someone else if they were kept in any other form of placement. 8 If a child is believed to be at risk of significant harm, they can be removed from their home and placed under police protection for up to 72 hours in a safe location, under the Children Act 1989 9 Under section 20 of the Children Act 1989, a child or young person may be accommodated by the local authority where there is agreement to this arrangement by those with Parental Responsibility. The child becomes Looked After under a section 20 arrangement.  12   2.3.3 On the contrary there were largely positive observations of Mother’s relationships with staff and peers, as well as her positive attitude to becoming a parent. She engaged with the FNP, was perceived to be focussed on self-care and on learning how to care for her baby. She gave up smoking and reported disliking alcohol.  2.3.4 Mother maintained frequent telephone contact with her mother and elder sister. She also reported speaking regularly to her baby’s father. It was noted that Mother was changeable in her views as to the father’s likely involvement with her baby’s birth, and provided contradictory information about her child’s paternity and her current communication with him. She gave a name, but an incorrect date of birth implying he was the same age as herself, so police checks failed to identify him. During the criminal investigation the police are understood to have identified the father, who was 21 when she became pregnant at age 15. 2.3.5 It was observed that Mother was a bright young person, who wished to become a lawyer, but school attendance continued to be problematic (see 5.3) throughout this period.  2.3.6 Mother’s social worker (SWM1) was from a specialist adolescent team: its primary function is the welfare of adolescents.  SWM1 made an appropriate referral for services for unborn Delta to have her own social worker (SWC1) and for a pre-birth risk assessment to be made.  2.3.7 Further arrangements were implemented for Mother to return to Brighton & Hove prior to the birth and be placed with foster carers in a specialist mother and baby placement, where they would be supported, whilst assessments were undertaken to help decide on future plans for both Mother and her baby.  These plans included: • Early Parenting Assessment Programme (EPAP) assessment of Mother and Baby • Initial Child Protection Conference to consider if the unborn baby should be subject to a child protection plan at birth • Family Group Conference (FGC) to facilitate family members to formulate a plan for the welfare of Mother’s unborn baby • Legal Planning Meeting to consider whether or not legal measures needed to be initiated to protect the baby. 2.4 February – July 2018: Mother and baby specialist foster carer placement; Mother and Delta ‘looked after’ and Delta subject to child protection plan 2.4.1 The plan outlined above was quickly implemented, once Mother moved to the foster care placement in February 2018. Mother’s unborn baby became subject to a child protection plan (CPP) in February 2018 along with a decision made to enter into Public Law Outline (PLO) process. The PLO process is a precursor to making a decision on whether to initiate care proceedings.   2.4.2 Delta was born in March 2018. Overall, in Delta’s first 5 months of life she was considered to be making good progress by health and social care practitioners, and there were no concerns identified about her health, development and welfare.   13   2.4.3 Within the first weeks of Delta’s life MGM and Mother expressed their wish to be reunited, for Mother and Delta to live with MGM (and Delta’s younger aunt). This proposal was the outcome plan of the Family Group Conference (FGC) held in April 2018.   2.4.4 A viability assessment of MGM’s ability to provide a safe supportive environment for Mother and her baby, was planned and undertaken in this period, concluding on 01.06.18 that MGM would be a viable carer for Mother and Delta. Solution Focused Therapy between Mother and MGM was commenced in this period, so as to further improve their relationship. MGM also engaged with WISE10 for weekly sessions to learn more about sexual exploitation after Mother and Delta moved to her home.  2.4.5 The EPAP specialist parenting assessment started in April 2018, and although not complete by July it was clear to colleagues that, by then, the assessing social worker had formed an extremely positive view of Mother’s parenting, with MGM’s support. 2.4.6 Mother and Delta moved back to live with MGM in July 2018. At this point Delta, aged nearly 4 months old, remained subject to a child protection plan [CPP], whilst Mother ceased to be a looked after child with the discharge of s.20 Children Act, 1989. MGM and Mother cancelled the review FGC on the basis things were going well, and it would be difficult to get the family together.  2.4.7 The move to MGM was brought forward to July, rather than September, due to perceived continuing tensions within the placement and a wish by Mother and MGM to expedite the plan for Mother and Delta to move home. Whilst foster carers views of Mother’s parenting was overall positive, they did report on a few minor observations which indicated that, on occasion, Mother put her needs above Delta’s. (See section 4 VI for further details). 2.4.8 Prior to the conclusion of the EPAP assessment, the social work team informed legal services that it intended to end the PLO process, as agreed at the FGC. No concerns were identified about the care and parenting of Delta. Mother was seen as a competent, nurturing parent, completely focussed on Delta. The assessment of MGM and specific work undertaken over five sessions between Mother and MGM on their relationship was also deemed to be positive.  2.4.9 Attention during these months was focused on Mother’s skills as a parent and her future educational plans for the autumn.     10 YMCA WiSE. provides support to children and young people up to the age of 25 who are at risk of, or experiencing sexual exploitation.  14   2.5 August 2018 – December 2018: Mother and Baby living with MGM, Delta subject to a child protection and then a child in need plan 2.5.1 Following the move to MGM’s home, Delta was subject to multi-agency co-ordinated practice with a focus on her welfare via firstly a child protection plan (CPP) and then a child in need (CIN) plan.  2.5.2 Mother took 5-month-old Delta for a neonatal clinic review in mid-August. Delta was noted to be doing well but referred to audiology because of possible maternal Cytomegalovirus, which can cause a hearing loss over time, in around 1 in 7 babies. Mother failed to take Delta to the review neonatal clinic in December 2018. 2.5.3 Delta’s CPP ended in September 2018, when it was determined by senior agency professionals at a child protection conference that the threshold for its continuance was not met. Delta then was ‘stepped down’11 and became subject to a CIN plan for 3 months. There was a change in social worker for Delta after this from SWC1 to SWC2. 2.5.4 Mother started college in September, but was asked to leave in November 2018, due to having only attended 5 lessons, spending her time on the internet in the library. Delta commenced nursery in early October and there were no concerns about either her development or care. However, funding for nursery ceased when Mother lost her college place, so Delta lost her nursery place. 2.5.5 There were no identified concerns around Delta’s care although the need for future accommodation for Mother and baby was an issue as there was increasing pressure given the overcrowded family accommodation. MGM’s home had 2 bedrooms: her daughters each had a room, Delta shared Mother’s room and MGM slept on the couch. In December Mother told her own social worker [SWM1] she wished to move out. SWM1 agreed to make a referral for her to the Supported Accommodation Panel.     11 The ‘step up’ and ‘step down’ process in child welfare is intended to ensure that children retain the appropriate level of professional co-ordinated support and intervention as their assessed need changes. In Brighton & Hove this currently identifies the levels as Universal, Early Help / Early Help & Partnership Plus and Specialist.  (Brighton & Hove: Helping Children and Families, Threshold Document. March 2021). This was essentially the same in 2019.    15   2.5.6 Delta’s case was closed by CSC in late December 2018, when the CIN plan ended. This meant Delta no longer had an allocated social worker.  Mother retained her social worker from the adolescent pod. Her status at that time was that of a ‘Relevant Child’12 under the Leaving Care regulations requiring ongoing statutory involvement to provide support to children leaving care.  2.6 January – August 2019: Mother and Delta in MGM home 2.6.1 During this period Mother and Delta continued to live with MGM, whilst waiting for supported accommodation. Delta no longer had a social worker and was not the subject of a CPP (as decided in September 2018 CP conference) nor a CIN plan (as decided by Delta’s last social worker and team manager in November / December 2018). No lead professional was identified to co-ordinate any team around the family (TAF) processes Mother retained her own social worker, due to her status as a ‘relevant child’ 13.  2.6.2 Mother’s allocated social worker changed in February 2019 to SWM2. The quality of engagement by Mother continued to be good; SWM2, was already known to her, having covered for SWM1 on occasion previously. Pathway plan review meetings were held: the agreed plan was for Mother and Delta to move into supported accommodation and Mother to re-engage in education.  2.6.3 Health Visitor 2 (HV2), a specialist in working with teenage parents, became involved in January 2019. She was the only practitioner whose involvement was specifically focused on Delta in this period, as well as trying to support Mother in accessing healthcare for herself as she was losing weight and possibly had an eating disorder. HV2 communicated well with other healthcare professionals and SWM2.  2.6.4 HV2 was initially concerned about Delta’s development when she saw her in late March for the 12-month review. She noted that she was a passive child, slow to explore her environment, with limited availability of toys and who did not seem interested in playing with a ball or turning pages in a book. Mother explained Delta had just woken.  2.6.5 HV2 saw Delta again in early May, when she was observed to be more alert, nearly walking, climbing and exploring the environment. Delta related to familiar adults and was appropriately wary of HV2. Mother agreed to have further support from the nursery nurse through group attendance; however, Mother failed subsequently to attend appointments for such community support.     12 Relevant children means young people looked after for at least 13 weeks after their 14th birthday and have left care. They must still be provided with a Personal Advisor, a needs assessment, and a Pathway Plan. The responsible authority must keep in touch, help to achieve the goals in the Pathway Plan and, importantly, arrange accommodation and maintenance. 13 Ibid  16   2.6.6 Mother continued to have the support of a YES worker throughout this period, to advise and assist her to access education and training, as well as nursery provision. Mother remained not in education, employment or training (NEET). 2.6.7 During these 8 months Mother began to miss some appointments made (both for her herself and for Delta) and was more difficult to contact. However, this was not sufficiently marked for practitioners to identify a pattern of non-compliance or negligence. Mother’s behaviour was inconsistent: she attended some appointments and cancelled and re-arranged some of those missed. Other times she responded to texts after she had missed appointments, usually explaining she was in London.  2.6.8 Mother visited London, with Delta, to stay with family, particularly her sister and aunt and to attend church. The social worker understood that MGM accompanied Mother to London when she began to visit again.  2.6.9 MGM never expressed any concerns about Mother’s whereabouts and told the first reviewer that Mother and Delta were known to be with family members who were in contact with MGM.  She explained to me that she understood Mother and Delta stayed either with family or friends in London. The friends were those she made in the short period she attended college in the autumn of 2018. This latter was unknown to practitioners, but there is now evidence that she visited and left Delta with friends from Brighton who were living in London.  See 5.2 for more information. 2.6.10 As part of Mother’s Pathway Plan, agreed by her and MGM, Mother was referred to the BHCC Supported Accommodation Panel in January 2019 by her first social worker (SWM1) and placed on a waiting list for the Young Families Service. There was a delay before Mother was offered accommodation. SWM2 pursued the application in July 2019 as Mother explained to SWM2 that this was causing increasing tension and as a result she spent increasing time with her family in London. SWM2 talked to both Mother and MGM and felt the situation could hold but needed a clear timescale.  2.7 September – December 2019  2.7.1 SWM2 was off work from early July for 2 months. On her return in early September 2019, Mother was offered supported accommodation. She accepted this and MGM moved Mother’s belongings over the next week as Mother (and presumably Delta) had gone to London. 2.7.2 Mother was subsequently offered an interview for an alternative self-contained flat, with a different provider and moved there at the end of September 2019. This provision was in accordance with CSC referral for low support.  It was explained to Mother that ‘low support’ meant she would have a key worker, with a minimum of weekly key work sessions, of up to 2 hours with staff available in the office during the week from 9-5 pm.    17   2.7.3 Mother moved into her supported accommodation at the end of the month. From the outset she was unreliable keeping to arrangements. HV2 met with Mother and Delta at the beginning of October and once again flagged concerns about Delta’s development and the need for play and stimulation.  2.7.4 Further concerns about the care of Delta emerged shortly after this in mid-October 2019  (see 4.7.10), when CCTV (viewed for reasons unconnected to mother) showed that 19 months old Delta was left alone in the flat for 15-30 minutes at a time when Mother and friends went outside to smoke. Additionally, there were issues around the consumption of alcohol that evening and overnight. It was subsequently confirmed that Delta was taken to MGM’s car late evening and spent the night with her. 2.7.5 Various agreements were made with Mother by SWM2 and staff at the supported accommodation, including the provision by SWM2 of a baby monitor to use to check on Delta if Mother left the flat briefly to smoke outside or empty rubbish (see 4.7.13).  2.7.6 Mother was 40 minutes late for her pathway plan review meeting on 24.10.19. The meeting focused on the positive progress made by Mother since becoming a parent, her calming down and the plans for transition from the adolescent team to the Leaving Care Team and from a social worker to a Personal Assistant (PA). HV2 attended, shared that Delta was not meeting her developmental milestones. An Early Help Plan was in place and a TAF meeting was planned for December to focus on Delta.  2.7.7 The concerns from the CCTV were mentioned, but it was agreed to discuss out of the meeting. These concerns were referred to Children’s Social Care FDFF (Front Door for Families) in late October 2019 by the social worker’s pod Manager, ‘for information only’. The decision by the Manager in the FDFF was that the threshold for a social work assessment of Delta was not met, as the concerns identified by the supported accommodation provider had already been addressed with Mother.  2.7.8  From this point in late October 2019, the pattern of missed appointments and communication difficulties continued and increased. Some appointments were kept, other times Mother gave credible explanations. There was no evidence she was being untruthful, but little evidence of attempts to challenge /triangulate Mother’s information: such monitoring activity ceased once Mother and Delta left the foster carers and were rehabilitated into their family, as from that point neither child (mother or daughter) was Looked After or subject to a CPP. 2.7.9 Mother was often absent from the accommodation and was at times difficult to contact on these occasions. She was reminded of the requirement to be resident 4 nights a week and explain absences to staff and also was threatened with implementation of formal ‘Missing Person’ procedures. Such threats would trigger Mother making contact.   18   2.7.10 On Mother’s 18th birthday in early December, SWM2 visited. Mother pulled the door shut on the bedroom. SWM2 did not see Delta who was said to be ill (and had been by this time for several days). Mother said she was having a meal with her family that day, but due to both her and Delta being unwell, had little else planned. Mother also told the keyworker (at the supported accommodation) the same regarding her plans. 2.7.11 4 days later (i.e., when staff returned after the weekend) a practitioner at the supported accommodation knocked on Mother’s door to deliver post. There was no answer; she looked through the letter box and observed the flat appeared cold and empty. Staff checked CCTV but there was no indication Mother had returned nor response to telephone calls. Daily visits by the mobile night team had not heard any noises from the flat. Meanwhile SWM2 was communicating with Mother and YES worker about plans for Mother’s education. 2.7.12 6 days from when Mother and Delta were last seen by practitioners (mother’s birthday), Mother spoke with both SWM2 and a supported accommodation practitioner on the telephone, reporting to have spent her birthday with her sister and family in Crawley, and returning that day. She reported to the supported accommodation that Delta was ‘good’ and it was noted that Mother sounded ‘happy’. 2.7.13 It is known from subsequent scrutiny of CCTV that Mother returned to Brighton at 15.20 on the 11th December, after being away for 6 days. She then stopped to shop and arrived back at the supported accommodation at 15.38. Mother posted on a group chat to friends that Delta was unwell. She delayed calling emergency services till 18.13.  2.7.14 From statements to the coroner, provided to the author with the witnesses’ agreement, Mother lied to her family, friends and professionals during this period, specifically about Delta’s whereabouts and then the circumstances surrounding Delta’s tragic death. Medical opinion since Delta’s death is that she was already dead by the time mother arrived home at 15.38.  2.7.15 Unknown to practitioners at the time, the criminal investigation has since established that Mother frequently stayed with friends, not family, during October-December 2019 in London, sometimes accompanied by Delta and sometimes alone. Moreover, the information from the criminal investigation (see table following 5.2.6) shows that Mother left Delta alone in the accommodation from the end of October 2019 on at least 7 occasions, for varying lengths of time, from 1 hour to nearly 6 days.        19   3 Family: structure and views 3.1 Family composition Family Member Ethnicity Term used in report to identify individual Subject of safeguarding practice review Black British Delta Delta’s mother Black British Mother Delta’s father Black British Father Delta’s maternal grandmother Black African MGM Delta’s maternal grandfather Black African MGF Delta’s elder maternal aunt  Black British Elder aunt Delta’s maternal uncle Black British Uncle Delta’s younger maternal aunt Black British Younger aunt Delta’s maternal great aunt Black British Great aunt  3.2 Views of family members 3.2.1 The views of Mother and MGM were obtained initially by the first reviewer in 2021 and subsequently by myself in October 2022. In addition, witness statements provided to the coroner, and which the author of this report has been allowed to view with the agreement of the witnesses concerned, has provided additional information from MGM. MGF and Delta’s father were provided with the opportunity to participate by the first reviewer but did not do so. Delta’s elder aunt did not respond to the offer (via MGM) to meet in person or virtually with the author. 3.2.2 The focus for the discussion with family members was their experience of the agencies which worked with the family, what was helpful, what was less so, and what services could do to improve. It is of note that views were provided subsequent to Delta’s death and may be informed by hindsight. Mother’s views  Schools and racism 3.2.3 Mother recalled moving from London in 2015, aged 14 to LA2, following her Mother and stepfather separating. She did not wish to move away from her extended family and friends. Moreover, she immediately felt different and experienced racist comments; in school 1 she recalled being the only black child in her year and one of only two black females in the school.     20   3.2.4 Mother described feeling unable to return to school following 2 distressing incidents: • Alleged racist bullying at school, which left her feeling unsafe and to which the teachers in her experience were ‘oblivious’; she described a serious bullying incident [to the first reviewer] at the school and said this led to the school visiting her and MGM to try to resolve the incident.   • The negative impact of being shamed online by a social media video posted by a sibling in the summer of 2016: this was widely shared and seen by pupils at the school and led to Mother receiving abusive messages.  3.2.5 The family subsequently moved home to LA3 and Mother commenced at school 3, but began visiting London, which she described as being primarily to escape her school environment. In Brighton & Hove she attended schools 2 and then 3, but her continued feeling of being the ‘odd one out’ continued and she avoided school. This continued following her move to LA4 when she was looked after in September 2017.  3.2.6 Mother felt that she could have been helped if there had been: • a ‘buddy /mentor’ to assist in transitions • a 1-1 relationship with a teacher she could trust • a diversity staff lead • staff understanding and awareness that racist bullying was taking place  • staff could provide reassurance to affected pupils.  3.2.7 Overall Mother felt that her school non-attendance needed to be understood in the context of her experience of racist bullying and her resulting anxiety.  Missing from home and child sexual exploitation 3.2.8 Mother described the periods she went missing from home, beginning in November 2016. Mother stated her anxiety about school and that the recent change of school then meant she lost any support networks, making the ‘pull’ of London stronger. 3.2.9 Mother described her experience in London, meeting up with other missing girls and being introduced to older men. She did not then consider herself as a victim of CSE and this was something she only began to identify for herself as she grew older, about the age of 17. Before this her experiences seemed ‘normal’ and her knowledge of CSE or of what constitutes healthy relationships was minimal. Mother confirmed she had not been able to discuss these experiences with anyone prior to her solicitor and team in the criminal proceedings. 3.2.10 Mother now recognises she was gradually being groomed, then abused and exploited by the father of her child and other older men. When she returned home from missing periods, she described experiencing only one welfare checks/return home interview. She felt this was a superficial process, with a uniformed male police officer, who visited her at MGM’s home, asking questions at the front door without offering a private interview away from home, as she would not have wanted MGM to overhear. Mother described the process as ‘intimidating’ and more of a ‘check’ than a conversation.   21   3.2.11 Mother found it impossible to be open with practitioners, partly because of not recognising herself as a victim of such abuse, but also because she felt this was ‘intrusive, shameful and embarrassing’ and did not feel comfortable discussing it. She described practitioners not using the right terminology or having the skill set or persistence to encourage her to discuss her experiences.  3.2.12 Her perception is that practitioners didn’t ask or stopped asking about her experiences of exploitation and abuse and the impact on her. It seemed to be expected that she would speak when she was ready, but that would never have happened. She needed someone to persist and then she might have felt able to speak.  3.2.13 Mother also described that once her pregnancy was known she felt the focus of all professional engagement was on the baby and herself as a parent, not as a 15/16-year-old child in her own right who had experienced trauma and abuse. Moreover, the focus of conversations about her time in London was less about what happened to her and more on the identity of the ‘father’, so he could be subject to assessment. The social workers ‘didn’t know how I got pregnant’ and she felt that they thought it may have been the ‘perfect conception’. They ‘assumed’ there was a dad, but ‘I didn’t know that what was happening to me was grooming/CSE’ and ‘It is like rape, but I did not have a name for it’ at the time. This focus on the father ‘scared me away as it was embarrassing to talk about the dad, I felt backed into a corner and didn’t want to talk’. 3.2.14 The eventual recognition of what had happened, came when aged 17 (2019), especially when living at the supported accommodation. Mother described the profound impact on her through an ‘accumulation of reflections, from looking at and watching things on-line about situations, which were triggering’ and that she had ‘nightmares’ and ‘flashbacks’. 3.2.15  She recalled feeling extremely lonely then, fearing being on her own at the flat, feeling depressed and needing to keep busy and go out, to avoid sitting and thinking of her experiences. She described herself at this time as at ‘breaking point’ and that she needed ‘someone to talk to at this point, but I was seen as very capable and mature, so it was hard to ask for help’. Also, London felt more supportive to her than being in Brighton and she tended to avoid family more when going through this difficult emotional time. 3.2.16 Mother described how generally when there were problems, rather than try and slow things down, she was offered ‘the next thing to try and then the next thing’ e.g. new school, next school, college, one-stop, the supported accommodation. As a consequence, problems were only dealt with at a ‘surface level’. 3.2.17 Mother described how she had a tendency to lose weight when she got anxious, dropping down from a size 10-12 to a size 6 after moving from MGM home. The loss was noticed by friends and family. She also spoke to the health visitor about this.    22   3.2.18 Mother said it would have helped if: • She could have had a ‘buddy’, ‘someone independent who could talk to young people, not social workers due to the fear of what they represent’, as well as provide help and support around shopping and food • Social workers felt more confident talking about these issues and that they may need more support in managing such difficult conversations • Delta had been attending nursery, as it was very hard never getting a break for herself (she says she requested this but was told she there was no funding) • Her anxiety and panic problems had been addressed i.e. why she felt unable to attend classes at college • Additional help in education e.g. a tutor, given the problems she faced as a young parent who had missed a lot of education • More expertise in return home interviews, such as a dedicated individual, not in uniform and gender appropriate to the child’s circumstances (in her case a woman). Where Mother lived 3.2.19 Mother said she was unhappy at her foster care placement, and that it was a ‘mismatch’ as they did not understand her ‘cultural or religious needs’.  3.2.20 Mother was positive about the parenting assessment and direct work with herself and MGM, and the outcome enabling her return to live with MGM. 3.2.21 Mother stated that she did not want to move to supported accommodation, as she knew she needed support and would always have preferred for the family to have been helped to find larger accommodation. Mother commented that it was left to them to try and arrange this and they were not provided with any support on this. It is of note that both MGM and practitioners recalled (supported by the evidence in agency records) that Mother was positive about a move to supported accommodation. 3.2.22  Mother said she was scared at the prosect of the move, as she had little clue about paying bills and felt everyone assumed she could do this. This mirrors the way practitioners perceived her as being able to cope with parenting, and she felt unable to speak about her doubts. Maternal grandmother’s views 3.2.23 The first independent reviewer spoke with MGM and I met her as part of this review. The following incorporates MGM’s contributions on both occasions.  3.2.24 The first reviewer noted that MGM confirmed the move to LA2 was to ‘get a fresh start’ after her relationship ended and she had friends living in the area. MGM described experiencing direct racist comments for the first time and that this had never happened in London.  3.2.25 MGM confirmed Mother experienced racist bullying at school 2.  Mother did not tell MGM initially, in order not to upset her. However, when she did do so, MGM tried to complain but felt it was not understood by school authorities. MGM was clear that Mother’s experiences had a significant impact on her confidence.  23   3.2.26 Given the experiences of racism, MGM decided to move house to LA3 (Brighton & Hove) to be nearer her friends and where she had experienced less racism.  3.2.27 MGM described the support she received from Children’s Social Care when Mother began running away as mainly helpful and that they worked together to try to find Mother and to keep her safe, hoping a new school would be positive. When Mother continued to run away, MGM agreed that she needed to become Looked After to keep her safe. MGM said over this period that Mother became different: secretive, uncommunicative and unable to open up to MGM about what had happened when she was missing. Prior to this she was ‘free, loving and happy’. 3.2.28 MGM was positive about the subsequent support from Children’s Social Care, the work undertaken in the parenting assessment and the direct work with her and Mother. MGM was less positive about either LA2 children’s home or the foster placement and felt neither were sensitive to the family’s culture. 3.2.29 MGM was particularly critical of the foster carers and described the placement as a “mismatch”. She had made a complaint and was extremely disappointed at the lack of response to this for over a year, and that the subsequent letter really did not address the issues. She felt that she was not listened to and not provided with a chance to openly discuss and explain to the foster carers why she was concerned about some aspects of their attitude to her daughter. Had this happened they may have been able to work together better. 3.2.30 MGM said she was pleased to have Mother and Delta at home following this. At that point there was no need for Delta to be subject of either child protection or child in need plans. MGM said Mother wanted to move and have independence, but MGM felt she needed support. Whilst Mother’s parenting of her daughter had been good, she had never had to combine this with total responsibility for finances, shopping, and cooking. MGM described her relationship with Mother was ‘ok’ at the time of the move, and she moved Mother and Delta’s belongings because they were in London, but then the rest of that month they split the time between her home and Mother’s father’s home, until she moved into the supported accommodation. 3.2.31 MGM was working part time and the accommodation was small, but she tried to support, guide and assist Mother. MGM stated that Mother often visited family in London with Delta, where she was supported by family members and attended a church. MGM believed she knew where Mother and Delta were staying when they went to London. After Mother moved into supported accommodation, this pattern of staying with relatives in London continued and she was unaware of any concerns about Mother being away from the supported accommodation. MGM and Mother spoke most days and there was never any indication of problems.  24   3.2.32 MGM said she had begun her degree in September 2019, and she was therefore far less available to support Mother and Delta due to her commitments. She understood the supported accommodation was offering more support to Mother and Delta than it actually was and felt this should have been clearer. This has caused her considerable distress. She noted that the supported accommodation never contacted her to ask if she knew Mother and Delta’s whereabouts, nor any concerns (although the accommodation provider records show such a call in November, asking if she knew Mother’s whereabouts). The social worker called once she recalled to confirm that Delta had been with her overnight and additionally in relation to discuss the issues relating to Delta’s development.  3.2.33 MGM described Delta as a happy baby, who never cried much except when communicating her distress. She had identified Delta as possibly being ‘autistic’ whilst she lived with her, based on her own professional experience. This she understood was also suspected by the health visitor and social worker and was about to be investigated. It is of note that MGM’s statement to police in December 2019 (provided to the reviewer), referred to her granddaughter being ‘peaceful, lovely, observant, pleasant’, but whom she had thought may have ‘autistic traits’. The basis for this was baby Delta’s lack of concentration and focus (whilst identifying this is not unusual at that age) and ‘when you sit with her, she would look the other way and blank you and not focus’.  3.2.34 MGM has reflected that initially she never expected Mother to be able to parent her baby at such a young age, and she and her sister were prepared to take over the parenting role. However, Mother surprised them all, as well as the professionals, with her apparent ability to be the ‘perfect parent’. MGM believes that the focus of support prior to Delta’s death was on Mother as a parent and not on Mother’s own needs as a traumatised child, who was neglecting her own health needs, such as her apparent eating disorder. She wondered if Mother felt enormous pressure to be a perfect parent and in this context was unable to express the challenges that this involved or to ask for help. MGM commented on the lack of provision of therapy, despite her being told this would be provided in LA2 children’s home. However, she did acknowledge that it may be that Mother was not emotionally able to accept such help then. 3.2.35 MGM described her close supportive family, and that Delta was her first and, so far, only grandchild. She was much loved by the entire family and her loss has been a tremendous shock. As far as she knew Mother always left her daughter with family or one of the various close friends she had made when attending college in 2018. MGM recognises that Mother herself has suffered great trauma in her life and the family are trying to provide support to her whilst in prison.  3.2.36 MGM would for the future hope that practitioners are educated about working with people of different cultures and that school staff are better able to identify racism and bullying, and get to the bottom of what is happening.    25   4 Thematic analysis 1: How were decisions about assessment of risk and safety planning made by practitioners in relation to Delta?  4.1 Introduction  4.1.1 The decisions and safety planning on this case were based on the positive assessments undertaken by practitioners with regard to Mother’s parenting and initially on Delta’s development. Since Delta’s death, the criminal investigation has highlighted Mother’s ability to manipulate those around her and her apparent skilled capacity for deceit of all those around her, including family, friends and professional staff.  4.1.2 The process of the review has enabled reflection and identification of areas where there is learning. This is analysed under the terms of reference (see appendix 1). This is split between this section 4 and section 5.  4.1.3 Section 4 addresses the critical and complex issues of the first term of reference: ‘How were decisions about assessment of risk and safety planning made by practitioners in relation to Delta?’. Section 5 addresses the remaining terms of reference.   4.1.4 Assessment and diagnosis are a vital aspect of the work of professionals in all agencies, in deciding on any risk to the welfare of a child and what decisions to be made to promote the child’s welfare. This is a:  ‘dynamic process, which analyses and responds to the changing nature and level of need and/or risk faced by the child from within and outside their family’. It is important that the impact of what is happening to a child is clearly identified and that information is gathered, recorded and checked systematically, and discussed with the child and their parents/carers where appropriate.’ 14 4.1.5 Section 4 examines the assessments – or lack of them- which informed each of the critical decisions taken for Delta:  • Pre-birth planning for unborn Delta  • Move of Delta to MGM, ending of legal planning for Delta, discharge of Mother and Baby from s.20 accommodation • Ending of Delta’s child protection plan (CPP) • Ending of Delta’s Child in Need plan (CIN), closure of Delta to children’s social care (CSC), withdrawal of social worker for Delta and absence subsequently of formal co-ordinated support and safety planning for Delta • Move to supported independent living for Mother and Delta • Response to emerging concerns during 9 weeks at the supported accommodation    14 Working Together to Safeguard Children 2018  26   4.2 Pre-birth assessment & planning (September 2017 – February 2018) 4.2.1 When Mother was in the residential placement in LA4, there was good quality assessment of risk and decision making in relation to the unborn child. Mother’s adolescent team social worker (SWM1) appropriately identified potential risk, related to Mother’s young age, her experience of being missing and likely being a victim of Child Sexual Exploitation [CSE]. 4.2.2 In line with procedures, the unborn baby was referred to a different social work pod to undertake the pre-birth assessment. This enabled a separate social worker (SWC1) to focus solely on the needs of the unborn baby, as opposed to the needs of the prospective Mother, a child herself, who was looked after by the local authority. 4.2.3 This timely assessment accurately identified the risks to the unborn child and highlighted the risk arising from the fact that Mother had still not spoken about what had happened to her during the time she was missing or the identity of the father.  4.2.4 This assessment identified the need for a specialist Mother and baby foster placement, a child protection plan and consideration for legal proceedings. All these plans to promote the safety of the unborn Baby were implemented in February 2018. Learning In this initial period of the review professional practice was of high quality, and provided a safe plan for baby Delta’s birth and future assessments required to be able to make safe decisions about both Delta and her Mother’s care. The assessment highlighted the risk associated with the fact that Mother had still not spoken about what had happened to her during the time she was missing nor the identity of her baby’s father. 4.3 Assessments leading to the move of Delta to MGM, ending of legal planning for Delta and discharge of Mother from s.20 accommodation (March – July 2018) 4.3.1 During this period Delta was born and lived with Mother in a specialist mother and baby foster care placement. Mother remained looked after whilst Delta was both looked after and subject to a child protection plan. The good quality planning and assessment from the pre-birth period was implemented.  4.3.2 The components of the assessment in this critical period were those undertaken by the health visitor (HV1), EPAP and MGM’s viability assessment by SWM1. Whilst these provided considerable information for decision making, there were opportunities missed to provide more information to provide other perspectives to the overall assessment and decision making i.e. foster carers feedback, legal assessment and advice over ending the PLO process, wider family involvement in the viability assessment and an investigation in response to MGM’s complaint.   27   I. Positive Early Parenting Assessment Programme (EPAP) assessment 4.3.3 The EPAP assessment submitted in September 2018 was based on Mother and Delta’s attendance on the programme for a period of 5 months, from April to August 2018, involving 120 hours of observation at the programme and home visits. This in-depth assessment considered Mother’s traumatic past, ongoing experience of racism and bullying since moving from London, her developing parenting skills, parent/child interaction, attachment and emotional care, Mother/MGM relationship and looking forward to Mother’s transition to adulthood. The latter considered the challenge of being a parent whilst also seeking a relationship/sexual partner.  4.3.4 This assessment provided an extremely positive judgement in relation to Mother, with no concerns regarding her parenting capacity in the context of the ongoing support of MGM. It also reported on the restorative therapy undertaken between Mother and MGM which had helped resolve previous tensions arising when Mother was going missing for extended periods.  The description of Mother as ‘extremely polite, caring, intelligent and likeable’ is one reflected in other practitioners’ descriptions. 4.3.5 The emerging findings were communicated within CSC during the process and fed into the decision making to end the PLO (see 4.4) and for Mother and her baby to move to MGM in July 2018. These findings provided the strongest possible indications that there were minimal, if any, risks in Mother’s parenting of Delta and confirmed the positive observations by all practitioners at that point. The slight cautions articulated by foster carers in relation to Mother’s occasional prioritising of her own needs above that of Delta, was not considered at all as part of this, or any other, assessment (see Section 4. V below).   4.3.6 This EPAP assessment challenged other social workers, suggesting that, in the assessor’s opinion, Mother and MGM had to ‘manage some ambiguous obstacles caused by … institutional racism’. This opinion seems to be based on Mother’s accounts in relation to foster carer’s alleged cultural insensitivity (see sections 4. IV and V below).  Also, Mother spoke of the pressure on her to accept the view that she was a victim of CSE. The assessor refers to assumptions based on racial stereotypes that Mother was the victim of CSE when missing in London, despite never disclosing it and in this assessment denied it having happened to her.  It is of note that she has subsequently told the first reviewer, myself and MGM that it did happen to her.  4.3.7 The social workers who held case responsibility [SWM1 and SWC1] largely ignored the assessor’s view that Mother was not a victim of CSE, on the basis of her behaviour in 2016/17. However, the issue of possible institutional racism is one that had a large impact on the practitioners in this case in CSC, with the social workers being extremely sensitive to possible racism in their own and other’s practise in relation to Mother and MGM.    28   4.3.8 When I met the EPAP assessing social worker she spoke of the tensions that arise in her role about stating negative observations which may discourage the family (who are given the report). For example, it was observed that Mother, at times would get up and leave the room without thinking of asking anyone else to look out for Delta. Also, she was cut off emotionally, with a ‘blankness behind her eyes’. These issues would be no different to many parents on the programme, so was not considered significant and we were told it is considered ‘‘not good for relationships with young parents to include every ‘negative’ or concern in reports and meetings, if parenting is ‘good enough’’, especially if you know services are involved. See below in Learning for comment on this. 4.3.9 The EPAP social worker’s assessment had recommended the ending of social work support for Delta, as with the support of MGM this would not be necessary. She explained that whilst there would have been merit in being able to provide longer term support, particularly to MGM, that the current process driven approach, does not enable this, if the case is deemed not to have met the thresholds (see 5.8).  Learning This assessment was undertaken in respect of what was perceived as a long-term plan at family rehabilitation, so MGM would be present to support Mother in her parenting. What was missing from the assessment was any realistic view of such rehabilitation plans succeeding given the overcrowded accommodation. By not addressing the reality of the situation, the assessment was over optimistic and did not address the future probability of Mother’s parenting if living independently. Moreover, had the assessment addressed the practical issue of overcrowding, it might have prompted SWM1, SWC1 and SWC2 (and their managers) to push for the family to be helped to move into a 3 bedroomed house. The lack of open acknowledgement of any weaker parenting skill areas recurs repeatedly in this case; in the desire not to risk relationships with families or discourage Mother in her positive progress, it is possible to miss an understanding of the entire picture. This in turn risks Delta’s lead professional having incomplete information on which to base decisions. It also meant that Mother was not necessarily informed of any weaker areas in her parenting and given support to improve her skills. II. Positive viability assessment of MGM 4.3.10 The viability assessment of MGM, undertaken by SWC1, concluded on 01.06.18 that MGM would be a viable carer for Mother and Delta. 4.3.11 MGM spoke openly about her own family’s traumatic early history, including her parents’ deaths in the Rwanda genocide. She also spoke of her positive parenting experiences and that Mother’s 2 elder siblings grew up to be independent capable adults.   29   4.3.12 She mentioned the domestic abuse she suffered but in comparison with both LA1’s records and mother’s descriptions, this account minimised the severity of at least one incident and denied it was witnessed by her 5 year old daughter (Mother). See 2.2.4 -5. She said that domestic abuse was only an issue with Mother’s stepfather, describing him as aggressive on a few occasions, shouting and on one occasion when he slapped her, but MGM said this was not in front of the children. The couple subsequently parted and MGM, Mother and younger aunt moved to LA2.  4.3.13 The assessment did not explore the apparent contradiction with either Mother’s accounts, nor explore in depth the at times apparently problematic relationship between MGM and Mother i.e. during pregnancy MGM was perceived as being angry with or hostile to Mother when she was living in the LA4 children’s home. The social worker explained that previous records from LA1 were not accessed, so the extent of contradictory information would have been impossible to challenge. 4.3.14 MGM planned great changes to her life to support daughter and granddaughter, reducing her working hours from full time to 2 days a week, looking after Delta when Mother attended college and only working when Mother was with Delta. MGM had deferred her plans to commence a university course to facilitate support to Mother and Delta. This indicated positive evidence of the support Mother would receive from MGM. 4.3.15 MGM’s 2 bedroomed accommodation was discussed and the plans for MGM to sleep on the lounge sofa bed, whilst both her daughters had each bedroom and Delta shared a room with her mother. This was an over optimistic plan and should have been identified as likely to break down in the longer term unless larger accommodation was obtained. SWC1 has confirmed that the move to MGM’s home was seen as rehabilitation and a long-term plan for Mother and Delta. 4.3.16 Another aspect missing from this assessment was the wider family. MGM and Mother both spoke of their strong bonds with wider family members, especially Delta’s oldest aunt and her great aunt in London, but they were not seen as part of this assessment, despite their involvement in the FGC and the aunt’s attendance at a subsequent review meeting. The role of MGF in any future support of Mother was also not explored, and the earlier plans to assess him appear to have been dropped over time, in the face of difficulty making contact. 4.3.17 There is no evidence of the viability assessment checking out family members likely role (and hence responsibilities) in future support to Mother and Delta. Given the ending of family group conferences as Mother was returning home, this was even more important.     30   Learning The lack of exploration of the discrepancy between accounts of the domestic abuse missed an opportunity for the assessment to have dug deeper and perhaps surfaced any underlying tensions within the family and any significance for them. Had the historical records at LA1 been accessed, this would have provided a better base on which to start a more in-depth assessment. Options for obtaining larger accommodation needed to be explored at this point, including how CSC might help facilitate such a move, rather than wait for tensions to arise due to overcrowding and lack of personal space for MGM.  Where wider family members are understood to form part of the support network around a young child (in this case 2 children: mother and baby), the assessment should involve such people so there is an understanding by both the individuals and the assessor of what is involved and the capacity of those named to undertake this responsibility. Moreover, this would enable direct communication between CSC and family members, which would have been extremely helpful to have established when concerns arose in autumn 2019. III. Positive health assessment 4.3.18 The health visitor (HV1) saw, or tried to see, Delta on 4 occasions and noted that at the: • new birth visit (early April): Mother was kind and loving to Delta, smiling at and handling her well • 6/8-week review (early May): Delta was alert and responsive, had good eye contact and sought Mother’s face, tracking her as she moved. • first attempt of 12-week review (mid-May): Mother seen at EPAP, but HV1 unable to do the assessment as Mother too tearful about the restrictions of living in placement  • 12-week review held at MGM’s home (early June): Delta bright and responsive, ‘lovely’ face to face interactions with Mother observed and Delta was appropriately stranger aware. • Visit at MGM (early July):  Delta continued to make good progress but needed to be taken to hospital for a urine test  4.3.19 The health visitor’s assessments of Mother’s parenting and Delta’s development were entirely positive, and there were no concerns raised about the following exceptions to this: • Mother took 26 days to take baby Delta for a urine test as advised by HV1 at the 12 week follow up (see above, 5th bullet point) • From birth Delta was noted to have a cloudy cornea, which was followed up locally and by Great Ormond Street Hospital (GOSH): Mother forgot or (as she said) never received an appointment for the review at GOSH in July 2018, which was rearranged for September (when she attended)     31   IV. Lack of assessment of MGM’s complaint and cause of tensions in home 4.3.20 6 days after Delta’s birth the foster placement set up meeting in early April, clarified the child protection remit of the placement and the detailed specific requirements including the following specific expectations of Mother: • for 1st 2 weeks parent remain with carers except for any professional meetings • no overnight stays for Mother and Delta at MGM’s until a ‘risk assessment’ concluded  • Mother’s Church attendance with MGM and on her own at specified times (with changes made 2 days in advance)  • Mother able to take Delta out of placement for 3 hours, 3 days a week • Mother not to visit anyone’s home other than MGM • Baby could be left with carers for up to 3 hours twice a week • Mother to give carers notice of plans and let carers know of her whereabouts • Mother not to travel outside of Brighton and Hove. 4.3.21 It is evident from the carers’ daily logs that they made efforts to welcome Mother and Delta in the placement, and facilitated friends’ visits and on occasion invited friends to share the evening meal. Despite good relationships within the placement much of the time, tensions emerged which practitioners judged to be a cultural ‘mismatch’ between the carers and Mother and MGM. 4.3.22 It is unclear how these tensions arose, but the day after Mother moved into the parent and baby placement, in February 2018, the chair of the Pathway Plan review meeting noted that both he and SWM1 had reservations about the plan for the unborn baby to be Looked After and to be subject to a child protection plan. This may indicate a different perspective between those whose focus was on the baby and those on Mother, also a Looked After Child. However, it is possible that such open expressions of professional disagreement may have had an impact on Mother’s respect for the subsequent child protection basis for arrangements (see 4.3.20) made after Delta’s birth in late March, and the foster carers attempts to implement them.  4.3.23 From the outset there were repeated tensions about the various arrangements agreed after Delta’s birth. In particular, Mother sometimes extended her and Delta’s time out of the placement for longer than agreed and, as a consequence, the carers not always knowing Delta’s whereabouts. There were several attempts to clarify the roles and expectations of carers, Mother and MGM, but the tensions continued. This was perhaps exacerbated by social workers sometimes giving permission for last minute changes in plans, without consulting or informing carers.   4.3.24 By the end of April 2018 MGM wrote a letter of complaint to SWM1 about the foster carers, following earlier verbal complaints. MGM’s complaint included several allegations requiring investigation and show that she did not understand why the carers had ceased to allow Mother and Delta to stay overnight with her – as agreed for a period following Delta’s birth and the set-up meeting (see 4.3.20).  32   4.3.25 There appears to be confusion about how this complaint was handled, and if it was indeed a complaint or just raising ‘issues’.  4.3.26 The complaints procedure (of that time) was not followed and the instruction that ‘All comments, complaints and compliments about services to children should be recorded by the front-line manager who receives them and forwarded to the Complaints Manager’15 did not occur.  4.3.27 The 2 social workers involved did not recall if this complaint was investigated or resolved, other than that SWM1 handed the letter from MGM to a manager. The EPAP assessing social worker and manager knew there had been a complaint and that MGM never received any response to it.  4.3.28 The then manager of the fostering pod has been able to provide information on responses to what she perceived as the ‘issues of concern’ raised by MGM, providing me with documentation she made of 2 meetings in May 2018, which were held involving herself and the various professionals involved with the placement. Such meetings occurred regularly in recognition of the complexity of the circumstances and the need to keep the large number of professionals working and communicating well together. The notes of the meetings were sent to both SWM1, SWC1, their managers and the IROs involved in the case.  4.3.29 At the 1st meeting in mid-May, the manager of the fostering pod had not yet seen the letter from MGM, but there was discussion of the misunderstandings by Mother and MGM about the role and responsibilities of the foster carers. The second meeting addressed the specific complaints MGM raised and show that the foster carer’s supervising social worker and manager had looked into what they defined as ‘issues’ (as opposed to complaints) and concluded the issues raised were not supported by evidence. 4.3.30 Actions were agreed in both meetings for the social workers and their managers including: SWM1 and manager to meet with MGM in first instance to discuss the complaint, rather than providing a written response at this stage; SWM1 and SWC1 to meet with Mother to explain the expectations of carers; SWM1 to meet with carers and Mother to discuss concerns; SWC1 to discuss with MGM and to undertake a viability assessment to enable overnight stays. The only evidence of any of these actions being undertaken was the completion of the viability assessment.      15 Section 5, Complaints and Representations, 2015  33   4.3.31 There is no investigation or resolution to this complaint, other than that undertaken by the foster carers support social worker. The carers said they were unaware of there being a complaint when they spoke with the first reviewer, which makes sense given the supervising social worker and manager did not identify the ‘issues’ as a complaint. It is not clear who was managing responses, albeit as the letter was written to SWM1 and her manager, the responsibility lay there, at least in terms of initial communication with MGM and the Complaints Manager.  4.3.32 However, it is clear the matter was not resolved for MGM and Mother, as evidenced by Mother’s repeated complaints when meeting with HV1, social workers and their managers that the carers judged her, that they treated her as a young Mother with a child, rather than a child herself in local authority care. MGM told the EPAP assessor in June 2018 of how difficult it was for her to complain, and her disappointment in not having received any response.   4.3.33 A year later in 2019, the manager of EPAP wrote to MGM explaining that further to their work with Mother and MGM and hearing of the racial discrimination they have suffered the manager had met with managers from both the safeguarding team and the fostering service to reflect on changes needed to practice, including mandatory training for carers designed to ‘address, discuss and think about racism.’ This was perceived as feedback to the complaint, and perhaps reflected the views of EPAP as to the cause of the underlying tensions between the carers and MGM and Mother, albeit this assumption is not supported by evidence in records.  4.3.34  The view of some professionals about the cause of the tensions is reflected in various written comments in records, which state opinion, but without evidence. For example, a strengthening families assessment dated 24.09.18, recommending the ending of the child protection plan, made negative statements relating to the foster carers’ ‘treatment’ of Mother and that there would be an investigation by a named senior manager into them. The latter was repeated several times in the records I have seen, but I am informed, it was never the intention for an investigation into the carers. However, what was needed was an adequate investigation of MGM’s complaint. Without this, practitioners were left with allegations and assumptions that were to some extent assumed by them to be fact, and repeated to me during this review.  4.3.35 The carers did suggest at the time that there be a meeting between MGM, professionals and themselves to try to have open discussion of the tensions; this never occurred. Such action may have helped MGM and the carers to be able to work together to support Mother and Delta.  4.3.36 MGM strongly expressed her disappointment when she met us, at the lack of any response to her complaint for over a year, and then a letter that was too late and did not address her concerns. She agreed that a meeting, as the carers suggested, would have been helpful at the time, and may have enabled them to work together better to support Mother and Delta.  34   4.3.37 The ongoing tensions and the feelings expressed by EPAP and social care practitioners, are likely to have caused insufficient attention being paid to the foster carer’s reports as discussed below. This consequently had an adverse impact on the assessment at this stage. Learning The open expression of reservations regarding the use of legal and child protection process for the unborn baby (by the chair and social worker at the Pathway Planning meeting) may have contributed to Mother’s and MGM’s lack of appreciation of the reasons behind later arrangements made in the placement and contributed to the tensions between MGM, Mother and carers. The complaints procedure was not followed in this case, and with it the opportunity was lost to speak openly about MGM’s concerns, explain the rationale about the specific issues and through this facilitate a good working relationship between carers and MGM, to better support Mother and Delta. V. Carer’s reports not fully integrated into assessment and decision making 4.3.38 6 days after Delta’s birth the foster placement set up meeting (held in early April), clarified the clear child protection remit of the placement (see 4.3.20). 4.3.39 The carers wrote daily logs providing detailed information for SWM1 and SWC1 which show largely positive observations of Mother’s care of Delta e.g. • Mother was calm and competent at basic caring skills and able to care for Delta overnight without support • Mother was very good at bath times and was, ‘calm, focused and soothed’ Delta • Delta made good progress and was babbling, smiling etc  • Mother described as attentive to Delta • Mother was able to keep their room tidy. 4.3.40 Amongst the many positive observations though were some indicating that occasionally Mother did not prioritise Delta’s needs above her own impulses and wishes, such as:  • Mother could be a little disorganised not always keeping tabs on feed times e.g. in early July, when Delta was due a feed, Mother wandered off, did a big shop then got herself a McDonald’s – meanwhile Delta (waiting in car with carers) was very unsettled by the time Mother returned • On occasions carers had to remind Mother that Delta was her priority not for example spending time getting ready to go out • Mother’s increase in smoking and danger of Delta inhaling second hand smoke.  35   4.3.41 There were also some suggestions of Mother’s wish for more freedom and lack of compliance with the placement rules (see 4.3.20), particularly in relation to the time periods out of the home and the need to keep the carers notified of Delta’s whereabouts. On several occasions Mother pushed boundaries, returning late, changing arrangements at the last minute. e.g. In early May, Mother was late back from church and was out of contact for a period, whilst Delta (6 weeks) was in her care – Mother arrived home over an hour later and the carers were on the verge of reporting her missing and had been out looking for her. 4.3.42 Mother moaned about the restrictions being placed on her to the practitioners undertaking the EPAP assessment, the health visitor and to social workers and managers who were making decisions about Delta’s future. 4.3.43 The foster carers, in conversation with the first reviewer in October 2021, explained their perception that Mother was not challenged sufficiently about her behaviour at times by professionals. Moreover, they experienced difficulties themselves in raising concerns and were discouraged from doing so at meetings. On one occasion when they tried to do this, a professional sitting with Mother responded ‘how do you think Mother feels about you saying that?’  4.3.44 An example of their concerns given to the first reviewer was being informed by Mother that she had been given permission by a professional to stay out later after an EPAP session: she remained out for a further 3.5 hours, without the carers knowing of her or Delta’s whereabouts. Carers expressed feeling unable to challenge Mother as professionals were said to have given permission for her and presumably Delta, to remain out, but did not communicate this to them. Mother was frequently late, albeit typically for shorter periods.  4.3.45 The carers felt that the usual system of boundaries within Parent and Baby placements in their experience was not in place, with Mother given greater freedoms and able to manipulate practitioners. Also, they felt that MGM did not understand the nature of the placement and the carers responsibilities, nor take advantage of their invitation for her to visit Mother and Delta at the carer’s home.  4.3.46 Overall, the foster carers, despite sending in daily observations did not feel their views fed into decision making. In general, though, the carers reported that Mother was fun, likeable and appeared to enjoy life in their household. There were no concerns about Mother’s care of Delta, but they were concerned about what happened when Mother and Delta were out of the home, when their whereabouts were unknown.  4.3.47 The foster carer’s critical observations do not appear to have been factored into the EPAP assessment or into wider assessments and decision making. The reasons for this are not clear but, comments made about the carers in case recording suggest their concerns were perceived as part of the tensions between the carers, Mother and MGM.     36   Learning In this case SWM1, SWC1 and EPAP, without any assessment, investigation, or open discussion into complaints, appear to have held a negative view of the placement. This is in contrast to the views of the carer’s supervising social worker and managers. The CSC recording inappropriately presented the practitioners’ opinion as fact.  From reading records and speaking with practitioners, the foster carers were performing the child protection role they were requested to do. I cannot comment on the tone of communications between the carers, MGM and Mother, but the points the carers made were pertinent and needed to be factored into the overall assessments. The lack of inclusion of the carers’ cautionary observations within any assessment of risk to Delta was a weakness in the overall assessments. If included, they would not have altered the decisions made but may have acted as a warning for the future about potential risks that could become more critical if the plan to live with MGM was changed, VI. Ending of legal processes for Delta 4.3.48 A legal planning meeting was held in February 2018 which considered potential risks for unborn Delta arising from Mother’s previous pattern of absconding for significant periods of time, her ongoing reluctance to discuss this and apparent lack of appreciation of the risks involved.  4.3.49 The extent of any trauma Mother may have suffered was unknown, and consequently also unknown was any likely impact this could have on her in the future. Further unknowns were risks arising from Mother’s disengagement with education, lack of information about the father and Mother’s unknown parenting capacity. 4.3.50 The meeting agreed in this context to proceed with a Letter Before Action outlining concerns and a meeting with Mother and her legal representative in mid-March (a Meeting Before Action). There was subsequently much correspondence between lawyers agreeing the restrictions on Mother’s ability to leave the placement, largely as described in 4.2.20.  4.3.51 The agency report, provided by legal services to this review, observes that by June 2018, Mother was only spending 2 days a week at the carers, and was with MGM the rest of the week. The lawyer appropriately queried what the plan would be if issues arose in the meantime about Mother’s and MGM’s relationship. The social worker spoke of the positive indications from the EPAP report along with what the social worker perceived as the issue of the carers not being as nurturing as they could have been (NB this concern was never investigated and hence was an opinion, not a fact). 4.3.52 The lawyer was notified in mid-July that the plan had changed to Mother transitioning to MGM’s home in late July and discharging the s.20 agreement (for Mother and Delta). The Public Law Outline (PLO) process was consequently ended at that point without any legal advice being sought or further / updated information provided to the lawyer.  37   4.3.53 The legal services agency report raises the point that it was surprising that the risks earlier appear to have resolved so quickly, prior to the completion of the major planned EPAP assessment, which was only completed in September 2018. The social worker was by that point confident about the likely content of the EPAP assessment, but it would have been better and safer practice to have not made such a decision without taking advice from the lawyer involved in the case, and preferably providing the lawyer with emerging details from the EPAP assessment, along with the possibility to review all areas of information, including foster carers and MGM’s daily reporting. 4.3.54 At the time there was no procedural requirement to do this; this has now changed and there is a Joint Protocol for closing PLO involving a joint review with legal.  Learning If less positive issues had been taken into account in assessments and a joint review with legal held, the decision for Delta and Mother to live with MGM would most likely have been the same. However, it may have led to increased monitoring and more caution in subsequent events.  4.4 Ending of Delta’s child protection plan 4.4.1 Delta ceased to be subject to a child protection plan in September 2018, when she was ‘stepped down’ to a Child in Need plan. The assessments behind this decision were the EPAP assessment, the viability assessment of MGM and both HV1’s and SWC1’s positive assessment reports.  4.4.2 HV1 report to the conference stated that Delta was meeting developmental milestones, with good attachment between Mother and her baby and Mother ‘has shown a capacity to put her own needs second to none’. HV1 did though at the conference caution potential risks when Mother’s decisions would not be contained by her placement and the child protection plan, and that there remained the unknown of Delta’s father’s identity and relationship with Mother. HV1 supported a child in need plan.  4.4.3 SWC1’s ‘Strengthening Families Assessment’ prepared as the report for the September conference provides a glowing account of Mother’s progress and in the box for ‘risks’ stated there are none. In the conference SWC1 recommended no continuing social work involvement for Delta, in line with the EPAP assessment report.  4.4.4 The conference decided to step down to a child in need plan for at least 3 months and therefore for continuing social work for Delta. It was agreed that the threshold for a protection plan was no longer met in the context of the positive reports of Mother’s parenting and of Delta’s health and development. However, the decision making had the same flaws as the earlier assessments and decision making – see learning below.    4.4.5 The child in need plan that was made did continue to offer multi-agency coordinated monitoring of Delta’s welfare. Moreover, the plan was for Delta to attend nursery 3 or 4 days a week, which would enable consistent observation and monitoring.  38   4.4.6 The conference also sensibly planned for all professionals to support the family to obtain more suitable accommodation, through a joint letter and a network meeting to be held in November. Given the overcrowding at MGM’s home, this was urgent and planned to be undertaken within the next 7 days, but did not happen. Learning The decision to end the CPP was based on the same assessments that led to the decision for Delta to move with her mother to MGM, and consequently had the same omissions and minimisations. None of the assessments focused on potential risks for Delta in the future given:   * Unknown circumstances of Mother’s extended missing periods and of Delta’s paternity  * Mother returning back to the place from which she constantly went missing  * Overcrowded housing circumstances  * That looking after a toddler may be more challenging for Mother than caring for a baby. However, even if these risks had been articulated more clearly it is unlikely that the CP plan would have been maintained at that point: Mother and Delta had been at MGM’s for 2 months and Mother had been settled for a year.  4.5 Ending of Delta’s Child in Need plan: October – December 2018 4.5.1 Between September and December 2018 Mother and Delta lived with MGM and each had their own social worker, although there was a change in Delta’s social worker in early October to SWC2.  4.5.2 Multi-agency work and collaboration during this period was limited. A CIN network meeting was held at the beginning of November 2018 with HV1, both Mother and Delta’s social workers, MGM and Mother. There were apologies from the nursery, which Delta attended 3 days a week, with a plan to increase this to 4 days. The nursery reported that Delta was very ‘friendly’ and sociable’ and there were no concerns.     4.5.3 Whilst Mother reported positively that her education was progressing, SWM1 wrote that she had just discovered that Mother was spending her time in the library and did not attend her course, so had her place at college terminated. There was an understanding that Mother suffered from anxiety and panic attacks when entering the classroom situation, but there appears to be little understanding the cause of such emotional disturbance and whether this was an indicator of needing mental health support. Nor was there any reflection on Mother’s dishonesty about her feelings about and attendance at college, and any implications of this for future monitoring or planning.   39   4.5.4 The record of the Pathway Plan Review meeting the next day repeated the very positive views of Mother’s progress, her parenting and that Delta was thriving in her care. The record shows support for Mother’s wish to live independently, which she had been discussing with SWM1. Critically, though the IRO stated clearly as part of the actions, that this plan be discussed with SWM1’s managers and be subject to a ’an assessment of your housing needs’ within 4 weeks. This was never done, unless the completion of the housing forms constitutes such an assessment. If this is the case, that is a concern. (See 5.4.14 - 17 for discussion of forms). 4.5.5 By December 2018 it was becoming clearer that Mother was struggling with some practical organisational responsibilities. Her education plans were unresolved and HV1 (according to SCFT records) had not seen Delta awake since July (despite trying to make contact). Moreover, Mother failed to take her baby to the neonatologist appointment in early December 2018.  4.5.6 Unknown to the SWM1, SWC2 or HV1 Delta and Mother were without a GP, following informing their GP practice of their new address. The surgery wrote to Mother on 03.09.18 to inform her that they would be removed from their GP’s list on 31.10.18. Had this been known it would have been further evidence that Mother was struggling with her responsibilities, despite living with MGM. 4.5.7 SWM1 made a referral to the Supported Accommodation Panel in January 2019. There was no assessment if she was ready for this major step yet, but with this decision there was no further consideration of helping the family to obtain larger accommodation, nor of exploring their wishes and feelings about the possible option of larger accommodation. 4.5.8 SWC2’s only recorded visit to Mother (at MGM’s home), was in mid-December when she informed Mother of the imminent plan to end the CIN plan and cease Delta having a social worker. The record of the decision making was in supervision with the team manager at the end of November. 4.5.9 The CSC agency report explains that the rationale of this decision is not explained in records, but it was what would be expected in a busy social work team, if thresholds were not met to keep the case open on a CIN plan, as Mother had her own social worker, and Delta ‘was receiving health visiting service and attending nursery.’ However, there had been no contact by the health visitor when Delta was awake since July, and by the time the decision was implemented Mother was NEET again and Delta was out of nursery. Moreover, there is no evidence of any consultation within the network, or the holding of a network meeting to agree this and any future need for a lead professional and multi-agency meetings.  HV1 was unaware of this change, which in reality left her as the lead professional for Delta. There was no ‘step down’ planning which could have usefully agreed a team around the family with a designated lead professional and ongoing multi-agency meetings.   40   4.5.10 At that time the ‘What If’ procedure for CIN cases was not in place, only introduced in 2019. This enables other agencies to agree case closure of a CIN plan at a CIN Review meeting, identify a lead professional and agree a ‘What If’ plan. The Plan looks to identify if there were changes in a family’s situation which might impact on risk and which of those should require re referral to CSC. If that had been in place at the point of closure, this decision would have been subject to multi-agency review and there would have hopefully been a system to flag potential risks for the future.   4.5.11 There was no assessment in relation to this significant change and there is no process requiring this. If there had been, a CIN plan should, in my opinion, have continued given the uncertainty described above of Mother being NEET, the lack of direct contact and assessment of Delta’s health, welfare and development, that Delta had not been taken to 2 hospital appointments, not attended baby groups and had her nursery attendance terminated. Moreover, had Delta continued as a CIN, CSC may have identified the need to continue paying for nursery provision so as to monitor her welfare and support the family.  4.5.12 It is not clear from any records or practitioners’ contributions to this review, whether SWC2 or her manager were aware of: the plans to move Mother into independence , the nursery placement having ended, Mother having lost her college place and her dishonesty about her college attendance. Unfortunately, it has not been possible to locate SWC2 for this case review, so as to establish what was and was not known when the earlier decision to close the case was implemented. Her manager did not recall being told of this change of circumstances and expressed his surprise at learning Mother and Delta were moving from MGM later in 2019, having thought the plan was to remain with MGM. 4.5.13 Mother retained her own social worker, who would inevitably have some involvement with Delta, albeit her primary focus would be Mother’s transition to independence. This closing of Delta’s case by CSC was a critical decision as it marked the end of any identified concerns about Delta’s care and confidence in Mother’s parenting capacity, even in the face of her potential imminent move from MGM’s home and into independence. Such a move would inevitably involve greater risks, and it would have been prudent to retain the CIN plan until Delta was in a settled new home situation.  Learning There were 2 major changes at the end of these 3 months of the CIN plan. Firstly, to abandon the plan for larger accommodation and secondly to terminate the CIN plan. Neither was made with any form of assessment for Delta, other than the Pathway Plan and Needs Assessment, which focused entirely on Mother’s wishes and needs.  41   Unknown to other professionals, including the social workers and managers, Delta and Mother were deregistered at their GP surgery. This followed Mother informing the surgery of their change of address: the surgery wrote on 03.09.18 that they would be removed from the GP’s list on 31.10.18. This did happen. Worryingly, despite the decision being taken when Delta was aged 5 months old and subject to a CPP, and implemented when she was aged 7 months old and subject to a CIN plan, the GP surgery did not inform any professionals in the network. Although good practice to do so, there is no requirement for this to occur.  This information if shared would have provided social workers with evidence about both Mother’s difficulties coping, even with MGM’s support, and a lack of prioritising Delta’s needs to be registered with a GP. The lack of an assessment regarding Housing needs ignored the specific recommendation of the Pathway Plan Review. Moreover, it may not have been compliant with government guidance for the undertaking of a multi-agency assessment to prevent homelessness for 16 and 17 year olds16 (unless the application process constituted such an assessment).  It has been suggested that the plan for supported accommodation was not implemented to prevent homelessness, but rather to assist the relationships between Mother and Delta, so the guidance may not be applicable. If that is correct, then it is worrying that such a plan would be implemented in preference to keeping the family together by supporting them into larger housing provision. Although not a requirement, good practice would be for stepping down plans from CSC to be subject to a multi-agency review /assessment process which considers all available information known, including that held by other social work teams.  Such an assessment needs to involve consultation with other agencies on their views and agreement if a team around the family is required and if so, the identified lead professional for the child/ren. If such an assessment had been undertaken in this case it is possible that the CIN plan would have continued due to the increasing uncertainty about the future with the plans for Mother and Delta to move from MGM, Mother having lost her college course and consequently Delta was no longer attending nursery. It maybe that the ‘If What’ procedure for CIN cases fulfils this need, but that needs further research.     16 Prevention of homelessness and provision of accommodation for 16 and 17 year old young people who may be homeless and/or require accommodation (3.14 – 3.30), April 2018, Ministry of Housing, Communities & Local Government and Department for Education  42   4.6 The decision to move Delta and Mother to supported accommodation: January - September 2019 without further assessment of Mother and Delta’s needs and the risks to each from such changed circumstances 4.6.1 The decision for Mother and Delta to move into supported accommodation had been an objective agreed by practitioners and MGM from November 2018, as part of Mother’s Pathway Plan, arising from the increasing tensions within the overcrowded household. It was not subjected to an in-depth holistic assessment as would benefit such an enormous change in Delta and her mother’s life, and as recommended by the IRO of the Pathway Plan Review meeting in November 2018.  4.6.2 The subsequent assessments undertaken in the 8 months prior to the move were the new health visitor’s (HV2’s) 12-month assessment in March 2019 and the pathway plan and need assessment document in May 2019. The referral process to Housing additionally provides 2 largely tick box forms for referral and for risk assessment, which may constitute an assessment, albeit brief (see 5.4.14 - 17 for discussion).  Health visitor developmental assessment  4.6.3 A new health visitor, HV2, visited in March 2019 for the 12-month review and had concerns about Delta’s possible developmental delay, noting she was a passive child who was slow to explore the environment and who did not seem interested in playing with a ball or turning pages in a book. Also, HV2 observed the limited availability of toys.  Mother explained Delta had just woken. This marked a total change from previous descriptions of Delta by HV1, EPAP, nursery or social workers. 4.6.4 HV2 saw Delta again in early May, when she was observed to be more alert, nearly walking, climbing and exploring the environment. Delta related to familiar adults and was appropriately wary of HV2. Mother agreed then to have further support from the nursery nurse through group attendance and home visits. HV2’s concerns were allayed.  Pathway plan and need assessment 4.6.5 The pathway plan and need assessment document, produced for the review in early May 2019 provides an overview and updated entries from the previous review, with descriptions of current events and plans. What it did not do, and its format perhaps does not encourage, is specific analysis of the overviews presented. The only point when this may be encouraged is the ‘social worker/personal advisor overview and analysis’ section, which in May 2019 refers to mother and child doing well, concerns about the stability of home life and that Mother would benefit from living independently. This does not provide an assessment around the planned move, its benefits, the risks (in both settings) and how they might be mitigated. In particular how potential risk factors might be identified.  Whether it is possible for such an assessment of both children’s needs to occur as part of Mother’s pathway plan review is unclear, as the focus of the assessment and the subsequent review was on Mother’s progress and move to independence, albeit Delta’s welfare was inextricably tied to all such planning.  43   Application process for supported housing 4.6.6 The process in this case took place in the context of there being no up to date holistic assessment of Mother and Delta’s needs as recommended by the IRO at the last Pathway Plan Review in November 2018.  4.6.7 Paragraphs 5.4.13-24 discuss the application process for supported accommodation and the limitations of any assessments made as part of this. It uses a largely tick box referral and risk assessment forms, which evaluated Mother as having low support needs and low risk for abuse and for high-risk sexual practices and medium risk of an eating disorder. 4.6.8 The information provided by social workers was a brief history relating to paternity of Delta, unknown and previous ‘involvement in CSE in London, gangs, petty crime thefts and used cannabis’ but that ‘Since 2017 ... not displayed any of these behaviours’. There is no mention of any risks relating to such experiences on her parenting, nor what might constitute warning indicators which should prompt assessment or notification to social workers. The forms could be more user friendly to encourage such details to be provided.  4.6.9 Had an in-depth assessment been undertaken focused on both Mother and Delta, it should have considered the possibility of unresolved areas of earlier trauma and any consequent potential risk to Mother or her child because of this. Neither social worker considered any potential risks that might arise in Mother’s progress to independence given her history and potential risk indicators (e.g. spending increased time away from the home), nor what level of support might be needed to mitigate any risk.   4.6.10 The completed forms did not take into account that Mother’s own self-care / health needed support, as there were concerns that she had not accessed appointments in relation to her loss of weight (queried eating disorder), or lumps in her breast. There also remained the outstanding potential need to access therapy about her earlier life experiences, along with her repeated accounts of high levels of anxiety which prevented her from accessing classes when attending college, some health appointments or baby groups. 4.6.11 On a practical level, despite Mother’s impressive parenting skills, MGM mentioned that Mother did not have experience of shopping and budgeting for herself and Mother also mentioned her fear of being able to manage shopping, cooking and budgeting.  4.6.12 Had an in-depth assessment been undertaken, it would have been unlikely to have reached the conclusion that the family’s support and risk levels were low. However, even if it had concluded the risks were at a medium level, my understanding is that this would have made little change to the accommodation provided, other than an additional keyworker session per week.     44   Changes during 8/9 months waiting for independent accommodation 4.6.13 From January 2019 to August 2019 Mother and Delta remained living with MGM, whilst waiting to be allocated supported accommodation. Mother continued to receive support from her social worker and YES, but there was no social work support specifically for Delta. During these 9 months there were some changes that should have been factored into any assessment about the needs of Mother and her baby. 4.6.14 The main change in this period was the 1st emergence of concerns about baby Delta’s development, although this was an inconsistent picture (see above 4.6.3 – 4.6.4) and discounted in HV2’s next visit.  4.6.15 During this period there was also evidence of missed health appointments / offers of support, both by Mother for herself and for Delta:  • HV2 persevered in seeing Delta, despite 5 appointments when Mother either cancelled at the last minute or was not home   • Mother failed to engage with the community nursery nurse (CNN) as planned, despite the CNN’s repeated efforts to communicate with Mother, including unanswered texts and not answering the door for 2 arranged home visits • Following a children’s emergency department visit in January 2019, with a chesty cough, Mother failed to bring Delta for requested follow up, and when telephoned said this was because she was getting better and they were due "to go to Church in London".     • In May 2019 Mother failed to bring Delta for the 2nd and 3rd time to the neonatal clinic: The consultant spoke to HV2 and learnt of the positive developmental progress and weight gain. A further appointment was offered, and failed in early June, and Delta was discharged, albeit the consultant asked HV2 to re-refer if any concerns.  • In June Mother did not attend a new registration appointment with the GP – she had not been registered with a GP since the end of October 2018 • Delta was not brought to her appointments at GOSH in 2019, missing one in January 2019 and one in May 2019, and there is no evidence of there being any subsequent attempts by GOSH to follow up (they have reported that there is a new electronic system at GOSH to prevent patients being ‘lost to follow up’ as in this case)  4.6.16 Both SWM2 and HV2 became involved at various times in reminding Mother or supporting her to attend health appointments, or in the case of HV2 in making appointments following nonattendance (albeit not at GOSH). Whilst there was communication between HV2 and SWM2 regarding the developmental concerns, the non-attendance at appointments was not identified as a concern, largely because there was a tolerance of a young parent’s disorganisation, none of the missed appointments were perceived as a health or welfare problem and Mother gave reasonable explanations and re-arranged appointments. 4.6.17 It was known Mother was visiting London again to visit family and to go to Church in this period. The social worker believed that MGM had accompanied Mother and Delta to London when she began to visit again. MGM had not expressed any concerns.  45   4.6.18 Unknown to professionals at the time, the criminal investigation into Delta’s death has shown that Mother was already spending time in London with friends (as opposed to family) and possibly neglecting Delta’s needs (see 5.2.11-15) as early as January 2019.  4.6.19 Even without this knowledge there was an indication that Mother was not consistently putting Delta’s needs first. HV2 made a detailed plan in mid-June including the initiation of an Early Help Plan if Mother did not address Delta’s health needs. At this point HV2 had become aware of the lack of GP, following Delta not being brought to a neonatal appointment. Subsequently Mother did register with a GP and attend the next neonatal appointment, so stalling HV2’s planned action.  4.6.20 The delay in assessment was understandable given Mother’s new compliance, although by this time there was sufficient evidence to have initiated such an assessment. HV2 then referred Mother to the Community Nursery Nurse for support with play and meeting Delta’s developmental needs, but Mother did not respond to 5 attempted contacts, including home visits.  4.6.21 The lack of assessment with regard to readiness for independent living (see 4.6.6 – 4.6.12) became more critical with the emerging concerns about baby Delta’s development, Mother’s inconsistency at taking Delta to health appointments and their frequent absences in London. Also, Mother stated the relationship with MGM had deteriorated. What this meant in practice is unclear in terms of MGM’s support at that time and how it would change after the move.  4.6.22 An assessment would have allowed an objective multi-agency analysis of Mother and Delta’s support needs, the triangulation of information and analysis of any risk to parent (a child herself) and her baby. Such an assessment should have been undertaken from the perspective of Delta, the most vulnerable child, and consequently would have needed a re-referral to FDFF.  4.6.23 Neither a social work or Early Help HV2 assessment occurred because overall Mother was considered to be an impressive parent, and able to provide plausible excuses for her inconsistent keeping of appointments. There were no reported or identified issues in relation to Delta’s welfare as a result of Mother’s missing appointments. Neither Mother nor Delta were accommodated nor subject to child protection or child in need processes, so MGM and the wider family were relied upon to raise any concerns. However, the criminal investigation has established that from the accounts of Mother’s friends (in their witness statements for the Coroner) there were concerns regarding neglect which were never reported to social workers or MGM.  Lack of GP and GOSH feedback 4.6.24 Following the GP surgery removing Mother and Delta from their list in October 2018, both remained without a GP until June 2019. It is of concern that this is able to occur without health visitors and social workers being informed, despite the decision being taken when Delta (aged 5 months old and subject to a CPP) and implemented when aged 7 months old and subject to a CIN plan.  46   4.6.25 The lack of follow up with regard to the 2 GOSH appointments was due primarily to Delta becoming lost in the system at GOSH and consequently GOSH neither provided another appointment, nor discharged her nor apparently informed local practitioners of Delta’s nonattendance. These appointments may have been significant. They provided an opportunity for Delta’s vision to be checked, which given the concerns observed regarding her lack of focus may have been helpful. Additionally, it would have provided an opportunity for Delta to be seen by a paediatrician who may (or may not) have identified wider welfare concerns relating to Delta’s health and development. 4.6.26 Locally, without an allocated GP until mid-June 2019, there was no health professional with holistic health information and hence ability to notice a lack of feedback from GOSH to the appointments. HV2 had no information about the GOSH appointments, so was unable to chase these up. Learning HV2 was considering undertaking an Early Help Assessment in this period due to her concerns, but following Mother’s compliance a plan to further support the family was implemented. Given the repeated on/off nature of concerns about Delta’s development, missed health appointments, 8 months without a GP registration and subsequently mother’s lack of co-operation with nursery nurse support, such an assessment would have been prudent.  HV2 would have been more likely to have been tipped into such an assessment has she also known of the missed appointments at GOSH (and earlier about the lack of a GP). However, because Delta was ‘lost’ in the system at GOSH (and without a GP to note the lack of any GOSH feedback) HV2 was unaware of these missed appointments, which may have been relevant given the developmental concerns for Delta. In general, up to date assessments should be undertaken prior to making any major decisions which change a care/pathway plan within CSC, such as the transition to independence of care leavers who are parents. Such an assessment should consider if the parent is ready for this move, what support is needed, any risks to the child/ren and parent who is a child, how progress will be monitored and what indicators of risk must alert staff for the need for further assessment. In this case such an assessment may have identified that the family’s support needs were greater than available at the supported accommodation, and/or consideration given to nursery provision for Delta regardless of Mother’s college attendance for both her welfare and Mother’s.    47   4.7 Responses to emerging concerns and re-referral of Delta to CSC in October 2019 Uncertainty about Mother and Delta’s whereabouts in September 2019 4.7.1 In early September 2019 Mother was offered (and accepted) a flat with an accommodation provider. MGM moved her belongings there, because Mother and Delta had gone to London. They never stayed there and by mid-September Mother was offered and accepted a place at an alternative provider where she would not have to share facilities with others and have her own self-contained flat.  4.7.2 SWM2 returned to work in September after 2-month absence and was informed that the situation had broken down at home, with Mother and MGM arguing. MGM told the author that their relationship was fine and Mother spent September either with MGF in London or at home with MGM. Mother told SWM2 she was staying with her sister (older aunt) in London.  4.7.3 Mother and Delta were allocated the tenancy of a first floor flat at the supported accommodation on 18.09.19, in accordance to Mother’s Pathway Plan. This property provides support for 8 young families transitioning to independent living, where they can reside for up to two years. At this point Mother was coming up for 18 years old and receiving support from her adolescent pod social worker, SWM2.  4.7.4 The property has 2 members of staff present at the premises Monday to Fridays during day time working hours. They provide up to 4 hours of support per week to parents, plus group activities. Mother was assessed on referral as low support needs by her social worker so the support allocation was for two hours a week. 4.7.5 At her interview Mother was told of the weekly keyworker sessions, that she should inform staff if away overnight and that she was only permitted to stay away a maximum of 3 nights a week. There is CCTV on the premises, but this is not routinely checked, consequently staff would be unaware of the comings and goings of families out of office hours on week days and all weekends. 4.7.6 Mother only moved into the flat late on 30.09.19. SWM2 described her as not being well prepared and without essentials. SWM2 provided a great deal of assistance to Mother and Delta during this period, setting up the cot, arranging for furniture and frequently visiting with items for Delta. Emerging concerns 4.7.7 From the outset, Mother was unreliable in keeping her appointments with practitioners, having missed her first scheduled key worker session after her tenancy commenced but prior to her arrival. She then missed 2 further sessions and in total in the 9 weeks she lived at the supported accommodation she attended 4 out of 9 scheduled sessions. In mid-October the keyworker reminded Mother that these sessions were part of the tenancy agreement.  48   4.7.8 The plan had been for Mother to re-engage with college and her education in September 2019, but Mother had not made the required arrangements and lost her place. In consequence the anticipated nursery provision was not made for Delta. Mother then cancelled her appointment with the YES/aspire worker to consider alternative plans. 4.7.9 After meeting with Mother and Delta in early October, HV2 again identified concerns in relation to Delta’s development and her need for play and stimulation. Mother agreed to engage if re-referred for home and group sessions with the nursery nurse. Positively HV2 noted that Mother was very loving to Delta. A referral was also made for audiology.  4.7.10 In mid-October concerns were identified about Delta’s care following a review of CCTV footage within the supported accommodation, prompted for reasons totally unconnected with Mother. This showed that 6 days previously [11 days after moving there]: • Mother and friends carried an unstrapped Delta in pushchair up the stairs • between 19.00-23.00 hours Mother and friends were going in/out of building to smoke, carrying cups unsteadily and leaving Delta alone for 15/30 minutes at a time – Mother had previously been warned not to leave Delta alone whilst smoking  • At 23.55 a friend carried Delta, whilst Mother followed unsteady on her feet –Delta was taken to a waiting car  • Mother returned to the flat at 1.54: she was carried in by her friends  • Delta returned next morning – a friend answered the front door to the flats and carried Delta - Mother accompanied friend but was not observed to greet her baby 4.7.11 These concerns were discussed with Mother by staff, when Mother lied, stating initially Delta went to MGM at 17.00 and she was not drunk but hurt her ankle. Staff appropriately informed SWM2, who advised them to inform FDFF (but this did not occur). 4.7.12 Mother missed the keywork session on the 21st, saying she never received the letter the keyworker put through her door. The session was held 2 days later when Mother changed her explanation of the events stating Delta had been collected by MGM, after her shift work had finished and stayed with her overnight.  4.7.13 Mother was advised not to leave Delta alone but provided by SWM2 with a baby monitor to use when she left her sleeping in order to have a cigarette outside. The use of a monitor to be able to leave Delta alone for short periods, was a concerning message to give Mother, both as a principle, but given Delta was mobile this was particularly worrying as she could have had an accident. 4.7.14 Staff at the supported accommodation gave Mother a warning that an alcohol ban would be initiated as she was under 18 and implemented a one week ban for friends to visit the flat. Staff would in future check CCTV regularly and night staff would check communal areas.  49   4.7.15 The Pathway Plan review meeting for Mother as a Care Leaver was held on 24/10/19 and the concerns were referred to by the Chair, but not discussed at the meeting, which was Mother’s final review. The chair and social worker wished to keep the meeting a positive experience for Mother. This missed a critical opportunity for full and frank discussion of Mother and Delta’s progress since moving to the supported accommodation. This might have enabled a wider multi-agency discussion about Mother’s non engagement with key worker sessions, informing staff of her plans to be away and provide contact details of where she would be, along with the concerns arising from what was found on the CCTV.  4.7.16 Mother being 40 minutes late for the meeting functioned to make such discussion with her less likely. Not known to professionals at that time, but discovered in the criminal investigation, was that Delta was left alone the previous night for 7 hours whilst Mother attended a party. 4.7.17 This lack of discussion with Mother at the Pathway Plan Review was taken with Mother’s welfare at heart, not wishing to upset what seemed to have been a successful outcome to her care experience and marking the positive end of this stage of her life. The chair took pains to ensure the concerns about Delta were progressed elsewhere (advising referral to FDFF), but the continuing overall positive message to Mother of her progress may not have been helpful in getting her to focus on Delta’s welfare and safety, along with Mother’s perceived needs for positive affirmation.  4.7.18 HV2 attended and shared her observations of Delta and her plan for a re-referral to a CNN, commencement of a Strengthening Families Early Help Plan and a planned Team around the Family (TAF) meeting scheduled for December 2019, where concerns of Delta’s development could be discussed in a multi-agency context. HV2 noted that Delta sat at the meeting for 1.5 hour, playing with paper and looking at a pen. 4.7.19 The following day MGM confirmed to SWM2 Mother’s explanation of Delta’s whereabouts the night of 11.10.19 (i.e. with her). A referral was passed ‘for information only’ by SWM2’s team manager to FDFF on 30.10.19. The FDFF Team Manager discussed the case with Delta’s previous social work Team Manager (i.e. from 2018), but without consultation with other agencies, and decided the referral did not meet the threshold for a children’s social care assessment.  4.7.20 At this point, whilst the circumstances of the 11th had been investigated and it was confirmed that Delta was with MGM, it would have been advisable to have a broader assessment focusing on Delta’s needs (and not on Mother’s Pathway Planning) given the pattern of Mother’s behaviour since September. However, it is unclear to what extent the supported accommodation staff, SWM2 and HV2 identified the following factors as possible indicators of concern:  • Mother missed keyworker/ appointments from the start: the first 2 sessions in September, she cancelled the 07.10.19 (as in London overnight) and missed the 21.10.19. Mother attended her first keyworker session on 16.10.19  50   • Mother remained NEET having not arranged her college course as originally planned, consequently the plan for Delta to attend nursery did not happen • HV2 had ongoing concerns for Delta’s development, missed health appointments and non-engagement with the CNN on and off since HV2’s first contact in March 2019 and the actions planned would take some time to provide further information about the causes of Delta’s developmental delays, and if there were physical explanations for this  • Staff at the supported accommodation had also by this stage identified Delta’s lack of responses to others  • Implications for Delta’s welfare, spending unknown but considerable periods in London, thought to be with different family members. 4.7.21 Practitioners were reassured by Mother, who was always friendly and co-operative and seemed focused on her 19-month-old baby’s needs. There was sympathy for Mother’s anxiety about her Leaving Care transition (from a social worker to a Personal Assistant), and desire for her not to feel ‘judged’ but supported. Moreover HV2 was acting on concerns (see 4.7.18), which felt an appropriate level of response in the first instance, although a CIN assessment would have been more appropriate, taking into account what appears to be changed behaviour by Mother since moving into the supported accommodation.  4.7.22 From this point in late October 2019 and through November there was a continuing picture of Mother repeatedly cancelling or not keeping appointments with community nurse, ‘Safety Net’ (a charity contacted by HV2 to provide child safety equipment), keyworker sessions at the supported accommodation and SWM2. Mother also left Delta alone for a short period (when Mother popped to office on premises), took Delta out late at night (despite being told to avoid this) and did not tell the supported accommodation (as agreed) that she would be away overnight.  4.7.23 Mother was increasingly absent from the accommodation and was difficult to contact on these occasions, missing her keyworker sessions for 3 weeks by 01.12.19, with it being explained to her (again) this is in breach of the support agreement and that residents were required to be at the property at least 4 nights a week and to explain any absence to staff. When reminded, Mother did sometimes discuss and agree her planned absence to be with family with her social worker, albeit any attempts to check this out failed with maternal aunt or MGF. 4.7.24 The supported accommodation staff identified their intention on 4 occasions in November to implement formal ‘Missing Person’ procedures because of unexplained absence after 24 hours. However, Mother would then eventually made contact with her social worker or them and return. It is of note that Mother’s absences and lack of contact were such that on 20.11.19, the supported accommodation described to SWM2 that Mother was disengaging with the service and that HV2 had told her that she was also struggling to make contact with Mother.  51   4.7.25 It is unclear to what extent information was shared between agencies during these weeks about Mother’s cancellation or missed appointments. The supported accommodation provider’s concern of Mother’s disengagement with the service might have then been identified as applicable to all services. If there has been 1 lead practitioner with such full information, it may have been more likely that Mother’s apparent increasing withdrawal might have been identified. However, against this perception was one where Mother would communicate sometimes and provide believable explanations for her absences etc. Mother did see SWM2 on 22.11.19, when SWM2 accompanied her on an audiology appointment for Delta, and finally saw the community nurse on 28.11.19, when Delta was asleep. 4.7.26 Over these last few weeks of Delta’s life HV2 referred Delta for assessment of the developmental delay and made contact with GOSH asking if Delta needed to be seen again given issues about eye contact. GOSH agreed to offer a further appointment in 2020, despite Mother having failed to bring Delta to 2 out of 4 appointments.  4.7.27 By early December staff at the supported accommodation raised concerns with SWM2 that they had barely seen Mother and Delta in the previous 3 weeks and not for 4 days. They did not know their whereabouts and Mother had not responded to emails or texts. They again threatened to report her as missing. Mother responded to SWM2 saying she was unwell and needed help caring for Delta, so went to her sister in London. SWM2 asked for the sister to make contact to confirm this, but she did not do so.  4.7.28 On Mother’s 18th birthday, SWM2 visited to deliver toys, clothes, buggy etc for Delta, who was asleep in the bedroom after a bad night. See 2.7.13 – 2.7.19 for details of what was known by practitioners over the next days. What was notable with regard to service provision was that because the supported accommodation was not staffed at weekends, staff only became aware of Mother’s absence after 4 days – and with no indication to the contrary, assumed Delta was with Mother. Mother continued to communicate with both SWM2 and the YES worker, so no concerns were raised by their apparent absence. 4.7.29 This 9 weeks at the supported accommodation was the first opportunity since the foster carers and brief attendance at nursery for practitioners to have a sustained glimpse into both Delta and Mother’s life. During the brief 9 weeks, staff began to identify inconsistencies in Mother’s explanations but the slowness to institute formal processes, such as reporting Mother and baby as missing, initiating CIN or more urgent TAC processes limited the ability of practitioners to identify the risks to Delta, and whether the extent of monitoring of the family was sufficient in this context. 4.7.30 However, even if FDFF had received the referral earlier and initiated a child in need assessment of Delta’s welfare, or HV2 had initiated a faster plan for assessment and TAF meetings, it is unlikely that the immediate risk to Delta of being left home alone for longer than a cigarette break would have been identified, given the lack of any suspicion of this potential risk.  It maybe that she would have been subject to a child in need plan, but this is unlikely to have changed the outcome.   52   Learning The lack of assessment prior to moving to independence meant little articulation of potential risks and of a risk management plan to assist identification of risks and how to mitigate them. The referral to FDFF was 20 days after the concerning episode occurred and 12 days from the events becoming known. This was too long and in part lay in the confusion about whether the supported accommodation provider should make the referral, as advised by SWM2, or if SWM2 needed to do this. Whilst CSC are clear it was for the supported accommodation to do so, this was not obvious to them. However, this delay is unlikely to have affected the outcome. The decision for no further action by FDFF was based on the prevalent positive view of Mother’s parenting and that HV2 had initiated the December Team Around the Family process. This meant a considerable delay in further assessment, and would not provide the social work assessment focused on Delta’s needs indicated by the changed circumstances since moving, the lack of any such assessment since the summer of 2018 and the emerging concerns over and above what was seen on CCTV. These concerns were not identified and detailed on the referral.   53   5 Thematic Analysis 2: Terms of Reference 2 - 7 5.1 Introduction 5.1.1 Section 5 addresses the terms of reference numbers 2 – 7. Number 1 is discussed in Section 4. See appendix 1 for the full terms of reference. 5.2 What was practitioner’s understanding of Delta’s lived experience? First 4 months: living with Mother at foster carers 5.2.1 Following Delta’s birth, she was observed in the foster placement, during the EPAP parenting assessment, by SWC1 and by HV2. There were no identified concerns about her care, based on her presentation and her interaction with her Mother and HV1’s assessment of her development.  5.2.2 The foster carers reported to the first reviewer that in the house Delta hardly ever cried, was easy to look after and Mother was generally attentive. When they cared for Delta she was more fretful. The carers’ daily recording was largely positive, but showed that on occasion Delta’s did not receive priority, such as when she needed a feed but Mother was diverted by her wish to shop.    5.2.3 During this period Delta experienced a busy life. She lived initially with Mother and foster carers and spent increasing times with Mother and MGM, regularly attending Church and seeing Mother’s friends in Brighton. The Church attendance was an important aspect of the family’s culture, albeit it did mean Delta sometimes being out in the evening from a very early age, including, against carers’ advice at 8 days old, 3 days following discharge from hospital.  5.2.4 The EPAP assessment of September 2018, based largely on observations during this period stated:  ‘Delta has a strong attachment to her Mother and would tolerate being cared for by staff when her Mother had to leave her, tracking her as she left and becoming unsettled at this. She would then express relief when her Mother returned. Delta enjoys sustained eye contact with her Mother, her posture is comfortable whilst interacting with her Mother in reciprocal turn taking ‘chatter’ and she was noted to smile readily at her Mother. Delta expects to be given attention as she can also give big smiles to staff and other parents and can draw positive attention to herself.’  4 – 10 months: living with Mother and MGM: July – December 2018 5.2.5 From this point practitioners knew less about Delta’s lived experiences as she was no longer looked after or subject to a child protection plan, albeit for 3 months subsequently was a child in need. Practitioners had little specific contact with Delta outside of meetings and records provide few observations of her welfare and development at this point.   54   5.2.6 Delta did though attend nursery during this period and their perception was of a thriving baby. She was booked in 3 days a week from 01.10.18 and attended for 23 sessions over almost 10 weeks, but had to leave when Mother ceased attending college and the funding ended for a nursery placement. The nursery reported that: • Mother dropped off and collected her daughter and relayed information consistently about Delta’s welfare, bringing appropriate extras (clothes, nappy etc) and informed them if they would be late for any reason • Delta ‘was always clean, tidy and well-presented’ • Delta was a very happy little baby and very easy to make smile. She was sitting up and moving in accordance with the Early years foundation stage (EYFS) statutory framework17 and ‘was a pleasure to look after’.  • There were no concerns noted regarding Delta’s development: she responded to her name and would smile when she saw Mother coming to collect her.  5.2.7 Both the Network meeting and Pathway Plan Review records of November 2018 mention that Delta was thriving, presumably based largely on reports by Mother, MGM and nursery, although Mother’s social worker (SWM1) was seeing Mother and sometimes also Delta.  January – September 2019 5.2.8 During the first 9 months of 2019, there is little information about Delta’s life, as she no longer had her own social worker and was not attending a nursery. The only specific contacts with Delta were by health practitioners, although Mother’s new social worker (SWM2) would see Delta sometimes when seeing Mother.   5.2.9 Mother and Delta were understood to visit relatives and a Church in London, but the frequency of this and the detail of their activities were unknown, as were their whereabouts. Neither Mother nor Delta were looked after, subject to a child protection plan nor a child in need plan, so not subject to professional monitoring. MGM never reported concerns about Delta’s welfare / Mother’s whereabouts.  Information unknown by professionals at the time As early as January 2019, Delta’s experiences were not always consistent with the positive observations of practitioners or of their expectations relating to Mother staying with relatives.  A friend, reporting in a witness statement for the coroner, stated that Mother and Delta came to stay with her in January 2019. On arrival Mother said she was going out on a date for a couple of hours and gave the friend no choice about leaving her to care for Delta. Mother went out around midnight, left Delta to be fed and put to sleep. Mother did not return the next morning, did not call to check on her baby and did not answer telephone calls initially. When she did, Mother requested that Delta be delivered to her at another friend’s home.    17 EYFS is the standards that school and childcare providers must meet for the learning, development and care of children from birth to 5.  55   Another friend’s statement includes that Mother left Delta with her at her family home in Brighton, for a couple of hours, but did not return for 2 days, saying she had gone to meet somebody. Delta was said to be less than a year old at this point i.e. this occurred before March 2019. Mother left no supplies of nappies or food. Mother did this again 2 weeks later, leaving Delta with the friend’s sister, again without provisions. This statement also referred to knowing that sometime ‘last summer’ [presumably summer 2019], Mother left Delta for a ‘whole day and night with a lady in East London: the friend considered this not to be an acceptable house for children, nor someone appropriate to look after children. Delta did not have her nappy or clothes changed whilst there.  Unfortunately, professionals were unaware of all these incidents in London which provided evidence of Mother’s neglect of Delta – had they been reported to social workers, this would have prompted investigation focused on Delta’s safeguarding. 5.2.10 HV2’s first meeting with Mother and Delta in March 2019 provides an assessment of Delta’s development very different to any previous observations by any practitioner, noting that she was a passive child, slow to explore the environment, with limited availability of toys and who did not seem interested in playing with a ball or turning pages in a book. Mother explained Delta had just woken. Given earlier observations of Delta this marked change was particularly concerning, and if the knowledge of Delta being neglected had been known there would have been a greater response to Delta’s emerging developmental issues, with no doubt a social work assessment.  5.2.11 However, at HV2’s next visit in May, Delta was seen to be more alert, nearly walking, climbing and exploring the environment. Delta related to familiar adults and was appropriately wary of HV2. The Health Visitor observed some babbling, banging two bricks together and a neat pincer grip. This reassured HV2 about Delta’s welfare. HV2 referred Mother to the CNN to support and assess child focussed Mother and Baby groups and help Mother to engage and play with Delta. The Community Nurse made attempts to contact Mother from July–August 2019 without success.  After move to supported accommodation: October – December 2019 5.2.12 Prior to Delta’s death, little was known about her life experiences during the 9 weeks at the supported accommodation. It was understood that she was taken frequently with Mother to stay with relatives in London. It was also evident that Mother’s friends often visited and stayed at the flat, helping Mother. MGM was also understood to be supporting Mother and Delta, with Delta staying with her overnight on at least one occasion. 5.2.13 There are contradictory observations of Delta’s welfare and development during this period. SWM2 recounted to the CSC agency report author examples showing Mother’s prioritisation of Delta’s needs e.g. when SWM2 took them out for a burger meal, Mother went to another shop to get Delta more healthy food, so she did not get into bad habits. Mother told SWM2 of being teased by a friend on another occasion for supplying carrot sticks rather than chips for Delta.  56   5.2.14 SWM2 also recalled calling into Mother’s flat unannounced and finding evidence of healthy meals being cooked and bath toys in the bath. SWM2 accompanied Mother and Delta to appointments, on one occasion caring for Delta. She described Delta as slightly anxious when Mother was absent and that Mother’s behaviour was appropriate with her daughter, singing nursery rhymes, to which Delta babbled along. SWM2 concluded that there was nothing to suggest trauma responses or that she was experiencing harm. 5.2.15 HV2 had no concerns about Mother meeting Delta’s basic needs and observed positive interactions between them, Mother would gently moisturise Delta’s skin, she was always dressed beautifully in clean clothes and was a healthy child.  5.2.16 However, when HV2 visited Mother and Delta in October 2019, she was concerned about developmental delay and that Delta’s interaction with others appeared limited. HV2 referred Delta to a Child Developmental centre in November 2019 for an assessment by a paediatrician to rule out any underlying medical condition for the developmental delay. This assessment had not taken place prior to Delta’s death. HV2 also referred Delta for a hearing assessment which was undertaken in November 2019, where no concerns were identified. HV2 supported Mother to enrol Delta at nursery to provide important stimulation for her; she was to start in January 2020 but was not taken to her planned settling in visit (scheduled for date when Mother left her alone prior to her death) 5.2.17 Staff at the supported accommodation reported that Delta always looked well dressed and well cared for, her hair was immaculate, her skin looked healthy, and she had lots of toys. There was though concern expressed in their witness statements to the coroner about Delta’s interaction with others. Delta was described as not making eye contact, responding to her name or to staff talking to her or offering her toys. Generally, she seemed averse to contact. One staff member thought that Delta had an underlying disability. This worker also noticed that although there were no concerns about Mother’s care of her baby, she had noticed an absence of usual cuddles, for example on one occasion when reunited after Delta had been away for the night. 5.2.18 Unknown to practitioners at the time, there is more worrying evidence from a number of Mother’s friends who had contact with Mother and Delta in this period. These are from witness statements to the Coroner and include the following descriptions: • ‘Loving Mother’, ‘but not a responsible Mother’, …. ‘only ever saw’ Delta ‘eating bread/pizza/pasta/crisps and junk food’…Mother ‘didn’t brush Delta’s hair…’ • Mother and Delta turned up 01.11.12…the friend ’reluctantly left them alone at my flat….boyfriend joined her and they left Delta alone in flat whilst she and boyfriend downstairs in cinema room, without a baby monitor’…..the friend was locked out of her flat between 4.00am and 6.00am during which time Mother did not answer her phone • Friend gave Delta a shower on 20th November, and thought maybe she was malnourished as she had a huge tummy  57   • Mother left Delta with a friend at 10.00am (November 4th) without prior notice or agreement, saying she would be 2 hours but did not return till 23.00 the next day, explaining she went to hospital with boyfriend for blood transfusion as he had sickle cell. Mother had responded to texts in the day, always saying she was coming back, but did not • In November 2019, Mother called around 21.00 or 22.00 hours, asking to stay one night- but instead Delta and Mother stayed a week, taking over the friend’s bedroom. Mother’s boyfriend came most days and when he slept over, Delta slept in her buggy. Delta appeared very hungry, approaching one of the 4 people in the flat for food. Mother usually only fed Delta left overs, such as pizza or fried chicken.  • Mother turned up one night near the end of November, without Delta • A friend stayed with Mother and Delta, who was unwell, on 30.11.19: there was no heating and it was freezing in the flat - Mother said she would go to the shop, but did not, there was ‘only pasta in flat, no baby food, no milk, no breakfast’ – the friend ordered pizza and wedges and gave Delta some to nibble –Mother left and was out all night, Mother would mention milk but never saw her give Delta any – 2nd night again Mother did not give Delta food and she nibbled on left over pizza and wedges 5.2.19 In general Mother was felt by her friends not to prioritise Delta’s needs. She did not have her own food but ‘picked’ at takeaway food, was living in a freezing flat without heating on, got left with friends without food/nappies provided and for longer periods of time than had been agreed. The impression from the statements of friends is that Delta was not a demanding child, who rarely cried or demanded attention.  5.2.20 From the criminal investigation it has been learnt that in the period leading up to Delta’s death, Mother left her home on her own on 7 previous occasions, sometimes for hours, sometimes longer or even days. None of the practitioners supporting the family were aware, or suspected this to be a possibility and Mother went to great lengths to hide this through her communications by text and email with staff, whilst away, and also seemingly planning in advance by for example on 5th December, telling both SWM2 and the supported accommodation staff she was having problems with her phone charger. 5.2.21 The following information showing when mother was away from the flat leaving Delta on her own has been provided to the author by the current Assistant Director for Children’s Safeguarding & Care (see table overleaf) and is contained in her report for the Coroner.   58   Date and period baby Delta left alone Source of information on missing episodes and when known Information known at the time  Information learnt after Delta’s death 23/10/19 - 24/10/19: Absence duration: 7 hrs 18mins Police - known after Delta’s death On 23/10/19 Mother met with her keyworker and on 24/10/19 she was 40 mins late attending pathway review meeting in the afternoon.   Mother at a party   26/10/19 - 26/10/19 Absence duration: 1hrs 1min during the night Police - known after Delta’s death  Attempted, and was refused, entry to a nightclub – a Saturday 07/11/19 - 08/11/19 - Absence duration: 10hrs 36mins Police - known after Delta’s death On 07/11/19 Mother contacted SWM2 telling her she would try and go into the social work office that day with a passport photo that was required. On 08/11/19 at 9.32am she contacted the accommodation provider with regard to an appointment she had the following Tuesday with her YES worker. Overnight absence - at a house party. Mother returned home at 08:37 on 08/11/19   09/11/19 - 09/11/19 - Absence duration: 17hrs 12mins Police - known after Delta’s death  Whereabouts not known – this was a Saturday 23/11/19 - 25/11/19 - Absence duration: 2 days, 5hrs 51mins Police - known after Delta’s death Mother emailed the supported accommodation staff on 24/11 - advising them that she was in London at an uncle’s 60th and would be returning the next day. Went to London Saturday to Monday  28/11/19 - 29/11/19 - Absence duration: 11hrs 37mins Police - known after Delta’s death On 28/11/19 Mother was seen by SWM2 and later met with her post 18 worker and saw HV2.  On 29/11/18 the supported accommodation staff contacted Mother: advised her that as they had been having difficulties contacting her, they will report her missing, she said she was on way back from London to home with Child Delta.    05/12/19 - 11/12/19 - Absence duration:  5 days 22 hrs Police - known after Delta’s death On 05/12/19 SWM2 visited mother at her flat - said she planned that evening to see her family for a family meal, but given she was ill that she was not planning anything else. She saw staff, both in the office and as she walked back to her flat and told them that she was spending that evening with her family. Mother reported problems with her phone charger to both SWM2 and the supported accommodation staff. 10/12/19: email exchange between mother and SWM2 around future plans. Mother said Child Delta got on well in nursery on 06/12/19. Following her death SWM2 learnt that she had not attended the nursery.  11/12/19: Mother replied to a text from the supported accommodation with an email telling them she was in Crawley with family and retuning that day.  She had also communicated with SWM2.  In London and the Midlands    59   5.2.22 During the last 2/3 months of Delta’s life, once they left MGM’s home in September, Delta’s life experiences deteriorated, with Mother seemingly having little boundaries and ignoring those that the supported accommodation tried to impose. It is horrific to learn of how Delta must have suffered in the last weeks of her life, being left alone on 7 occasions at age 18 - 20 months, in a very cold flat, without heating, food or drink. Given she was mobile, she was repeatedly either at great risk of accidents on these occasions, or was strapped helpless into her buggy. 5.2.23 Whilst Mother’s friends were, with the exception of 1 incident, unaware of Delta being left alone, some had knowledge of her being neglected (see 5.2.18 above). Had this information been reported to social workers, or to any practitioner, or MGM, there would have been social work assessment and intervention to safeguard Delta. Learning  When Delta lived at the foster carers home and subsequently when she attended nursery whilst living with MGM, there was adequate understanding of Delta’s lived experience. However, once this provision ceased practitioners knew very little about Delta’s life as neither Mother nor Delta were subject to looked after or child protection plans. It was considered monitoring of Mother’s and Delta’s whereabouts was MGM’s responsibility and there was never any direct contact made with family members.  It is now known that even before moving to supported accommodation Mother was leaving Delta with people outside the family to give her time with a boyfriend, and not always with the person’s consent. Moreover, friends had information about Delta being neglected, which if shared with CSC would have triggered assessment/investigations by social workers. From the beginning of September there is very little knowledge of Delta’s experiences, except as found out in the criminal investigation, she was spending increasing periods at home alone.  Whilst this was not known at the time, it was known that Mother, and it was assumed Delta, were spending considerable time travelling and staying in unknown locations in London, presumed to be with family. There appears to have been little curiosity about what this might mean for Delta and if it in any way contributed to the remarkable changes observed at her 12 month developmental check.   5.3 What was known and understood about the impact of Mother’s education experience on Delta’s welfare? 5.3.1 Mother from the outset of the review period was recognised to be bright and ambitious, with aspirations of becoming a lawyer. However, from autumn 2016 there is evidence that Mother struggled to sustain first mainstream school and subsequently any college courses.   60   5.3.2 Mother spoke in 2017/18, and again in 2021 to the first reviewer, of an incident involving one of Mother’s older siblings on social media, which Mother herself confirmed was widely shared just prior to Year 10. Mother spoke of the impact of school peers being aware through social media of this and she became subject to racist bullying as a result. Both Mother and MGM regard the racism she experienced at this school as having been extremely damaging to Mother’s self-esteem and development. From this point onwards mother’s full-time education was marked by non -attendance at 4 different schools. In year 10, her school attendance was only 19.7%. 5.3.3 From September 2017 Mother was looked after and placed in LA4. The overall impact of her previous disrupted education by this point meant that a return to main stream school would be a challenge for her. As Mother did not have an Education and Health Plan (EHCP18), the only option was a mainstream school. Mother started at the local secondary school, but her attendance during this period was only 9.34%; Mother stated she had experienced a racist incident and been subjected to bullying. She also felt ‘different’, being pregnant and known by other children to be in care.  One to one tuition was arranged for her.  5.3.4 From this point despite extensive support and advice provided to Mother from a Youth Employability Service 19(YES) worker in Brighton & Hove, she did not sustain any plans for her return to education. The Education agency report provides an analysis of the service provision available for Mother, pointing out the limited provision for specialised education for those without an EHCP and the limited options for a more personalised and flexible response to settling a looked after child into new educational settings e.g. home or part-time education. 5.3.5 When Mother was enrolled at college in September 2018, she lost her place when discovered to be sitting in the library on the internet rather than attending her course sessions. Whilst Mother explained she had suffered panic attacks and anxiety when attending classes, she was not offered support either to help her within the classroom, or to consider her mental health needs, given such high levels of reported anxiety.      18 Education Health and Care Plans (EHCP) are legal documents which set out a child or young person's special educational needs and the support that is required to meet these needs. This includes a suitable education setting (nursery/school/college). 19 The Youth Employability Service provides person centred support to young people aged 16-18 to enable them to access Education, Employment, and Training opportunities to move from Not in education employment or training (NEET) to in Education, Employment and Training (EET)  61   5.3.6 The plan was for Mother to re-engage with college and her education in September 2019, but Mother did not make arrangements and lost her place. When the YES worker checked, it was discovered that Mother had not turned up for any of the appointments arranged for her to enrol, had no appointment arranged for the date she had told the YES worker and would have now to write a letter explaining what had been going on. This did not occur and Mother lost her place at the college. Plans were made for her education to resume in January, and a nursery place for Delta to commence at the same time. 5.3.7 From this point onwards Mother was NEET and consequently Delta did not have the benefit of attending nursery, albeit both college and nursery were being arranged for January 2020. However, in the meantime mother was out of any structure to her days and spent increasing time in London with friends, which given her history was a risk indicator.  Learning The impact of young people being NEET, on both themselves and any children they have if they are parents, is significant. For the young person, this not only affects their future life opportunities, but gives them a structure to their days, a break from parenting responsibilities, socialising with peers and hopefully feeling able to achieve their aspirations. Children of such young people are able to benefit, if funding is available, to attend nurseries, be seen and their welfare monitored. This is particularly important where there are any safeguarding issues. It was most unfortunate that the college in 2018 terminated Mother’s place because of her non-attendance without giving warning to the YES worker or the social worker, so that attempts could have been made to integrate her back into the classroom. Mother’s reports of panic attacks and anxiety should have triggered mental health support or therapy, especially in the context of this never being accessed in relation to earlier trauma, including CSE.   5.4 How were accommodation services used and understood by other agencies to support Mother and Delta? Context of Housing Demand in Brighton & Hove 5.4.1 There is a shortage of affordable housing in the city, with social housing only accounting for approximately 15% of the housing stock in the city, 11% of which is owned by the local authority. This places great demand on social housing with demand greatly outweighing supply and with approximately 600 social lets per year, the waiting times can be lengthy.  62   5.4.2 Overcrowding is one of the main categories amongst home seekers on the housing register and applicants can wait several months to bid successfully on a property.  5.4.3 However, there are several mechanisms within the Council’s Allocations policy that can prioritise a move i.e. through the Council Interest Queue where social services have priority nomination rights on 10% of properties within every bidding cycle; through the Care Leaver’s protocol, or in cases of adoption, fostering or to prevent a child becoming looked after, there are a range of measures that can be considered e.g. extending properties, priority transfer or direct let. Role of housing resources in this case 5.4.4 The role of housing accommodation for Delta and her family was critical in relation to her safety and security as follows: a. The plan to rehabilitate Mother and Delta (aged 4 months) to live long term with MGM and 10 year old younger aunt would need accommodation large enough: MGM and younger aunt were living in a 2 bedroomed property b. Provision of supported accommodation for Mother and Delta Provision of suitable accommodation for MGM, Mother, Delta and younger aunt 5.4.5 The initial plan was for Mother and Delta to move from a mother and baby foster care placement, to live with MGM and 10-year-old younger aunt. Both Mother and Delta’s first social workers have confirmed to me this rehabilitation into the family was perceived to be a long-term plan, and not a brief stepping stone to Mother’s independence. One manager spoke of their surprise when hearing that they had moved in September 2019.  5.4.6 Had the move home to MGM been successful, it is likely to have provided a safer plan for Delta’s long-term care, than having a 17-year-old living independently with an active toddler. Admittedly this may also not have been totally safe care, given that we now know from the witness statements to the Coroner, that Mother did not always stay with relatives when in London, and that she did not always make arrangements for the safe care of her daughter on such occasions (see 5.2), but it would have prevented Delta being left alone (at the very least for extended periods) and hopefully enabled MGM to have identified Mother’s emotional state and decreasing focus on Delta’s welfare.   5.4.7 Unfortunately, the plan to have MGM sleeping on the couch in the lounge, Mother and Delta sharing MGM’s room and younger aunt having the other room, was extremely unlikely to be able to last beyond a short-term emergency period. In fact, by December 2018 tensions were such that Mother’s social worker agreed to put in an application for supported accommodation.  63   5.4.8 The need for larger accommodation for the whole family had been discussed vaguely without an agreed action as part of the viability assessment. It was identified as a matter to be dealt with urgently at the September 2018 child protection conference, with action as part of the CIN plan to be undertaken within a week. This did not happen and SWC1 left, with case responsibility transferred to SWC2.  It was then raised again at the only CIN network meeting held, 6 weeks after the CPC, when the matter was deferred until after Mother’s Pathway Plan Review meeting. There was some discussion in Delta’s social worker’s [SWC2’s] supervision about referring the family for larger accommodation in late November 2018, but the Pathway Plan Review at that time changed the plan to one for supported accommodation, based apparently on Mother’s wishes. The plan included the provision first for an assessment to confirm this was appropriate; that assessment never happened and from that point the option of a larger house for the family was lost. 5.4.9 In discussion with both SWM1 and SWC1 and the latter’s manager, there was little recollection of the option of a housing transfer. When probed, it seems that all perceived the housing shortage in Brighton & Hove was such that the option of a housing transfer was not feasible and there was no point trying to do anything, albeit SWC1 recollects that Mother did make enquiries about this at a local Housing Office.     5.4.10 This perception of a move to larger housing being impossible was incorrect as described in 5.4.3. Such options should have been tried from the point of the viability assessment or from Mother and Delta’s move to MGM in July 2018, 4 months before the Pathway Plan was changed to supported accommodation and subsequently any time prior to Mother’s move to the supported accommodation in September 2019.  5.4.11 Had any such options been tried, all members of the household including infants, would have been considered in the housing need assessment.  5.4.12 Records show that at no point during the period covered by the review was a housing need assessment, housing advice enquiry, or mutual exchange made by or on behalf of MGM, or Mother and Delta. 5.4.13 Both Mother and MGM say that they preferred the option of larger accommodation for the family, but this was not offered. MGM and the social workers were of the view that Mother wanted the independence option, but Mother, perhaps with the benefit of hindsight (in October 2022) said that she wanted a larger family house and was scared of living independently: however, she recalls that the expectation was that the family should find their own larger property.    64   Provision of supported accommodation 5.4.14 Please see 4.6.6.-4.6.12 for discussion of the application process for Mother and Delta in 2019 and the limitations of the assessments undertaken as part of this. 5.4.15 The applications for supported accommodation made in January 2019 by SWM1 and revisited in July 2019 by SWM2 were based on the overcrowding at MGM’s home, with the July 2019 referral also including tension and arguments between MGM and Mother, to the point where MGM had advised Mother to seek emergency housing. The move to supported accommodation was perceived by social workers as a way to facilitate the maintenance of good relationships between Mother and MGM. 5.4.16 The largely tick box forms focus on the ‘applicant’ i.e. Mother in this case, her support needs and her risks. The forms are designed for single homeless young people and do not facilitate consideration of the support needs and risks for any child/ren, although they do ask if there is a partner. The risks for Mother and Delta did not fit easily into the boxes, as they relate to potential impact of past traumas on future risks when living independently for the first time.  5.4.17 It is not clear if these forms, along with a subsequent panel discussion, are perceived to constitute the required multi-agency assessment / joint assessment specified in the government guidance20 (para 3.18 and 3.19), or it has been suggested that this guidance was not applicable in this case as Mother was not ‘homeless’. However, the decision making for such a move was prompted by a perception that Mother would become homeless due to the overcrowded conditions in the family home.  If a holistic assessment of all the household and their needs had been undertaken it may have concluded a larger house for all the family was required, or that Mother and Delta needed more support than available through supported housing options. 5.4.18 Both social workers who completed the application forms (January and again June 2018) for Mother concluded low support needs. Mother was on the waiting list for a dispersed flat in the Young Families Service, before being offered the 2 options for supported accommodation provision in September. She opted for the one providing her with a self-contained flat. This had the most support available through Brighton & Hove’s commissioned services, none of which provide a monitoring function or 24/7 staff presence. Had such a level of support been assessed as required, alternatives provided via social care would have needed to be considered, such as foster carers or lodgings. Mother did not wish to become accommodated under S.20, which would have meant becoming ‘looked after’ for 9 weeks.      20 Prevention of homelessness and provision of accommodation for 16 and 17 year old young people who may be homeless and/or require accommodation, April 2018, Department for Education and Ministry of Housing, Communities and Local Government  65   5.4.19 SWM1 who completed the original form in January 2019, told us she anticipated that Mother would be provided with accommodation in somewhere like the provision she received, but which SWM1 mistakenly understood to provide 24/7 staff coverage. 5.4.20 Mother was placed under Section 17 of the Children Act 1989 and financially supported by CSC until she became 18. support meant that there was a weekly 1-to-2-hour session with a keyworker and access to staff every day at the office located in the accommodation from 9-5 Monday to Friday. The focus of the support was in developing practical skills to support the transition to independence.  5.4.21 Learning has been identified by Children’s Social Care and the accommodation provider that there needs to be explicit expectations set out in the contract on role, purpose and expectations. It may be helpful to build on existing multi-agency network meetings i.e. young person’s homelessness group to ensure a shared understanding of roles and function. There is also learning that the fullest possible information on the histories of those referred to the service is received, requested and any potential risks known and understood and recorded.  5.4.22 Additional learning identified by agencies is the need for all agencies to understand the terminology of a ‘Relevant child’ who is a care leaver, the implications of the status and the role and focus of their social worker, as opposed to a social worker for their child.  5.4.23 The learning evidenced in this review is that often agencies outside Children’s Social Care are not clear of the differing statutory statuses of children and the impact of this on the service from CSC. In this case the focus of the social worker was with a Mother, who is a Care Leaver, and supporting her move to independence. It is not the same focus as a social worker for the child’s own baby. In other LA areas, usually the support given to a Care Leaver is provided by a Personal Adviser (PA) who are often not qualified social workers, and the arrangement in Brighton and Hove although positive, may have made that distinction less clear.  Learning Staff in CSC need to be aware of the Homemove policy which enables senior managers to nominate families where there is a proven need, and that this should be tried to enable families to remain together in the first instance.   Referral and assessment forms used in the application for supported accommodation are not a replacement for a holistic assessment by a social worker to decide what type of support needs a family have. The requirements for supported accommodation application process should be compliant with government guidance (see 5.4.17 above) e.g. this could be achieved if it mirrored the housing needs assessment, which includes household composition, support needs and risks relating to dependent children. It would also be helpful to have a section to prompt sharing of any non-current risks that could potentially arise from the young person’s history and how these might be identified.  66   Social workers need to have a better understanding of exactly what support is available for each level of assessed need and risk.  There needs to be explicit expectations set out in the contract on role, purpose and expectations, as well as a risk management plan around any identified current or potential risks. The local authority should consider whether there is a need for further commissioning of a service, which is able to provide a higher level of support than currently available i.e. with 24/7 staff presence and where it is possible to be aware of which residents are present and which away at any time. 5.5 How was Mother understood and supported by practitioners? Childhood Trauma 5.5.1 Mother spoke of adverse childhood experiences including witnessing domestic abuse, violent deaths of relatives and friends and being a victim of racism and bullying. Additionally, it was believed that she had been a victim of CSE, although she never spoke of this and the EPAP report suggested that such an assumption may be incorrect. Mother has now confirmed that she was a victim of CSE, that Delta’s father was involved in this abuse and that she felt unable to share this with anyone at all (professionals, family or friends) until after Delta’s death. 5.5.2 Mother spent much time out of school which will have impacted on her development and she experienced a lot of change, from the shock of moving from London to Sussex, where black children were a significant minority at schools, in contrast to Mother’s London experience. 5.5.3 Mother and MGM have been clear about the traumatic racist experiences Mother suffered following the move from LA1 and out of London.  The only incident of racism towards Mother which is evidenced in records was at her school in LA1. Reported incidents by Mother at her school in LA2 were not identified by the school. This maybe because LA1’s school had experience of pupils from more diverse backgrounds and consequently were more likely to be sensitive to racism. In LA4, Mother’s allegation of racist bullying was never established despite attempts made to do so. Practitioners there had concluded that Mother used this as a way to avoid school attendance. In Brighton & Hove, the family’s reported racist experiences have been taken very seriously, which understandably increased sympathy for Mother.  5.5.4 Further distress occurred for Mother, spending considerable periods away from her family and home from the age of 14/15, moving schools a number of times, becoming a mother, moving placements and changes of social workers and health professionals. This is likely to have impacted on her ability to trust and sustain relationships, in addition to her reported childhood trauma.     67   Mother’s character 5.5.5 One of the critical features of this case review is the extent to which practitioners largely liked, admired and trusted mother, taking great pride in how well she had settled once pregnant and perceived to be an excellent parent to baby Delta, prioritising her needs. She was viewed as open, friendly and responsive to practitioners, appreciating the help and support provided.  5.5.6 The LA4 practitioners, whilst also being positive about Mother in general, were in a position to be able to observe her in a setting with other young people and noticed characteristics not observed by community practitioners e.g. “commanding”. “quite fiery at times” “hard as nails” (in relation to another girl). These observations are more in line with those made in witness statements made by friends for the Coroner (see 5.5.9 – 5.5.12). 5.5.7 Practitioners in Brighton & Hove accepted Mother’s explanation that, despite presenting as bright, articulate and polite, she struggled to meet people and new situations and suffered greatly with anxiety issues, especially in relation to attending settings where she might be the only black person there, such as educational settings or baby groups. In contrast, LA4 practitioners’ experience was that she did not struggle to meet new people nor was she especially anxious. It is of note that despite her anxieties, Mother seems to have made good friends, having taken friends from her new school to London on one occasion (2017), having made an apparently good friend attending EPAP (2018) and several friends from sitting in the library at college (in 2018). These latter friendships continued until Delta’s death. Mother’s plausibility   5.5.8 Even when there were potential concerns, such as missed appointments or an identified lie, Mother was quickly able to re-assure practitioners through seemingly plausible explanations. She was also able to adjust her behaviour to charm professionals to believe that she was a loving responsible parent. An example was following HV2’s visit in late October 2019, Mother emailed HV2 saying: ‘Thank you for the visit today, it was lovely and we both really enjoyed it. Hopefully things will start to improve she thrives through the roof. Lots of love Mother and Delta.’ 5.5.1 Although often difficult to contact, especially in the last 3 months of baby Delta’s life, Mother was able to provide believable excuses and would respond to her social worker, SWM2, so maintaining their apparently trusting relationship.  The responses to Mother as a Looked After Child 5.5.2 Mother received a great deal of attention and support from the various practitioners working with her, both emotional and extensive practical support, especially SWM2. The practitioners responded to her both as a mother, but even more as a looked after child, who was trying her best to achieve against adverse circumstances.   68   5.5.3 It is evident that SWM2 made great efforts to consider all aspects of mother’s life and tried to engage her to talk about friends and enquire about boyfriends, so as to establish how Mother was managing as a young parent with her own needs and desires. From what was learnt after Delta’s death, it would appear that in actual practice Mother was extremely guarded in her conversations and gave no clues about her long-term boyfriend or her extensive social life in London, maintaining the pretence of staying with family and attending Church. She seems to have also maintained her privacy from MGM, who had no knowledge of Mother’s boyfriend prior to Delta’s death. 5.5.4 Generally, there appears to have been a great desire for Mother to achieve, and pride, especially by social care practitioners, in the way she had changed since becoming looked after in 2017. This in all probability also applies to Mother’s family, with MGM commenting on how surprised and delighted they were at how well Mother had adjusted to parenthood. 5.5.5 This desire not to discourage Mother perhaps led to the avoidance of discussing issues in some reports (e.g. EPAP report) and meetings that were more critical of mother as a parent. This happened in meetings when foster carers felt unable to raise concerns or when the meeting’s focus was on Mother in her own right i.e. Pathway Plan review.   Any such concerns were to be discussed (or maybe not in the case of the foster carers) outside of such multi-agency fora. This perhaps minimised the significance of these concerns for Mother and for practitioners. Moreover, through avoiding such opportunities for discussion at multi-agency meetings, it was easier for Mother to be able to mislead, or manipulate, individual practitioners.   5.5.6 MGM and Mother have both suggested that the pressure to be the perfect mother caused pressure and an inability to open up about problems and challenges in her life. If this is the case, the lack of challenge at meetings might have also discouraged Mother to be able to speak more freely and acknowledge her inner conflicts about the huge responsibilities of being a parent of an increasingly active child. 5.5.7 In the last few weeks before Delta’s death, attempts were made to verify some of mother’s explanations, with SWM2 asking to speak to maternal aunt to verify Mother’s whereabouts, and requests to have MGF’s address and telephone number when Mother alleged she was staying there. MGM was also contacted by the supported accommodation staff to ask if she knew Mother’s whereabouts, but she did not know (albeit MGM has does not recall being contacted by them). 5.5.8 Given the above understanding of Mother, all were horrified and shocked to learn of Delta’s suffering and death. In terms of how practitioners understood Mother’s character, it was inconceivable that she could leave Delta alone for anything more than short periods when she smoked a cigarette. It was thought that through use of a monitor any risks to Delta through such behaviour were ameliorated, albeit the use of a monitor weakened the strong message that was needed of the risk to Delta if left alone, ever.    69   Mother’s ability to manipulate and deceive 5.5.9 The practitioner’s view of Mother is in stark contrast to what has emerged from the criminal investigation. This has shown markedly different character traits as well as earlier neglect of Delta’s needs. 5.5.10 One major aspect of Mother’s character to emerge is her capacity to tell lies as evidenced in the statements of her former friends, often told with no apparent purpose. As one friend explained ‘Mother lies a lot and sometimes it’s not anything that she needs to lie about, small things’.   An example was telling friend/s that she was having a big 18th birthday party and had already spent £700.00 on it and would book an apartment for it in London.   5.5.11 Another aspect of her character from these statements is her ability to manipulate friends, as she also did to practitioners. A friend said she liked Mother but did not trust her as she ‘lies about things’ and ‘makes things up’, such as (if wanting to stay with them) that she could not find her key, or that her father had it. She seemed to manipulate friends into allowing her and Delta to stay with them, even though they did not want her there and then to leave Delta with the friend, without asking, and not returning as promised. One spoke of realising that if ‘she set foot in your house she would not leave for a few days’. Adultification 5.5.12 One of the notable features about Mother is the mature way she presents, along with her intelligence and perceptiveness. Both she and MGM have spoken about how this meant that she felt unable to share her problems, and expose the child inside who by autumn 2019 was as she describes on the verge of breakdown.  5.5.13 She also spoke about how frightened she was at the prospect of living independently and coping on her own, and how lonely she felt. Again, she did not share such emotions with professionals, who judged her as being this mature capable parent, despite her youth and background traumatic experiences. 5.5.14 Jahnine Davis21 has undertaken research into CSE in black communities and refers to adultification bias: where children are perceived as being more adult like, and where they are seen through a lens of deviancy and not necessarily acknowledged as deserving victims, and where their innocence and vulnerability is erased over time. She quotes Epstein (2017) who found that from the age of five, African American girls were viewed as more adult-like throughout all stages of childhood in comparison to their White peers. 22     21 Where are the Black girls in our CSA services, studies and statistics? Community Care, 20.11.19 22 Girlhood Interrupted: The Erasure of Black Girls’ Childhood, Epstein et al, 2017  70   5.5.15 Davis points out that if we are not seeing Black children as children, and not therefore ‘acknowledging the innate vulnerability all children have, if we are dehumanising Black children; professionals are potentially increasing their risk of harm, or the harm Black children are already experiencing.’ This adultification can lead to victim blaming which ‘may assume Black children are somehow complicit in their own abuse’. Learning Social workers appear to have responded to Mother largely as a Looked After Child and then a Care Leaver, taking great pride in her parenting and progress from being missing and suspected victim of CSE to a capable responsible parent. Issues which may have caused concerns in other parents, in these circumstances are potentially more likely to be minimised and perceived (often appropriately) as associated with the youth and trauma of the young parent’s past, without sufficient focus on the risks to the child of the parent.  Such perception of Mother’s maturity and progress, is linked to the concept of adultification, not sufficiently recognising the child as opposed to the mature adult: this contributed to Mother feeling unable to share her fears and negative feelings, and that inside she was a scared child, not always a responsible parent.  5.6 What was known and understood about Mother’s experience of exploitation (including CSE or other forms of exploitation) and the impact on her? 5.6.1 It is known that from November 2016, Mother, aged 14/15, went missing for increasingly lengthy periods of time on at least 8 occasions over a period of 9 months. The longest period was for 9 weeks immediately prior to her becoming a Looked After Child in August 2017 and her placement in residential care in LA3.  5.6.2 This was before the period under review and during the review period Mother did not speak about this, as explained in Section 3.2 and during the EPAP assessment denied being a victim of CSE, suggesting that she was being pressurised to say this by practitioners.  5.6.3 The evidence from Police records was that Mother was thought to have been subject to child sexual exploitation involving older men in London during this period. There were no charges brought against any men but after being missing for extended periods Mother had come back with expensive goods and had been formally linked by the police to adult males who may have been exploiting her. It was also believed by agencies that she may have been exploited into taking girls from Brighton to London on more than one occasion and at least one of these girls made an allegation of sexual assault. The Metropolitan Police investigated these incidents in 2017, but no charges were brought.   71   5.6.4 The concerns had been discussed at a number of CSE Adolescent Vulnerability and Risk Meetings (AVRM) and strategy discussions prior to Mother’s admission to care. Mother consistently denied being a victim of CSE saying that she was just more comfortable with older friends /connections in London. Most professionals, given the signs of CSE, did not see her denials as credible.  5.6.5 Whilst there was a range of opinions amongst professionals about what had happened to Mother, the detail of her experiences was unknown. Mother has now confirmed that by the time she was 17 years old she began to recognise her she had been exploited, groomed, abused and found herself in situations where she was unsafe but could not easily leave. Moreover, the father of Delta is one of the people she says exploited her. 5.6.6 It is not unusual for children who have been victims of CSE to not recognise it as such, as Mother explained she thought what had happened was ‘normal’, albeit embarrassing. Although Mother appeared by her behaviour to show no obvious signs /evidence of trauma from her experiences, it is likely to have had an impact and maybe associated with Mother’s ongoing anxiety, panic attacks and possible eating disorder, although none of these have been formally diagnosed. Her secretiveness and what is now known to be manipulativeness and deceit of friends, family and practitioners may also be associated with her earlier traumatic experiences. 5.6.7 Mother says therapy was not offered to her and that practitioners did not persevere in asking about what happened in London. However, practitioners describe trying to ask her about her experiences of CSE and to offer access to therapy but she refused this, denying she had been such a victim.  5.6.8 This highlights the challenge of providing victims with therapeutic support; such provision has to be available at the right time for people. However, where such abuse is suspected, but the individual has been unable to speak of this and/or access therapeutic support, the individual may be more vulnerable to further exploitation. In these circumstances practitioners need to be very sensitive to changes in behaviour and compliance with safety strategies. This is particularly important if the suspected victim is also a parent.  5.6.9 In this case from the start of 2019 the increasing difficulties practitioners experienced in communication, in Mother keeping all appointments, her failure to take Delta to some health appointments, the concerns about Delta’s development, Mother’s failure to return to education and increasing trips of Mother and Delta to London should have alerted practitioners to changes in Mother’s behaviour and possible increased risks therefore for Delta. Supportive strategies could have involved nursery provision for Delta, irrespective of whether Mother attended college and further attempts to provide therapeutic support.  5.6.10 Such support could have been offered throughout the period of the review: if Mother did not acknowledge the need in relation to CSE, she may well have done so with regard to the traumas she did speak about i.e. racism, anxiety and panic attacks and weight loss.  72   Learning Children who are either Looked After themselves, or are Care Leavers, are likely to have additional vulnerabilities due to childhood trauma and their children may need longer term support even when there are no identified safeguarding issues. Where young parents have suffered trauma in the past, including suspected CSE, it is vital to be sensitive to behavioural changes, which may be indicative of increased vulnerability. This is particularly important if the parent has not ever disclosed the abuse or received therapy. In such circumstances it is vital to identify potential risk factors. There should have been greater emphasis on Mother’s emotional and mental health, given her past, her reported anxiety and weight loss. Greater consideration should have been given for her need for therapy throughout the period of the review, and how she could be encouraged to accept this.  5.7 What was known about or understood regarding Delta’s father and how was this addressed by practitioners in terms of safety planning? 5.7.1 When pregnant, Mother only provided information about Father’s name and date of birth to Children’s Social Care and the date was inaccurate resulting in Father not being identified by Police checks. Mother would not give any further contact details about Father so contact could not be pursued.  5.7.2 Mother expressed different views about Father, sometimes saying she wanted him to have involvement and other times saying that she did not. At the time of the initial child protection conference, she said that he was not interested in the baby and he had not been in touch with her.  5.7.3 Mother did not speak to her family about this relationship and MGM told social workers she did not know Father’s identity. Mother told the EPAP parenting assessor that the relationship was consensual, and the father was her long-term boyfriend who was a similar age. She further told her and HV1 that he wasn’t interested in baby Delta. From the first reviewer’s discussions with Mother it appears Father was older, groomed and exploited Mother and she was fearful of identifying him or acknowledging the nature of the relationship.  5.7.4 There was evidence from assessments that social workers and other practitioners were professionally curious about baby Delta’s father and understood the importance of identifying him and that he could potentially play a role in baby Delta’s life and needed to be assessed. The contradictory and inaccurate information given by Mother meant it was impossible to evaluate any risks associated with him or support that he could offer.    73   5.8 Systemic and organisational issues Facilitating a child focused service for children of parents who are themselves Looked After/Care leavers 5.8.1 Overall learning from this review, has identified the need to consider the structural approach by Children’s Social Care to children who are Looked After or are care leavers, and also parents. Currently adolescent children who are Looked After have an allocated social worker (often from the adolescent pod) and as care leavers they will have an allocated Personal Adviser (PA). The PA’s role is specifically on supporting care leavers into independence. In this case unusually the PA was also a qualified social worker.  5.8.2 As described in 5.5, this risks a focus on the young parent, who is also a child, and supporting them as opposed to their child. Brighton & Hove are to be commended in their recognition that in these circumstances the parent’s own child should have a separate social worker able to focus entirely on the child’s needs and welfare. However, this only occurs if there are identified safeguarding issues, which in this case were judged not to be the case from January 2019. In part this was due to the lack of assessments, focused on Delta (rather than Mother as a care leaver), following the EPAP assessment which ended in September 2018. It does though also raise the question of whether the service to care leavers sufficiently addresses the ongoing risks arising from likely vulnerability of the child, who is also a parent, and has suffered childhood trauma without ever having had therapy or spoken openly about such trauma. 5.8.3 This learning is not to imply that had this arrangement been in place there would have been a different outcome for Delta. It simply recognises the fact that children who are in care or care leavers are likely to have experienced trauma and be more vulnerable and therefore the Local Authority and other agencies need to continue to offer support to their children in their role as corporate parents and corporate grandparents. This is particularly critical if the child who is a parent transitions into independence. 5.8.4 The National Child Safeguarding Practice Review Panel has identified a need to focus on young parents with particular vulnerabilities including those previously in the care system. They have noted the number of SCRs/LCSPRs and Rapid Reviews since July 2018 where one or either parent is a care leaver. It is apparent in a number of SCR/LCSPR that a parent who has a care history and is a care leaver may have additional vulnerabilities due to known or unknown childhood trauma and therefore may require longer term support even if the parenting appears ‘good enough’ and their trauma is not readily apparent.  The separation of social workers for Mother and Child 5.8.5 The recognition that parents, who are also children, need their own social worker, separate to the social worker for their child, is good practice, but in this case led to some obstacles:  74   • The separation of roles may be well understood within CSC, but it is confusing to practitioners in other agencies; in this case staff at the supported accommodation did not fully understand the distinction, given that Delta had no social worker of her own. Consequently, they reported concerns to Mother’s social worker not FDFF when they related to Delta’s welfare, despite (according to her manager) SWM2’s attempts to encourage staff to understand she was not Delta’s social worker and concerns about Delta should be addressed to FFDF. • The open expression of reservations regarding the use of legal and child protection processes for the unborn baby (by the chair and social worker at the Pathway Planning meeting in February 2018) may have contributed to Mother’s and MGM’s lack of appreciation of the reasons behind later child protection arrangements made in the placement. This misunderstanding was an underlying cause of the tensions between MGM, Mother and carers and raises the issue of which social worker is the lead professional for the family as a whole, and is it appropriate for the plan made for Delta to be undermined with the family by those whose focus is on the mother?  • The decision to end the CIN plan in December 2018 was taken in November 2018 in parallel with the changes relating to Mother and her Pathway Plan (her education and Delta’s nursery place were terminated, the home situation was breaking down and the plan was to move Mother to supported accommodation): whilst I have been assured by practitioners  that there was good communication between social workers, there clearly was an absence of joint working to ensure plans for each child were compatible and assessed risk for each of them. Step-down processes for Children in Need 5.8.1 In this case Delta ceased to be a Child in Need with her own social worker in December 2018. This decision was taken by CSC without any assessment, consultation or communication with other agencies.  5.8.2 At that time the ‘What If’ procedure for CIN cases was not in place, only introduced in 2019. This enables other agencies to agree case closure of a CIN plan at a CIN Review meeting, identify a lead professional and to agree a ‘What If’ plan. The Plan looks to identify if there were changes in a family’s situation which might impact on risk and which of those should require re referral to CSC. If that had been in place at the point of closure, risk indicators for the future may have been identified and the lead professional might have decided to re-refer Delta when concerns arose about her developmental delay.  Options for accommodation at 16+ and for parents who are children 5.8.3 Learning was identified by practitioners and within agency reports that both nationally and locally there is limited flexibility in accommodation options and there is a gap in tailored provision for young, more vulnerable parents and their children which could include family-based care and support.     75   Education  5.8.4 There were limited options for education facilities for Mother (see 5.3), because she was not subject to an EHCP. The Education agency report points out the limited provision for specialised education for those without an EHCP and the limited options for a more personalised and flexible response to settling a looked after child into new educational settings e.g. home or part-time education. 5.8.5 Section 5.3 highlights the impact for Mother, and consequently Delta, of her non-attendance at college and subsequently being excluded from the course. Had CSC and YES been alerted to Mother’s non-attendance at an earlier stage, it might have been possible to support her to overcome her anxieties and return to a classroom for the 1st time in over 2 years.  Do systems within health identify children without GPs? 5.8.6 The GP management review for this case review did not identify that Mother, and more critically Delta, was without a GP for 8 months. This reflects a systemic obstacle to good practice as there is no system for professionals to be informed of the GP’s action, unless the GP surgery shares such information directly themselves.  5.8.7 The lack of identification is particularly concerning in relation to Delta who would have been a 5 month old baby subject to a CPP when the GP practice wrote to Mother to explain she and Delta would be deregistered from the practice following their change of address. Delta was aged 7 months when the family was removed from the GP’s list. By this point Delta was subject to a CIN plan.  5.8.8 Whilst there is no suggestion this 8 month period of being without a GP would have impacted on the outcome of this case, had social workers known of this, it would have contributed to the evidence of Mother’s difficulties in managing, even with the support of MGM, as well as the challenges in being able to rely on her to prioritise Delta’s welfare and health.         76   6  Conclusions, Findings and Recommendations 6.1 Conclusions  6.1.1 The tragic death of Delta through neglect occurred in the context of a great deal of resources and services being provided to Mother and Delta, including frequent contact with social workers, health visitor and, in the last 9 weeks of Delta’s life, practitioners at the supported accommodation. Practitioners and MGM were of the view that from Delta’s birth, Mother demonstrated that she was an exceptionally capable and loving parent. That she would have left her 20 month old daughter ill and home alone has shocked all who knew Delta. It was not predictable to any of the practitioners involved with the family. 6.1.2 Whilst there was much good practice by practitioners, this report identifies ways this could be improved, albeit these are unlikely to have altered most of the decisions made.  6.1.3 The constant underlying tension for practitioners, was how much weight to place on risks arising from earlier trauma when Mother was aged 14/15 as opposed to subsequent impressive observations of parenting of Delta. Unfortunately, the latter dominated.  6.1.4 Contemporary social work services are based around focused support and assessment.  Hence when no clear current risks were identified for Delta, she no longer met the criteria to be subject to a child protection plan and subsequently it was judged that this also applied to a child in need plan. It is not clear if that latter decision took account of the changed circumstances after mother lost her college place for not attending her course lessons, which meant Delta would no longer be monitored at a nursery. Moreover, at this point the plan for Mother changed to one of moving to supported accommodation, because of the increasing tensions at home with MGM.  It seems that the 2 separate social work processes, for Mother as a Care Leaver, and for Delta as a vulnerable 10-month-old, were not working well enough together at this time.   6.1.5 Greater possible risks to Delta may have been identified had there been: • Identification of Mother’s ongoing mental health needs, as indicated by her reported anxiety, panic attacks and eating problems, along with her lack of speaking about her CSE • Identification that Mother’s lack of acknowledgement of, and receipt of therapy for, her earlier traumas could in itself be a risk indicator for her long-term emotional welfare and consequently a potential risk for her daughter’s welfare • An assessment from Delta’s perspective, in December 2018, prior to closing the CIN service; this should have taken account of Mother’s deceit in relation to college attendance, the loss of a nursery placement providing monitoring of Delta’s welfare and plans for mother’s independence  • A step-down process from CIN which involves the identification of a lead professional and continued multi-agency meetings focused on Delta  77   • A holistic assessment prior to any decision about independence and the type of accommodation required to provide safe care of Delta. 6.1.6 Assessments need to address risk, in terms of planned changes, taking into account mother’s history of trauma, that as yet she had never spoken about this, the possibility that looking after a toddler was likely to be a great deal more challenging for Mother than caring for a baby, Mother’s youth and questions about her ability to consistently prioritise Delta’s needs consistently over her own needs.  6.1.7 Whilst such an assessment is unlikely to have changed the plans made for Mother and Delta, it could have led to the continuation of the CIN plan and support focused on Delta, possible consideration of financing a nursery placement to provide stimulation and monitoring of Delta’s welfare, as well as the break needed by such a young parent. Most critically, by identifying potential future risks, a plan could have been formulated to help staff identify what risk indicators may look like and to formulate a risk management plan. 6.1.8 Had the family moved into larger accommodation from the outset in July 2018, the home situation may not have broken down. If this had occurred it is unlikely that Delta would have been left home alone, albeit Mother may still have taken Delta to London with her and to unknown care arrangements there. The plan for a housing transfer was not implemented. There is no evidence of its feasibility being explored in any sense, not even in a discussion with MGM and Mother. The reasons for this appear to lie in a mistaken belief that such provision would be impossible to attain, so the possibility was never investigated.  This was extremely unfortunate. 6.1.9 Had an assessment been undertaken in relation to Mother and Delta’s needs at the breakdown of the long-term plan to live with MGM, it is possible that this would have pointed to the need for more support and monitoring than the supported accommodation provided, including 24 hour staff availability and monitoring of residents’ comings and goings. Such alternative provision is not available locally, without Mother being accommodated under s.20 Children Act, 1989 and living again with foster carers, or being placed in lodgings. Such alternative provision or placements would have reduced the opportunities for Mother to leave Delta alone, and enabled Mother’s behavioural changes to be identified. However, Mother did not wish for these options and her Pathway Plan at this point changed to transition to independence. Given the lack of evidence of any maltreatment of Delta, and the positive views of her parenting of Delta, it would not have been possible to place Mother against her wishes.  6.1.10 Once Mother and Delta moved to the supported accommodation concerns began to emerge. These were discussed with Mother within the first weeks of moving there and referred to FFDF. However, it was considered that Mother’s social worker and the supported accommodation practitioners had already dealt with the immediate concerns, so a more holistic assessment was not undertaken, which may have focused more clearly on Delta’s needs and for a risk management plan to be implemented.  78   6.1.11 The view throughout that Mother needed positive encouragement, especially in meetings, discouraged a multi-agency conversation with her about the concerns and what was going on for her. This was particularly critical in the last weeks of Delta’s life when a focus on Delta’s needs with the initiation of a child in need assessment might (or might not) have enabled Mother to speak openly about the challenges she was facing, and the conflicts for her in caring for Delta, but also wanting to enjoy her social life.   6.2 Findings & Recommendations Findings relating to Assessments 6.2.1 The quality of assessments, or their absence, was pivotal to the decisions that were made in this case and gives rise to the first 7 findings. It is however not suggested that any of these alone were critical in terms of being able to prevent Delta’s death. i. Whilst there were appropriate specific assessments undertaken both pre-birth and in the first months of Delta’s life, subsequently significant changes occurred without assessments and/or consultations with relevant professionals for Delta within the network. 6.2.2  In particular, no assessments occurred at the following points of change, when: • legal proceedings were ended without any form of review between social workers and their legal representatives • the CIN plan ended, despite changes in the plan for Mother and Delta to move into supported accommodation and the loss of nursery provision for Delta • concerns arose after Mother and Delta moved into the supported accommodation 6.2.3 Had an assessment focusing on Delta’s needs been undertaken prior to the ending of the CIN plan, it is possible that Delta’s plan would not have ended given the change made to Mother’s plan. Recommendation 1 BHSCP to review assessment guidance so that: * holistic multi-agency assessments take place prior to making significant changes to a child’s plan, except when emergency action is required to safeguard a child * changes in a child’s behaviour or development are identified as possibly indicative of increased vulnerability and this should trigger an assessment. ii. Whilst early assessments were undertaken in the first 6 months of Delta’s life, subsequent ones related purely to Mother, in the form of Pathway Plan Review documents.   6.2.4 As Delta ceased to have a social worker after the ending of her Child in Need Plan, the focus of decision making related to what was perceived to be Mother’s welfare.   79   6.2.5 Subsequent assessments all related to Mother i.e. the Pathway Plan Review document and the referral and risk assessments for supported housing. There is no consideration given to the risks for her child in these documents. Recommendation 2 BHSCP to review assessment guidance so that assessments of parents who are also children, always include a specific focus on the child’s vulnerable child, as well as the parent who is a child. This is particularly critical if the vulnerable child does not have their own social worker.  iii. The viability assessment of MGM did not adequately understand or assess the role of the wider family in supporting Mother and Delta. 6.2.6 Mother’s family had always played a significant part in supporting her, and it was envisaged that this would continue once Mother returned to live with MGM. Given the history of Mother going missing in London when understood to be staying with relatives, it was important to assess the relations ability to be responsible for Mother and Delta when they were in London.  Recommendation 3 BHSCP to review assessment guidance so that viability assessments include all family members who will be expected to play a part in the care of the children.   iv. There was insufficient focus on risk assessment evident in assessments. 6.2.7 With the exception of the application for supported housing, the term ‘risk’ did not appear in assessments after Mother and Delta moved to MGM’s home. Whilst the social worker’s report for child protection conference does include a relevant heading, risks were identified as ‘none’ when the protection plan ended in September 2018.  6.2.8 Subsequently the term is not used in Pathway planning documents. To be able to identify potential risks with a child / child who is a parent, should be a helpful process for that child who is a parent. 6.2.9 Whilst the use of the Assessment Framework should encourage social workers to consistently consider what risks are involved as part of any assessment and planning process, the evidence in this case was that this only featured in the pre-birth assessment. Recommendation 4 BHSCP to review assessment guidance and pro-formas so that all assessments relating to the welfare of a child (or child’s child) include an explicit section to address risks and any necessary risk management plan, including ‘Me and My World Review and Plan’ and ‘Pathway Plan and Needs Assessment’.    80   v. There were grounds to have initiated an Early Help Assessment before October 2019. 6.2.10 In June 2019, HV2 contemplated initiating an Early Help Assessment if Mother did not register with a GP and attend the missed neonatal appointment. Following Mother’s compliance, a plan of action was implemented providing support from a nursery nurse. The assessment was subsequently initiated in October 2019, following Mother’s lack of engagement with the nursery nurse (despite 5 attempts of contact) and a missed GP appointment. 6.2.11 It was good practice that despite Mother having demonstrated compliance, HV2 implemented a sound plan to monitor Delta’s welfare. It would though have been prudent to have commenced the Early Help Assessment at this point given Mother’s history, Delta’s observed developmental delay on one visit, missed health appointments and Mother not registering her and Delta at a GP for 8 months. Alternatively, by 02.08.19, Mother had already missed 5 opportunities to meet with the nursery nurse: this would have been an opportune point to commence such an assessment. Recommendation 5 BHSCB to undertake an audit of cases subject to Early Help Assessments to be assured that thresholds for initiation are appropriate. vi. The practice in this case highlights the need for practitioners and managers to include the impact of housing need within assessments.  6.2.12 The initial plan for Mother and Delta to live with MGM was based on the EPAP assessment and MGM’s viability assessment. These did not address the need for the family to have larger accommodation and without this, the plan was likely to fail within a short period. 6.2.13 The last child protection conference did address this urgent need for the family, and put it into the Child in Need plan, to be addressed within a week. This never happened. Within 2 months of the conference (4 months from the move) the overcrowding led to an alternative plan for Mother and Delta to live independently, without an assessment as to implications for the safe care of Delta.  6.2.14 Practitioners conveyed that this action was not addressed because they understood the housing shortage in Brighton & Hove meant that the plan was not feasible.    81   Recommendation 6 BHSCP to consider:    * how to be ensure staff are aware of the Allocations policy enabling senior managers within CSC to nominate a family for housing transfers when there is a need to keep a family together *how to establish if there is evidence of any impact the housing shortage may be having on child welfare in Brighton & Hove, and in particular any increase in the need for children to be accommodated or move to independence prematurely e.g. via a survey of social workers experiences.  vii. The provision of supported housing for children who are parents should be based on a holistic assessment for all members of the household. 6.2.15 Referral and assessment forms used in the application for supported accommodation are not a replacement for a holistic assessment by a social worker to decide what type of support needs a family have and specifically what housing provision is required.  6.2.16 The forms themselves could usefully be improved to include household composition and support and risks relating to dependent children. It would also be helpful to have a section to prompt sharing of any non-current risks that could potentially arise from the young person’s history and how these might be identified. 6.2.17 Social workers need to have a better understanding of exactly what support is available for each level of assessed need and risk. 6.2.18  There needs to be explicit expectations set out in the contract on role, purpose and expectations, as well as a risk management plan around any identified current or potential risks. Recommendation 7 BHSCP to consider how to improve the process involved with the application for housing and supported accommodation, so that the process provides a holistic assessment consistent with government guidance (Prevention of homelessness and provision of accommodation for 16- and 17-year-old young people who may be homeless and/or require accommodation, April 2018, Department for Education and Ministry of Housing, Communities and Local Government para 3.18 and 3.19). This could be achieved if the process mirrored the housing needs assessment, including household composition, support needs and risks relating to dependent children.     82   Finding relating to trauma viii. Some practice in this case demonstrated a lack of appreciation of the ongoing significance of family history and the impact of trauma in earlier childhood. 6.2.19 Whilst there are tensions about how to weigh historic risks and trauma against current lack of evidence of recurrence of such risks, assessments need to openly acknowledge and be aware of potential risks arising from this. 6.2.20 From the outset, historical records from LA1, were not accessed for any of the assessments undertaken, including the pre-birth assessment, the viability assessment of MGM and the EPAP assessment.  6.2.21 The pre-birth assessment appropriately identified the risk associated with Mother’s youth and lack of acknowledgement to professionals or family of what had happened to her when she was missing for long periods and the identity of her baby’s father.  Within 6 months, in the face of the evidence of Mother’s good parenting skills and desire for independence this risk was minimised.  6.2.22 In these circumstances, the impacts of earlier trauma are still likely to affect the individual and it is important to continue to offer therapy, especially in the context of continuing mental health concerns, such as anxiety, panic attacks and eating problems. 6.2.23 Where young parents have suffered trauma in the past, including suspected CSE, it is vital to be sensitive to behavioural changes, which may be indicative of increased vulnerability. This is particularly important if the parent has not ever disclosed the abuse or received therapy.  6.2.24 In such circumstances it is vital to provide effective monitoring of likely risks to children and should prompt an assessment to obtain an understanding of the reason for behavioural changes. This finding is addressed in recommendation 1. Recommendation 8 BHSCP to consider practitioners training needs on: * The long-term impacts of trauma for children, to include that some will show no current signs of trauma and/or may not acknowledge having suffered trauma and/or show other mental health needs, not recognised as being linked to the suspected trauma  *The need to access historical information to obtain an understanding of the child’s trauma, even if these are in a previous local authority *How best to work with and support such children, including how to encourage them to access therapy and to continue with such offers *How to assess such long-term impacts of trauma and its significance for risk assessment      83   Practitioners’ ability to challenge service users, whilst maintaining trusting relationships  ix. The aim of preserving a good relationship with parents, including children who are parents, must not prevent open discussion of concerns, including at multi-agency meetings.  6.2.25 The admiration of how well mother had seemingly overcome the earlier adversity of her life led practitioners to be protective of her feelings and to some extent they seem to have avoided open multi-agency discussion of some concerns; this may have minimised the significance of the issues and possibly was a barrier to open discussion of Mother’s feelings regarding the responsibilities of parenthood and the challenges she faced. 6.2.26 Issues which may have caused concerns in other parents, in these circumstances were potentially more likely to be minimised and perceived (often appropriately) as associated with the youth and trauma of the young parent’s past, without sufficient focus on the risks to the child of the parent (who was also a child). 6.2.27 A repeating theme with different practitioners involved avoiding discussion in meetings or reports of what were perceived as more minor concerns or weaker areas of parenting skills, so as to avoid damaging relationships or undermining Mother’s growing confidence 6.2.28 This happened several times in the context of positive overall perceptions and assessments of Mother’s parenting, but effectively blocked consideration of any underlying issues, which may or may not have been significant.  6.2.29 The focus on maintaining the valued good relationship, did not always provide Mother with the opportunity to acknowledge her problems, fears, any need of more help or that with Delta growing older the challenge of being a parent at such an early age was becoming increasingly difficult, especially once living on her won.  Recommendation 9 BHSCP to ensure that training of staff in relationship-based practice should include how open conversations regarding concerns are managed in a multi-agency setting to facilitate a better, more honest relationship and ensure concerns are adequately addressed and parents given the support they need.      84   Systemic issues x. The separation of social workers for parents who are children, and for their own young children presents challenges in practice, in relation to which is the lead professional overall for the family.   6.2.30 The open expression of reservations regarding the use of legal and child protection process for the unborn baby (by the chair and social worker at the Pathway Planning meeting) may have contributed to Mother’s and MGM’s lack of appreciation of the reasons behind later arrangements made in the placement. This misunderstanding was an underlying cause of the tensions between MGM, Mother and carers. 6.2.31 The separation of roles may be well understood within CSC, but it is confusing to practitioners in other agencies. 6.2.32 In December 2018 there were parallel plans made by the two social workers, which could be seen to be incompatible. Delta’s CIN plan and separate social worker was ended because of the lack of concerns about Delta living at MGM’s home, who was being monitored at the nursery. At the same time the nursery placement (and its funding) was ended because of Mother’s nonattendance on her college course, and the plan for her changed to moving to supported accommodation because of the tensions arising from the overcrowding at MGM’s home. Recommendation 10 BHSCP to request CSC address the challenges raised through having different social workers in a family and to consider the need to: * clarify which social worker is the lead professional for the family in these circumstances, so that plans are considered together, rather than in parallel * provide guidance to staff so as to ensure that any disagreements about each other’s plans do not lead to undermining plans in front of the family * consider how practitioners in other agencies can be assisted to be clear about the roles, and when they may need to make a referral directly to FDFF, in the absence of a social worker for the child of the parent who is a child     85   xi. Education provision for young people who are parents or have suffered childhood trauma needs to address additional needs which may arise as a result.  6.2.33 Education provision did not sufficiently address Mother’s needs for help and support in her return to class, despite her explanation of anxiety and panic attacks. 6.2.34 When Mother attended college in the autumn term of 2018, she did not attend her course, but spent her time in the library. She took Delta to nursery where she was able to be monitored.  6.2.35 When Mother’s place at the college was ended because of her non-attendance at course lessons, this came as a surprise to her social worker and YES practitioner, and they had no opportunity to intervene and provide support to try and help Mother overcome her reported anxieties. At this point she had been out of education for over 2 years, and a return to the classroom would inevitably be a challenge. 6.2.36 Had Mother been able to return to education, she might have developed routines and a life locally, as opposed to London. Moreover, Delta would have remained in nursery and her welfare monitored.  Recommendation 11 BHSCP to consider: *what systems need to be in place to meet the needs of children who have been out of education e.g. young parents, victims of CSE or other abuse? * how to ensure that when children who have a social worker are at risk of having their education place terminated, the social worker is informed prior to the final decision so has an opportunity to intervene (if appropriate)?  xii. Learning was identified by practitioners and within agency reports that both nationally and locally there is limited flexibility in accommodation options and there is a gap in tailored provision for young, more vulnerable parents and their children which could include family-based care and support. Recommendation 12 The local authority to develop a commissioning strategy to address the range of potential accommodation needs for young parents, to be able to provide a range of support provision, including supported accommodation with more intensive support, including 24/7 staff presence and where it is possible to be aware of which residents are present and which away at any time.    86   xiii. The fact that practitioners were unaware that Delta was not registered with a GP from the age of 5 – 15 months old, despite being initially subject to a CPP and then a CIN plan, suggests a possible systemic obstacle in the flagging up of this potential risk indicator 6.2.37 Until HV2 discovered in June 2019 that Delta and her mother were not registered with a GP, there appears to have been a lack of awareness of this potential risk indicator within the professional network. Such knowledge would have contributed to the slowly mounting evidence of Mother’s difficulty in managing some responsibilities of parenthood, despite having the support of MGM throughout this period.  6.2.38 It is of note that as part of this case review process the GP agency report also did not identify this lack of GP registration as a fact, let alone a concern. This may be linked to the approach taken in preparation of the management review, which did not include a chronology and rather than providing any sense of the overall GP involvement provided 2 separate reports for each GP practice. Recommendation 13   BHSCP to request: * Agencies and agency authors understand the requirements of agency reports, to include a chronology (if required) and an overview and analysis of the entire period of the review, including periods when no service provision was available. * The information sharing system between the Local Authority and Primary care includes the need for GPs to inform the local authority and health visitors / school nurses should they remove a child from their practice list if the child is either subject to a child protection or a child in need plan.   Complaints process xiv. The complaints procedure was not followed in this case, and with it the opportunity was lost to speak openly about MGM’s concerns, explain the foster carers responsibilities and the child protection nature of the placement and through this facilitate a good working relationship between carers and MGM, to better support Mother and Delta. 6.2.39 The lack of any complaint’s investigation, whether formal or informal, led to ongoing dissatisfaction and resentment by Mother and MGM, a misapprehension of the cause of the tensions in the household by Mother, MGM and the practitioners supporting and assessing the family, both Mother and Delta. This latter impact contributed to a minimisation of the few cautionary comments made by the carers regarding Mother’s parenting or behaviour in relation to keeping agreements, desire for freedom and sometimes placing her own needs above Delta’s.  87   6.2.40 It has not been possible to establish the reason for the failure to follow the complaints process, but records give an impression of practitioners trying to smooth things over so that the placement did not break down. Whilst understandable, this strategy ultimately failed and Mother and Delta moved earlier than planned to MGM. MGM remains upset that her concerns were not looked into, and the carers perhaps upset at not having the chance to defend themselves. Recommendation 14 BHSCP to ask CSC to ensure that practitioners and managers understand the requirements when a complaint is made and identify it as a learning opportunity and a chance to clear up misunderstandings in order to improve services. Child’s lived experience xv. There was little knowledge of and curiosity about Delta’s lived experience after she lost her nursery place. 6.2.41 Once Mother and Delta moved to MGM’s home when Delta was aged 4 months, it was considered to be MGM’s responsibility if there were any concerns about how Mother and baby spent their time in London, as neither child was Looked After anymore or subject to a child protection plan. 6.2.42 It was known that Mother and Delta were spending time with relatives in London, but because they had not been included in the viability assessment, they had not been subject to an assessment and there was no knowledge of how they understood their role and the potential risks of being in London for Mother. 6.2.43 It is now known that as early as January 2019, whilst still living with MGM, Mother was leaving Delta with various people, and not always family members, and that no concerns were ever reported by family members about their whereabouts, presumably because like practitioners, they trusted Mother’s care of Delta. This information was not known by practitioners at the time and only emerged through witness statements for the Coroner, which the author has been able to read. 6.2.44 The knowledge that Mother and Delta were spending increasing periods in London, especially from September 2019 did not, in itself, raise concerns about the quality of her life, being constantly on the move, staying with different relatives at different times (according to Mother’s accounts). This should have raised some level of consideration about how appropriate it was for such a young child to be constantly staying away from home for days at a time every week.   Recommendation 15 BHSCB to consider how best to facilitate all practitioners to focus on a child’s lived experience, even when the focus for involvement is the parent, a child themselves: this should be integrated into training as well as considered regularly in supervision case discussions.   88    Step Down practice xvi. The ‘What If?’ procedure for Child in Need cases should ensure that prior to a case being closed for a child in CSC, this is agreed with other agencies, a lead professional identified and a plan agreed if there are future changes in a family’s situation which might impact on risk and require the initiation of a referral to CSC. 6.2.45 Had this been in place in December 2018, it is possible that either other agencies might have challenged the case closure for Delta, or that the ‘What If’ plan might have identified risks which would have prompted: •  earlier initiation of Team Around the Family (TAF) meetings and formulation of a Strengthening Families Early Help Plan • a rereferral to CSC.  Recommendation 16 BHSCP to consider how to be assured of the effectiveness of the ‘What If’ procedure and timeliness of responses to concerns following this e.g through the use of a multi-agency audit of cases where the ‘what if’ procedure has been used Racism and adultification xvii. The issue of the trauma suffered by Mother due to her experiences of racism were a dominant theme for practitioners in this case, following the EPAP assessment, and raised training gaps for practitioners and carers. 6.2.46 Many changes have already been implemented within CSC as a result of this case, but this remains an ongoing challenge to equip practitioners to be aware of and constantly challenge themselves in relation to both cultural and racial issues, including that of adultification of black young people. Recommendation 17 BHSCP to continue the work already underway with agencies to provide training on anti-racist practice to increase cultural competence and the ability to identify when there are instances of racial or cultural bias occurring, even in the absence of complaints by those are victims of such bias.  Father’s identification during period under review xviii. There is evidence from assessments that practitioners were professionally curious about baby Delta’s father and understood the importance of identifying him and that he could potentially play a role in baby Delta’s life and needed to be assessed. They were unable to progress this due to Mother’s providing inaccurate information. 6.2.47 Professional practice with regard to trying to identify Delta’s father was appropriate. There is no recommendation from this finding.  89   Glossary of Terms & Abbreviations  Accommodated  Under section 20 of the Children Act 1989, a child or young person may be accommodated by the local authority where there is agreement to this arrangement by those with Parental Responsibility. The child becomes Looked After under a section 20 arrangement. BHSCP Brighton and Hove Safeguarding Children Partnership  CIN Child in Need (CIN) Plan is drawn up following a Single Assessment which identifies the child as having complex needs and where a coordinated response is needed in order that the child's needs can be met. CPP Child Protection Plan is made when a child is judged to be at risk of significant harm, significant harm being a level of harm that affects the health, welfare, and development of a child. The Plan will say what the specific risks are to the child and the actions that will be needed to keep the child safe. CSE  Child Sexual Exploitation  EHCP Education Health and Care Plans are legal documents which set out a child or young person's special educational needs and the support that is required to meet these needs. This includes a suitable education setting (nursery/school/college). EPAP  Early Parenting Assessment Programme EYFS Early years foundation stage statutory framework: standards that school and childcare providers must meet for the learning, development, and care of children from birth to 5 FGC Family Group Conference FDFF Front Door for Families provides support and guidance for parents, carers, members of the public, young people and professionals. LAC Looked after Child: Under section 20 of the Children Act 1989, a child or young person may be accommodated by the local authority where there is agreement to this arrangement by those with Parental Responsibility. The child becomes Looked After under a section 20 arrangement. NEET Not in education, employment, or training PA Personal Advisors support a child or young person as they leave care.   PLO Public Law Outline process is a precursor to making a decision on whether to initiate care proceedings.   Relevant Children Young people looked after for at least 13 weeks after their 14th birthday and have left care. They must still be provided with a Personal Advisor, a needs assessment and a Pathway Plan. The responsible authority must keep in touch, help to achieve the goals in the Pathway Plan and, importantly, arrange accommodation and maintenance. Safety Net  Brighton based charity providing support and resources to families and training to professionals working with children, young people and families.  s.20 Under section 20 of the Children Act 1989, a child or young person may be accommodated by the local authority where there is agreement to this arrangement by those with Parental Responsibility. The child becomes Looked After under a section 20 arrangement. SWM1 / SWM2 Social workers for Mother SWC1 / SWC2 Social workers for Delta TAC  Team Around the Child – Purpose: to bring together different agencies where there is concern about the child/children  90   TAF  Team Around the Family - children with high level additional/unmet needs and/or multiple needs likely to require longer term intervention from a multi-agency Team around the Family/specialist services Viability Assessment  An assessment to see if there is a reasonable possibility that a family member could care for a child/children on a long term basis, if required WiSE YMCA WiSE. provides support to children and young people up to the age of 25 who are at risk of, or experiencing sexual exploitation YES The Youth Employability Service provides person centred support to young people aged 16-18 to enable them to access Education, Employment, and Training opportunities to move from Not in Education, Employment, or Training (NEET) to in Education, Employment, and Training (EET).     91   Appendix 1: Terms of Reference Rationale for Commissioning: This Local Child Safeguarding Practice Review (LSCPR) is commissioned in accordance with Statutory Guidance under Working Together to Safeguard Children 2018. A rapid review was conducted in early 2020, following a serious safeguarding incident in December 2019. The outcome was that the criteria for a LCSPR had been met and the Child Safeguarding Practice Review Panel (National Panel) concurred. Commissioning of the review was delayed initially by post-mortem test results and investigations initiated by Sussex Police. A further short delay occurred following the arrest of mother in October 2020. A review author was appointed in December and the Case Review Group (CRG) met with the review author in January 2021 to appoint a panel and scope terms of reference and agree a review methodology.  Child Delta - Areas of inquiry/themes to be explored by Agency authors 1. How were decisions about assessment of risk and safety planning both single agency and multi-agency made by practitioners made in relation to child? Agencies to consider below issues under two time periods: Period 1. Sept 17- December 18 Period 2- January 19-December 19. o Were appropriate assessments undertaken in a timely manner? o Was the quality adequate and did they include all historical information?   o How well did the interface between the various statutory processes to support child Delta and their mother align e.g. CLA, Care Leaver processes for mother and CP and TAF/EH plans for child Delta? o Were decisions and assessments in relation to mother’s parenting trauma informed? o How was the multi-agency decision to step down child Delta’s Child Protection plan to a Child in need plan reached and what was the rationale? o From Jan 2019 and the closure of child Delta to Children’s Social Care, was the monitoring and support in place sufficiently focused on child Delta and not mother? o Were agencies overly optimistic about progress made by mother as a young parent and care leaver? o Did agencies share information about non-attendance, non-compliance with agency requests and ‘not brought’ appointments? o Was there an overreliance on mother’s account/version of events? o Did agencies work appropriately with the family to give them a better understanding of the care of child Delta that could have alerted them to Mother’s deception?  92   o Did practitioners have sufficient knowledge of safeguarding and know how to escalate safeguarding concerns?  2. What were practitioner’s understanding of child Delta’s lived experience?  o How was child Delta seen and assessed/viewed by practitioners? o Were assumptions made and if so, what were they? o Were practitioners and managers professionally curious? o Did practitioners consider child Delta’s day to day routine and experiences and did this include the presentation of a young non-verbal child being fully considered?  3. How were commissioned independent accommodation support services used and understood by other agencies to support mother and child Delta?  o Did all practitioners understand the level of support available to mother through the supported accommodation service and what else might be needed to keep child Delta safe? o Did practitioners have sufficient knowledge of safeguarding and know how to escalate safeguarding concerns? o Were thresholds understood and applied by all practitioners?  4. How was mother understood and supported by practitioners?  o Were practitioners aware of mother’s wider social/family support networks? o What was known about mother’s relationship with her father and was he considered within safety planning? o Were practitioners aware of and understood mother’s own parenting experience? o Were practitioners confident in considering and discussing the family’s culture and how to address potential cultural assumptions? o Were assessments and practice culturally aware/responsive and did they consider mother’s ethnicity, race, religion, and culture? o Was mother’s age considered as a risk, and was this view influenced by her ethnicity (‘adultification’)? o Did practitioners consider/ask mother about any experience of overt or systemic racism she may have experienced and the impact on her?  5. What was known and understood by practitioners about mother’s experience of child exploitation (including CSE or other forms of exploitation) and the impact on her?  o Was this information shared in multi-agency processes and considered in assessments of risk and support?  6. What was known and understood of mother’s education experience and the potential impact of disrupted education?   93   o Was this information shared in multi- agency processes and considered in assessments of risk and support? o How did schools address and provide for mother’s educational needs including the lack of a consistent school placement during this timeframe?  7. Fathers – what was known about or understood regarding child Delta’s father and how was this addressed by practitioners in terms of safety planning?  o Did practitioners apply professional curiosity? o Was child Delta’s father included in assessments? o Did practitioners consider whether child Delta’s father could have been capable of safeguarding and providing additional support to child Delta or did his apparent ‘invisibility’ to practitioners potentially present any additional risks?  8. Organisational issues  o Were there any organisational or resource factors which may have impacted on practice in this case? o Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case?  94   Appendix 2: Participating agencies in review Agencies participating in panel Brighton & Hove City Council - Children’s Social Care Brighton & Hove City Council – Health & Adult Social Care (HASC)  Brighton & Hove City Council – Housing  Education in Brighton & Hove NHS Sussex  LA4 County Council  Sussex Police Supported accommodation provider  Agencies providing a report / written information to reviewer  Brighton & Hove City Council – Children’s Social Care A London Council  Education in Brighton & Hove including schools and nurseries  Great Ormond Street Children’s Hospital  NHS Sussex Primary Care LA4 County Council  Safety Net SECAmbs Sussex Community Foundation Trust Sussex Police University Hospital Sussex YES – Youth Employability Service Supported accommodation provider 