Death of a 14-month old girl in July 2014. Cause of death was not ascertained but there were concerns that Child B had died while co-sleeping with her mother and maternal grandmother, who were both believed to have been under the influence of alcohol. Child B and her siblings were on a child protection plan under the category of neglect due to concerns about their mother's alcohol misuse. Mother was involved with a number of agencies, and practitioners described her as being pleasant, intelligent, and having insight into her difficulties. In total there were five critical incidents related to the children's mother's alcohol misuse. Key findings include: there was evidence of poor practice and a number of missed opportunities to safeguard Child B and her siblings; there was a tendency to parent-centred practice; Child B's mother was involved with a number of agencies yet was not challenged or confronted about her behaviour; there were no records of any inter-agency communication before the initial child protection conference; professionals did not listen to Child B's siblings who said they were left to care for Child B and did not want to live with their mother; there was failure to involve birth fathers in assessment and planning. Uses the Social Care Institute for Excellence (SCIE) Learning Together systems methodology. Makes recommendations around involving fathers and other significant men connected to a child in child protection cases; listening to the voice of the child; and interagency communication.
      
 Title:  Serious case review: Child B. LSCB: Staffordshire Safeguarding Children Board Author: Mick Muir Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                       Staffordshire Safeguarding Children Board  Serious Case Review  Child B  Final Report             Endorsed by the SSCB: 15th October 2015 Published on: 3rd January 2017  SCR Report-Child B – Final   Page 2  1. Introduction   1.1 Why this case was chosen to be reviewed  Child B died on 3rd July 2014.  At the time of her death, she was the subject of a child protection plan on the grounds of neglect attributable mainly to concerns about her mother’s alcohol misuse.  Following her death, Child B was the subject of a post-mortem examination which noted that while the cause of death was unascertained, there were concerns that Child B had died while co-sleeping with her mother and maternal grandmother, both of whom were believed to be under the influence of alcohol.  Child B’s case was considered at the Serious Case Review (SCR) Scoping Panel meeting on 14th September 2014. There was unanimous agreement by all present that the criteria for a SCR, outlined in Working Together 2013, were met and a recommendation was made to the Chairperson of the Safeguarding Board to conduct a SCR. The recommendation was accepted by the Board Chair on 14th October 2014.  Working Together 2013 states that LSCB’s may use any learning model which is consistent with the principles in the guidance, including the systems methodology recommended by Professor Munro*. It was agreed that this review would be conducted using the SCIE Learning Together methodology.  A Glossary of the acronyms and references used in this report can be found in Appendix A on page 53 of this document.                   * The Munro Review of Child Protection: A Child Centred System (2011)  SCR Report-Child B – Final   Page 3  1.2 Succinct Summary of the Case  Family Composition:     Maternal Great-grandfather Adult W Maternal Great-grandmother Adult V Maternal Grandmother Adult S Mother Father Child L Adult T Father Child M Adult U Father Child B Child L Half-brother (12 years) Child M Half-sister (9 years) Child B Subject (14 months) SCR Report-Child B – Final   Page 4  Child B first came to the attention of Children’s Social Care (CSC) in September 2013, following an allegation that Adult S had been intoxicated with alcohol while she was breastfeeding Child B. Child B was four months old. CSC made enquiries with the various agencies involved with the family at the time who were unable to provide any information to corroborate the expressed concerns and a decision was made by CSC to take no further action.  Child B was re-referred to CSC five months later following an incident when she and her older siblings were found in their mother’s care while she was intoxicated with alcohol. CSC began a section 17 (Children Act 1989) child social work assessment which concluded that all three children should become the subjects of a child in need (CiN) plan.  Over the next two months there were three further incidents when Adult S was found to be intoxicated while caring for her children which necessitated their removal to different members of the extended family. A decision was made to take the case to an initial child protection conference in May 2014, the outcome of which was that Child B and her older siblings were all made the subjects of child protection plans on the grounds of neglect.  Following the Conference, Child B remained in the care of her mother (living with Adult W) and the other children lived with Adult T.  There were no further incidents when Child B’s mother was found to be intoxicated, though there was some evidence to suggest that she continued to drink. After a relatively short period of time the relationship between Adult S and Adult W became strained and Adult S made plans to move to a different address. As a precursor to this move, she went to stay overnight with Adult V, where it is believed both adults were drinking during the course of the evening.  Later that night, Child B died while co-sleeping with her mother and grandmother.  Following Child B’s death Adult S was arrested, but was released without charge.   SCR Report-Child B – Final   Page 5  1.3 Timeline of Key Events   Date Event 03-09-2013 HV for another family reports to CSC information that Adult S was seen to be drunk while breastfeeding Child B. Lateral checks undertaken with Child B’s health visitor (HV) and Child L and Child M’s school. No evidence to corroborate concerns. CSC decides on no further action (NFA). 18-10-2013 Adult S contacts HV complaining she is depressed and discloses difficulties in her relationship with Adult U. HV advises Adult S to contact Pathway (DV Support Service) which she does later that day. 26-11-2013 Adult S consults GP about her depression and reports that she is receiving support from Pathway and HV. Her general practitioner (GP) prescribes anti-depressant medication. 28-01-2014 HV visits Adult S and completes the Edinburgh Post-Natal Depression Scale (EPNDS) which scores 23. HV recommends Adult S seeks a referral to a Post-Natal Group in the area the child lived. Adult S remains in contact with the Pathway worker. 28-02-2014 Adult T contacts CSC Emergency Duty Service (EDS) at 12:45am to report that he had been contacted by Child L because Adult S is ‘passed out’ under the influence of alcohol. Adult T reports that Adult S had threatened to ‘slit the older children’s throats’. Adult T tells EDS that he is taking the older children to his address and Child B will be cared for by a neighbour. Adult T says these are the usual arrangements when Adult S is drunk. Given the lateness of the hour, EDS accept this arrangement and refer the matter to the Area Team in the area the child lived the following morning. 28-02-2014 Upon receipt of the referral later the same morning, it is allocated to SW1 for a child social work assessment. SW1 does not complete any lateral checks, but does speak to Child L and Child M who confirm that Adult S ‘drinks all the time’. When SW1 speaks to Adult S, she admits that she had been drunk and identifies the use of drink as a coping mechanism to help her with her complex relationships with Adult T and Adult U. SW1 concludes that the case can be managed by CiN level underpinned with a written agreement and this conclusion is endorsed by her Team Manager.   SCR Report-Child B – Final   Page 6  02-04-2014 A neighbour of Adult S contacts the NSPCC to report that she is drunk and that her three children are with her. The neighbour says this is a common occurrence and the children are being neglected.  The neighbour is advised to call the Police and she does so. The Police attend and find Adult S in a highly intoxicated state.  They consider the use of S.46 powers but do not use them as Adult T arrives (having been contacted by Child L) and agrees to care for Child L and Child M. Adult S persuades the Police to contact Child B’s father, Adult U, who agrees to attend and stay overnight to care for Child B. 03-04-2014 In the early hours of the morning Adult S takes an overdose of Diazepam and she is admitted to hospital where her condition is monitored. She is the subject of a Rapid Assessment Interface and Discharge (RAID) assessment and is discharged with an urgent referral to the Community Mental Health Team in the area the child lived. 20-04-2014 Adult S calls 999 to report Adult U had taken Child L and Child M to Birmingham Airport en-route to a holiday abroad. She requests that the children are returned to her care. The Police collect Child L and Child M from the airport and attempt to reunite them with Adult S but she is not at home. The children are taken to the local police station from where Adult T is contacted and he agrees to take the children into his care. The Police attend Adult S’s address to inform her about what has happened and find her intoxicated and unable to care for Child B.  Adult S persuades the Police to contact Adult W (Child B’s maternal great-grandmother) who agrees to look after Child B. 25-04-2014 A single agency strategy meeting is convened, involving SW1 and Team Manager. A decision is made to take the case to a Child Protection Conference. 30-04-2014 At 5:00pm the Police receive a report that Adult S is drunk and in the street screaming at her older children. The Police attend and find Adult S intoxicated and in a highly emotional state. They make arrangements for Child L and Child M to be cared for by Adult T and for Child B to return to the care of Adult W. 02-05-2014 Adult S attended a mental health assessment appointment accompanied by SW1. She denied that she had attempted suicide and attributed her actions to her low mood, brought on by her complex personal relationships. She denied that she drank excessively and this was not challenged by SW1. The conclusion of the assessment was that Adult S would benefit from cognitive behaviour therapy (CBT) and she was advised to self-refer to the ‘Wellbeing Matters’ service.   SCR Report-Child B – Final   Page 7  12-05-2014 An initial Child Protection Conference is held, the outcome of which is that all three children become the subject of a child protection plan on the grounds of neglect. The plan recommends that Child L and Child M remain in the care of Adult T and that Child B and Adult S live with Adult W until Adult S finds suitable accommodation, close to Adult W and away from the area where they used to live. 21-05-2014 The first Core Group meeting is held. This is arranged in two parts to accommodate confidentiality issues associated with the different paternities of Child B and Child L and Child M. Adult S becomes upset over Adult T’s plans to apply for residence orders for Child L and Child M. The meeting ends abruptly and no detailed child protection plan is agreed. 30-05-2014 Home visit by Family Support Worker (FSW) to administer unannounced breathalyser test. Adult S tells FSW that she intends to move out of Adult W’s address in the near future to a house a few doors away. 05-06-2014 SW1 makes statutory visit to Child L and Child M at Adult T’s address. Both children state they do not wish to return to Adult S’s care. Child M tells SW1 that she thought Adult S had been drinking the last time she saw her. 06-06-2014 Adult T calls EDS to report that Child L and Child M have been returned to his care early following contact with Adult S. He says that he believes Adult S has been drinking. EDS contact Adult W who confirms that Adult S had had a drink but that she was capable of looking after Child B with her (Adult W’s) supervision. 18-06-2014 Decision to reallocate the case to SW2 as SW1 is leaving the local authority. 27-06-2014 Statutory visit by SW1 to Child B who was living with Adult S at her maternal niece’s home. The visit is uneventful and Adult S tells SW1 that she intends to move into her own rented property in the near future. 01-07-2014 Adult S telephones SW2 to inform her that she is staying temporarily with Adult V prior to a move to her own address on the following day. 02-07-2014 SW1 phone call to Adult T to inform him that the case has been transferred to SW2. Adult T reports two incidents of Adult S drinking. 03-07-2014 Child B reported as a child death at 02:27 hours.   SCR Report-Child B – Final   Page 8  1.4 Methodology  The case review used the systems methodology called Learning Together (Fish, Munro & Bairstow, 2009). The focus of a case review using a systems approach is on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the ‘deeper’, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case and changing them will contribute to improving practice more widely.  The methodological heart of the Learning Together model has three main components:   Reconstructing what happened – unearthing the ‘view from the tunnel’ and understanding the ‘local rationality’.   Appraising practice and explaining why it happened through the analysis of Key Practice Episodes (KPE’s).   Assessing relevance and understanding what the implications are for wider practice – using the particular case as a ‘window on the system’.  Using this approach for studying a system in which people and the context interact requires the use of qualitative research methods to improve transparency and rigour.  The key tasks are data collection and analysis. Data comes from structured conversations with involved professionals, case files and contextual documentation from organisations.    1.5 Review Team  The review has been carried out by a Review Team led by Mick Muir, an Accredited Learning Together Lead Reviewer. The Review Team received support throughout part of the process from the SSCB Business Manager and SSCB Business Support Officer.  It is usual for ‘Learning Together’ reviews to be undertaken using two Lead Reviewers. However, in this case, it was decided due to time and financial constraints to proceed with one Lead Reviewer with additional support from SCIE.  This was provided by the SCIE Head of Learning Together in the form of case consultation, supervision and a findings clinic for the Lead Reviewer.  Collectively, the role of the Review Team is to undertake the data collection and analysis and author the final report. Ownership of the final report lies with the SSCB as a commissioner of the SCR.  SCR Report-Child B – Final   Page 9  The Review Team was made up of senior representatives from the different agencies that had been directly involved with Child B. The role of the Review Team Member is to provide expert knowledge in relation to the practice of their individual agency, to contribute to the analysis of practice and to the development of the findings from the review. No members of the Review Team had any direct case management responsibility in relation to the services offered to Child B.  The Review Team was made up as follows:   Designation & Agency of Review Team Members SCIE Accredited Lead Reviewer – Mick Muir Detective Chief Inspector, Staffordshire Police County Manager, Specialist Safeguarding, Staffordshire County Council Named Nurse for Safeguarding Children, South Staffordshire and Shropshire NHS Foundation Trust Head of Safeguarding, Staffordshire and Stoke-on-Trent Partnership NHS Trust Safeguarding Children Lead Nurse, Sandwell & West Birmingham Hospital Designated Nurse for Safeguarding Children, South Staffordshire Clinical Commissioning Group (CCG) South Staffs Designated Nurse for Safeguarding Children- Sandwell & West Birmingham CCG (Designated Nurse for Child Death Reviews)  Safeguarding Lead, West Midlands Ambulance Service Operation Director, Pathway Services Principal Social Worker (Children), Staffordshire County Council Staffordshire SSCB Development Officer Staffordshire SSCB Board Manager    1.6 Structure of the review process  The SCIE model uses a process of iterative learning, gathering and making sense of information about a case that is a gradual and cumulative process. Over the course of this review there have been a series of meetings between the Lead Reviewer, Review Team and Case Group members. Initially there was a meeting between the Lead Reviewer and the Review Team to explain the SCIE Learning Together model and the role of the Review Team in the process. The Review Team then decided the membership of the Case Group based on their individual involvement in the case.  SCR Report-Child B – Final   Page 10  An introductory meeting took place with the Case Group at which the Review Team was also present. At this meeting the SCIE model was explained to the Case Group and their role in the review process was clarified. Case Group members were informed they would be involved in individual conversations with Review Team members and Lead Reviewer and given the opportunity to reflect on and explain their involvement with the case. They were also informed that they could be accompanied by a supporter at the conversation if they wished. There were 14 individual conversations which took place over a period of three days. In addition, there was a telephone conversation between the Lead Reviewer and the EDS Manager.  During the course of the review the Review Team met on seven occasions and, in addition, attended a reading day. The Case Group met on three occasions, one for the introductory session and then for two Follow-on meetings, where the emerging analysis was discussed and challenged. The Review Team were also present in these meetings.   The review followed the process and meeting structures as outlined by SCIE with one additional final meeting of the Review Team to agree and sign off the report and reflect on the experience of using the SCIE model. In total, the Review Team met on ten occasions, including three which involved Case Group members.    1.7 Timeframe and mandate  In line with qualitative research principles, reviewers endeavour to start with an open mind in order that the focus is led by what they actually discover through the review process. This replaces the terms of reference (that have a specific focus of analysis before the review process has begun) which are a fundamental feature of traditional Serious Case Reviews.  The timeframe for the review was set at the initial meeting between the Lead Reviewer and the Review Team on 3rd February 2015. It was agreed that the timeframe was from 4th December 2012 (the date of Adult S’s booking-in appointment) until 3rd July 2014.  Within the period under review, eight key practice episodes (KPE’s) were identified (covering the period from 3rd September 2013 until 19th June 2014). These KPE’s were then analysed in detail to provide insight into not only what happened with Child B but also why things happened as they did. It was from this process of analysis that the learning from the review (presented later as findings) was generated.   SCR Report-Child B – Final   Page 11  1.8 Sources of data  The systems approach requires the Review Team to avoid hindsight bias in the case analysis and to discover how people saw things at the time – the ‘view from the tunnel’. This process reveals what sense practitioners made of what was happening at the time of their involvement and begins to explain why they acted as they did.  This is known as the ‘local rationality’. It requires those who had direct involvement in the case to play a major part in the review in sharing information about how the ‘safeguarding system’ works and analysing how and why practice unfolded the way it did, while at the same time explaining the broader organisational context.      Data from Practitioners  Information was provided by members of the Case Group who were directly involved with the family through a process of individual conversations. They were invited to share their experiences of working with Child B and her family in the context of their knowledge of the systems and practice at that time. A total of 14 conversations were held with individual practitioners (who fulfil the roles outlined below), who together formed the Case Group for the review. Two members of the Review Team were involved in each conversation, with the exception of the telephone conversation between the Lead Reviewer and the EDS Manager.   Designation and Agency of Case Group Members Police Officer 1   ) Staffordshire Police Police Officer 2   ) Area Team Manager  ) Staffordshire County Council Area Social Worker   ) Mental Health Professional  ) South Staffordshire & Shropshire NHS  Community Psychiatric Nurse )         Foundation Trust Health Visitor    ) Staffordshire & Stoke-on-Trent Partnership School Nurse   ) NHS Trust Named Nurse for Safeguarding ) Health Visitor     Sandwell & West Birmingham Hospital GP      South Staffordshire CCG GP      Sandwell & West Birmingham CCG Case Worker     Pathway Services Independent Conference Chair ) Staffordshire County Council EDS Manager   )  SCR Report-Child B – Final   Page 12  Data from Documentation  In the course of the review the Review Team members had access to the following documentation:   Referral information following incident on 3rd September 2013  Referral information following incident on 28th February 2014  Social Work case records from 6th March to 30th June 2014  Record of SW initial visit on 6th March 2014  Police records of incident on 2nd April 2014  Ambulance record of Adult S’s admission to hospital on 3rd April 2014  Hospital record of Adult S’s admission on 3rd April 2014  Hospital admission record  RAID Assessment  EDS record of incident on 30th April 2014  Written agreements to secure children’s placements, 28th April 2014  Record of strategy discussion to move case to ICPC  Police records of incident on 30th April 2014  Mental Health and Risk Assessment on Adult S, 21st May 2014  Social Worker report for ICPC, 12th May 2014  ICPC minutes and copy of initial CP plan  First Core Group minutes, 21st May 2014  Post-mortem report, dated 25th February 2015   Ofsted Inspection Report for the period 14th January to 5th February 2014  Staffordshire County Council ‘Summary of Audit Findings’ from Q3 2013/2014 – Q1 2015/2016  Edinburgh Post-Natal Depression Scale, completed on Adult S on 8th august 2013 (13/30); 28th January 2014 (25/30); 9th April 2014 (25/30)  Staffordshire County Council ‘written agreement’ protocol.    Data from Family, Friends and Community  The SSCB Business Manager wrote to Adult S, Adult T, Adult U and Adult V shortly after the decision to conduct a SCR was made in October 2014 to inform them that a review into the circumstances of Child B’s death was to be completed.  She wrote to them again following the commencement of the review in February 2015 to offer them the opportunity to make a contribution to the process. Adult U responded positively and he and the Lead Reviewer had an extended telephone conversation in which he provided useful information about family relationships and dynamics.  The SSCB Business Manager made two further attempts to make contact with the other adults involved with Child B to invite them to contribute to the review process but they declined to do so. SCR Report-Child B – Final   Page 13  The issue of whether to involve Child B’s siblings in the review was discussed at the first meeting of the Review Team. It was decided that it would be inappropriate to approach Child L and Child M, given their ages and relatively recent loss of their younger sister.    1.9 Local Context  Child B died at the end of what had been a very difficult period for the CSC Area Teams in the district the child lived in. The district is covered by two separate CSC teams which at the time of Child B’s death were effectively operating as a single team, due to the long-term sickness absence of one of the team’s Team Manager.  The consequence of this was that the other Team Manager assumed responsibility for managing both teams with 20+ direct reports from Social Workers and Family Support Workers. In addition, there were difficulties in recruiting and retaining experienced staff with the consequence that the staffing of both teams was comprised largely of a mixture of newly qualified staff and agency workers. At the time of Child B’s death one team had just under 400 open cases. SW1 was a relatively inexperienced social worker and there is a note on her supervision record that on 22nd April 2014 she had 43 open cases. The inevitable consequence of this volume of work in these circumstances was a deterioration in the quality of decision making and case planning.  This situation was recognised by Senior Management in June 2014 and an action plan was implemented to address the identified difficulties. The plan included the recruitment of an interim Team Manager to cover for the absent Manager’s sick leave plus an additional Manager to catch up on the backlog of work that had accumulated, improved levels of support for all three Team Managers, an audit of all open cases and robust tracking of cases to improve management oversight and decision making. In addition a piece of work was undertaken with Social Workers, led by the Principal Social Worker, to help them refocus on their performance and behaviours to improve the quality of interventions with the children and families.  Following this initial response, work continued over the following twelve months to consolidate and improve on the changes that had been made. The situation at present is that systems and processes are now in place to ensure that the two teams operate as two separate teams. They have their own dedicated Team Co-ordinators and separate duty and intake of work systems. There has been investment in training and team development and an increase in the level of support offered to Team Managers by the County Manager.  The situation at present is that both teams are fully staffed with no agency workers in either team, with 230 open cases in one of the teams being carried by 10.5 wte social work staff.  SCR Report-Child B – Final   Page 14  The particular circumstances that existed in the area the child lived at the time of Child B’s death have implications for the extent to which the key features of professional practice in this case are representative of practice generally. The Review Team has considered this issue carefully to ensure that for each finding there is sufficient evidence to say that it represents an underlying pattern of practice or (where there is insufficient evidence to say for certain) the issue is of such importance as to merit further enquiry.  Those practices which were evident in this case which were peculiar to the particular area team where the child lived and which have already been addressed, are identified later in the report.   SCR Report-Child B – Final   Page 15  2. The Findings   What light has this case review shed on the reliability of our systems to keep children safe?   2.1 Introduction  A case review plays an important part in efforts to achieve a safer child protection system. Consequently, it is necessary to understand what happened and why in the particular case, and go further to reflect on what this reveals about gaps and inadequacies in the child protection system. The particular case acts as a ‘window on the system’ (Vincent 2004: 13).  For this to happen, the outcome of the review has to say more than what happened in this particular case and needs to provide messages to the LSCB about usual practice and normal patterns of working. These messages are presented as Findings and they provide the LSCB with an insight into the underlying patterns that influence professional practice and outcomes for children. These Findings exist in the present and potentially impact on the future. By responding positively to the Findings the LSCB has the opportunity to change how the child protection system operates and to make it safer. It makes sense, therefore, to prioritise the Findings to identify those that need to be tackled most urgently for the benefit of children and families, even though these may not be the issues that appeared most critical in the context of this particular case.  In order to help with the identification and prioritisation of Findings, the systems model that SCIE has developed includes six broad categories of these underlying patterns. The ordering of these in any analysis is not fixed and will change according to which issues are felt to be most fundamental for systemic change. The categorisation of Findings is as follows:  1. Innate human biases (cognitive and emotional) 2. Family-professional interaction 3. Responses to incidents 4. Longer term work 5. Tools 6. Management systems  The Findings from each category convey a message to the SSCB about how that element of the child protection system is working currently. They state succinctly what is problematic about the system and are therefore helpful to the reader. It is not uncommon for there to be overlap between the categories of findings.  SCR Report-Child B – Final   Page 16  2.2 Appraisal of professional practice in this case – a synopsis  This section of the report sets out the view of the Review Team on the quality of multi-agency practice evident in this case, given what was known and knowable at the time. The Review Team is grateful for the contributions made by the members of the Case Group, some of whom found the process of the review quite difficult and personally challenging.  The period under review in this case stretches from 4th December 2012 until 3rd July 2014. However, in reality, Adult S’s confinement and the first four months of Child B’s life were uneventful and the events that formed the basis for the review extended from 3rd September 2013 to 2nd July 2014. Within this period there were five critical incidents, each of which represented a missed opportunity to take protective action on behalf of Child B.  The Review Team was aware of the problems that were being experienced by CSC in the area the child lived during the timeframe of the review and was sympathetic to the difficulties that these presented. Nonetheless, it was the view of the Review Team that the quality of the service provided by CSC throughout this time fell below expected standards. The Review Team was also critical of the practice of a number of partner agencies, particularly in relation to sharing information and their willingness to share responsibility in the safeguarding process. The Review Team noted the good practice of the Police Officers involved in the three incidents in April 2014 who, within the confines of their role, demonstrated effective, child-focused, safeguarding practice.  What follows are the key issues that emerged in the course of the review.  Where possible, a satisfactory explanation will be provided for the practice or an indication will be given where the issue will be discussed more fully in the findings.    Persistent failure to recognise risk  When Child B was referred to CSC EDS by Adult T on 28th February 2014 and the case was picked up by the CSC Area Team in the area the child lived, there was sufficient evidence of likely significant harm to justify a strategy discussion and a S.47 enquiry. Instead, the case was allocated for a S.17 child social work assessment, the outcome of which was a decision to manage the case at CiN level.  There were three further incidents when Adult S was found to be intoxicated with some or all of the children in her care, each of which was of sufficient significance to warrant a S.47 enquiry. It is a matter of some concern that despite the repeated presentation of likely significant harm (particularly in relation to Child B), that no S.47 enquiry was ever conducted in this case. This is evidence of poor practice and a number of missed opportunities to safeguard Adult S’s children.  SCR Report-Child B – Final   Page 17  The Review Team was concerned that the practice in this case was representative of practice of CSC in Staffordshire generally but was reassured that it was not by the evidence from a recent Ofsted Inspection Report and quality assurance data provided by CSC from quarter 3 of 2013-2014 to quarter 1 of 2015-2016.  The Ofsted inspection took place during the timeframe for this review. It found that safeguarding services were ‘good’ with evidence that “the vast majority of assessment (of risk) demonstrate good analysis of children’s needs and circumstances which supports sound decision making and planning”. This judgement represents an improvement on the previous inspection of safeguarding arrangements in November 2012 when the judgement was that these were ‘adequate’.  The quality assurance data indicated that CSC practice relating to the assessment of risk (which included a section on the ‘recognition of risk’) had been good or outstanding in 90% of cases from October 2013 until June 2015.  These two pieces of evidence, together with the evidence of the remedial action that has been taken over the past twelve months in the area the child lived, has persuaded the Review Team that the practice in this case could be attributed to the pressures and circumstances that were present in this particular Area Team at the time of Child B’s death and did not evidence a systemic weakness within CSC. As a consequence, there is no finding in relation to this issue as it relates to CSC. The Review Team did consider that partner agencies could have been more active in challenging the CSC responses to the concerns about the children as they arose and this issue is explored further in Finding 1 and Finding 4.    Tendency to parent-centred practice  Almost without exception, the members of the Case Group who had direct contact with Adult S liked her and were positively disposed to her. She was described as pleasant, intelligent and articulate. She was believed to have insight into her difficulties and appeared to be help-seeking and keen to overcome the problems she associated with her complex relationships with Adult T and Adult U. She was involved with a number of agencies, each of which believed she was actively engaged with their service with the intention of improving her own circumstances and, as a consequence, improving her children’s circumstances. In reality, Adult S did not engage with any agency in any meaningful way throughout the period of the review. As a consequence, she never changed and her children’s circumstances never changed. Despite this fact, there is no evidence that Adult S was ever challenged or confronted about the consequences of her behaviour for her children (except for one conversation with a Police Officer during the incident on 30th April 2014).  The failure of practitioners working with Adult S to see beyond her presenting difficulties and recognise the impact of what she did on her children’s safety and welfare was evidence of poor practice. What lay behind this response is explored further in Finding 6 and Finding 7. SCR Report-Child B – Final   Page 18  Poor inter-agency communication  Following the referral to CSC on 28th February 2014 there is no evidence that any lateral (multi-agency) checks were undertaken prior to the commencement of the S.17 child social work assessment. Thereafter, despite Adult S’s involvement with a number of agencies and the fact that all three children were nominally the subjects of CiN plans, there is virtually no record of any inter-agency communication prior to the initial child protection conference on 12th May 2014. The agencies that were involved with Adult S all had information that was relevant to the safeguarding process and the failure to share this information may have impacted adversely on the outcomes for Child B and her siblings. The explanation for this poor practice on the part of CSC staff is to be found in the circumstances that were prevalent in the Area Team where the child lived at the time. In relation to the partner agencies, this issue is considered further in Finding 3 and Finding 4.    Failure to take account of the child’s voice  In the course of the four significant incidents that lie at the heart of this review, Child L and Child M were spoken to by Police Officers and CSC staff on a number of occasions. On each occasion that they were spoken to, they repeated the same two things. The first was that their mother drank all of the time and that they were frequently left to care for Child B; the second was that they no longer wished to live with Adult S and wanted to stay with Adult T.  There is no evidence that the information about Adult S’s drinking was taken seriously when assessing the risks to which the children may be exposed. On the contrary, the minutes of the conference of 12th May 2014 which record “it was believed that Adult S’s excessive drinking represented the exception rather than the rule”, would suggest that the children were disbelieved and their information discounted.  The fact that the children eventually went to stay with Adult T following the serious incident on 30th April 2014 was due largely to circumstance rather than as a consequence of the children’s voices having been heard. They had been returned to Adult S’s care three times previously (between 28th February and 28th April 2014) despite having said on each occasion that they wished to remain with Adult T.  The failure of CSC staff to take seriously what the children were saying about the extent of Adult S’s problematic drinking and to take action to move them to a safe place and intervene more robustly to secure Child B’s safety represents poor practice and an important missed opportunity to safeguard and promote their welfare.  The Review Team recognised the importance of this issue and was minded to develop a finding to bring the matter to the Board’s attention. It was dissuaded from doing so by the conclusions of the Ofsted inspection (referred to earlier) and the quality assurance data provided by the CSC representatives on the Review Team. SCR Report-Child B – Final   Page 19 The Ofsted inspection identified the ‘voice of the child’ as a strong point in the Staffordshire safeguarding system.  It stated:   Social workers had a good understanding of the children they work with and appreciated the importance of listening to children’s experiences and views when making decisions that affect their lives.   Social workers were able to articulate the importance of understanding the child’s experiences and views. There were strong examples of records which told the child’s story very well.   There has been a significant improvement in the voice of the child being heard at case conferences.  The quality assurance data from CSC between quarter 3 of 2013-2014 to quarter 1 of 2015-2016 indicated that there was evidence of the child’s views, wishes and feelings impacting on intervention and outcomes was present in (on average) 75% of cases.  From this information the Review Team concluded that the poor practice in relation to hearing the child’s voice that was evident in this case was attributable to the circumstances that prevailed in the CSC Area Team where the child lived at the time of their death and did not represent practice in Staffordshire generally.    The use of written agreements  At the conclusion of the S.17 child social work assessment it was decided that the case should be held at CiN level, with a written agreement in place to address the risks that had been identified (though there is no record that such an agreement was drafted). Following the incident on 2nd April 2014, when Child L and M went to stay with Adult T, there is a record of a telephone conversation with Adult S to inform her of a written agreement to secure the children in Adult T’s care. Following the incident on 20th April 2014 there is a written agreement drafted by EDS requiring Child B to live with Adult W and Child L and Child M to live with Adult T. There were further, identical, written agreements drafted on 28th April 2014 (confirming the children’s places of residence and a requirement that Adult S will not drink while she has care of the children) that were signed by all parties two days before the fourth serious incident that required the children to be moved once again.  SCR Report-Child B – Final   Page 20  The written agreements were put in place in order to provide the Local Authority with assurances that Adult S and her extended family shared its concerns about the children and were prepared to act to secure their safety and welfare. In reality, the agreements were of no value. All of the agreements, both verbal and written, were breached almost immediately by Adult S and her family with no action taken in response to these breaches, only for them to be replaced with identical agreements following the next incident. At best, the agreements clarified the concerns of the Local Authority for the family, though they provided no added protection for the children. At worst, they served to undermine the protection of the children by providing a false sense of security about their welfare.  The CSC representative on the Review Team reported that the inappropriate use of written agreements had been widespread across the County and had come to the attention of senior management following the outcome of a Stage Two complaint and two case review reports from the SSCB. In response, a protocol was drafted which tightened the criteria for the use of written agreements and increased the level of management oversight of their use (up to County Manager level). The new protocol was signed off by the Policy and Procedure Board in October 2014. Following the implementation of the new protocol there has been a significant reduction in the use of written agreements and CSC quality assurance activity has not revealed any inappropriate written agreements in case file audits.  It was the view of the Review Team that the above constituted a satisfactory response from CSC and that as a consequence, no finding was necessary to bring this issue to the Board’s attention.    Non-engagement with men  Adult T and Adult U were key figures in the way the concerns about the three children were managed during the period under review. Adult T was important because he regularly reported concerns about Adult S’s drinking habits and he was the person that looked after Child L and Child M in times of crisis. Adult U was important because he was allegedly a source of distress to Adult S (which she claimed was a trigger for her problematic drinking) and also he was seen as a protective factor for Child B during the incident on 2nd April 2014 and subsequently when Adult S left Adult W’s home a short time after the child protection conference in May 2014. Both men attended the conference and both attended the subsequent core group, but there is no evidence that they were involved in the S.17 child social work assessment or spoken to alone about the nature and extent of Adult S’s use of alcohol or the nature of their relationships with any of the children. There is no record either that they were challenged when they breached the agreements that were made following the series of critical incidents.  SCR Report-Child B – Final   Page 21  The conversation between the Lead Reviewer and Adult U revealed that he had lots of information that would have been helpful in the assessment of Adult S. It is reasonable to assume that Adult T could have been equally helpful. The failure to engage fully with Adult T and Adult U, both in the assessment and in the longer term planning for the children, was evidence of poor practice and a significant missed opportunity in this case. What lay behind that pattern of practice is considered in Finding 5.    Recognition of the impact of neglect  When the concerns about Child B first came to light in September 2013 the neighbours who spoke to her Health Visitor alleged that Adult S neglected Child B.  A similar allegation was made by Adult S’s neighbour when she raised concerns about the children on 30th April 2014.  In the records of the interventions from all agencies prior to the case conference in May 2014, there is no mention of neglect or the impact of Adult S’s alcohol misuse on her children.  Instead, the focus is on Adult S and providing her with the support she said she needed to address her personal difficulties. Even at the case conference, when the children became subjects of child protection plans on the grounds of neglect, there is no acknowledgement of the impact of the neglect that the children had experienced (particularly Child L and Child M) and there is no recommendation to address any therapeutic needs they might have. From the information provided by Adult U it is likely that all of the children had experienced the consequences of Adult S’s problematic drinking behaviour throughout their entire childhoods. The failure to recognise this and take appropriate remedial action is evidence of poor practice and an important missed opportunity. An explanation for this practice is provided in Finding 2, Finding 7 and Finding 8.    2.3 In what way does this case provide a useful window into our systems?  As with all cases, there were features of this case that were unique to Child B and her family in terms of the relationships that existed between the significant adults and the difficulties and challenges these presented for Adult S which impacted on her children’s safety and welfare. It is also clear from the ‘appraisal of practice’ that there is evidence that some of the omissions and failures in this case were the consequence of the circumstances that prevailed in the CSC Area Office where the child lived were not representative of multi-agency practice in Staffordshire generally.  SCR Report-Child B – Final   Page 22  Nonetheless, it was the view of the members of the Case Group and Review Team that there were a number of aspects of this case that were typical of practice across the County, though it is necessary to point out that on a number of issues there was far from unanimous agreement that what happened in this case represented normal or usual practice. The wording of the findings is suitably nuanced to reflect these differences.  The areas in which there was some agreement included: the challenges of working with disguised co-operation; problems in inter-agency communication; difficulties in engaging with men in the safeguarding process; offering appropriate challenge to both clients and professional partners where there are safeguarding concerns and using child protection conferences effectively to develop outcome focused child protection plans.   The Review Team has identified eight findings for the Board to consider.   Finding 1 Is the capacity of multi-agency partners to provide sufficient challenge to social workers risk assessments undermined by their levels of understanding about risks to children?  (Management Systems)    Finding 2 The presentation of apparently episodic neglect caused by alcohol misuse makes it more likely that professionals will underestimate its adverse effects on children’s safety and welfare and compromise their ability to take appropriate protective action.  (Response to Incidents)   Finding 3 Is there a pattern of practice in the area where the child lived, whereby people don’t think to make contact with colleagues from other agencies to share or seek information that may have safeguarding implications, which leaves some professionals unaware of concerns about children which impacts adversely on their ability to safeguard and promote their welfare?  (Longer Term Work)   Finding 4 When decisions about safeguarding issues are being made, there is a tendency for some partner agencies to defer to CSC (who they believe ‘know best’) or assume that CSC involvement automatically means that safeguarding issues are being properly addressed.  (Response to Incidents)   Finding 5 There is a pattern of practice in Staffordshire where professionals routinely fail to engage with or challenge men in the safeguarding process, leading to untested assumptions about their role in promoting the safety and welfare of their children.  (Family/Professionals Interactions) SCR Report-Child B – Final   Page 23   Finding 6 Is there a pattern of practice in the area the child lived whereby some professionals are inclined to accept what parents tell them about their behaviour (without challenging them with available information that contradicts what they say) which leads to errors in assessment of risk to which children are exposed and compromises their ability to take protective action?  (Family/Professionals Interactions)   Finding 7 Is there a pattern of practice whereby neither multi-agency forums nor supervision in any agency are effective in challenging and disrupting a fixed view of a case (once established) as a means of checking its accuracy?  (Cognitive Biases)   Finding 8 The way in which child protection conferences operate in the area the child lived makes it more likely that they do not provide the necessary rigorous challenge to professionals’ assessment of parents’ capacity to safeguard their children’s welfare and do not produce sufficiently clear and risk focused child protection plans.  (Management Systems)    SCR Report-Child B – Final   Page 24  Finding 1  Is the capacity of multi-agency partners to provide sufficient challenge to social workers risk assessments undermined by their understanding about risks to children? (Management Systems)  Multi-agency involvement in the safeguarding process is intended to ensure that all available information is brought together and shared. The goal is to bring a healthy check and challenge to the difficult task of analysing the information to determine the level of risk to which children may be exposed. In this case there were a number of opportunities when partner agencies could have challenged the decision making of CSC in the management of risk in this case but failed to do so.    How did this issue manifest itself in this case?  The early decision making following the incident on 28th February 2014 was made unilaterally by CSC as it did not share information with partner agencies before concluding that the case could be managed at CiN level. Following the incident on 2nd April 2014 the case remained at CiN level. The Health Visitor was informed of the incident on 9th April 2014 by Adult S, but did not make contact with CSC and did not challenge the decision not to escalate to child protection. There were two further incidents on 20th and 30th April, both of which left Child B at risk of significant harm which were resolved on both occasions by a decision to allow Adult S to retain care of Child B under the supervision of her maternal great-grandmother. While the first of these decisions may have been understandable in the circumstances, the second (following the incident of 30th April 2014) was less so, given that the family were clearly in breach of a written agreement drafted only two days earlier. Neither of these decisions was challenged by the Police Officers who attended both incidents.    How do we know it is an underlying issue and not something unique to this case?  The evidence in relation to this Finding is equivocal.  A number of members from the Case Group said that they understood risk and that they had received risk assessment training. They also said that they were comfortable to challenge social workers where there was an opportunity and when necessary. The evidence from the CSC members of the Case Group suggested that challenge was sporadic and while it did occur from time to time, it tended to vary in relation to the confidence of the practitioner offering the challenge. Very few requests for formal escalations were reported.  SCR Report-Child B – Final   Page 25  How prevalent and widespread is this issue?  It is difficult to state categorically how prevalent and widespread this practice may be in Staffordshire, but there is evidence to suggest that it has the potential to be an issue of some significance given that between August 2014 and July 2015 there were 9040 S.17 child social work assessments completed across the county (660 in the area the child lived) and in the same period there were 5534 children who were the subject of CiN plans (with 261 in the area the child lived).    What are the implications for the reliability of the multi-agency child protection system?  Working Together (2015) identifies the Local Authority as the lead agency in safeguarding and promoting the welfare of children and goes on to clarify the role and responsibilities of partner agencies in supporting CSC in this function.  Accurate assessment of risk is an essential element of developing appropriate and proportionate intervention strategies at or near the significant harm threshold. For the system as a whole to be safe it is important that all agencies contribute to this process and that practitioners from partner agencies have the necessary knowledge, skills and confidence to act as a check and balance to social work assessment and formulations of risk. (See also Finding 4)   SCR Report-Child B – Final   Page 26   Finding 1  Is the capacity of multi-agency partners to provide sufficient challenge to social workers risk assessments undermined by their understanding about risks to children? (Management Systems)   Accurate assessment is the cornerstone of effective risk management, but assessing risk is itself a risky business. The sources of error and bias in risk assessment are well known* and it is easy for social work practitioners to arrive at false positive or, more dangerously, false negative conclusions from the process. In order to counter these tendencies, it is important that staff from partner agencies have the necessary knowledge and skills to understand what is happening in families, form their own view about the levels of risk that are present and have the confidence to offer robust challenge to what they perceive to be inaccurate formulations or risk. The absence of such challenge has the potential to allow children at risk of significant harm to remain avoidably unprotected.   *See: Contemporary Risk Assessment in Safeguarding Children (Calder, 2008)   Questions for the Board   Given the equivocal nature of the evidence for this Finding, is the Board minded to make further enquiries into the issue?   Do all partner agencies have in place ‘fit for purpose’ training strategies to enable practitioners to recognise and respond to risk to children?   Is there sufficient clarity of expectation of partner agencies in relation to challenging the outcome of risk assessments and formulations of risk completed by CSC?   If the obstacle to challenging CSC decision making in respect of risk is due to a lack of confidence on the part of partner practitioners, what can be done to overcome this obstacle?   What arrangements are needed to reassure the Board that this issue has been resolved?    SCR Report-Child B – Final   Page 27  Finding 2  The presentation of apparently episodic neglect caused by alcohol misuse makes it more likely that professionals will underestimate its adverse effects on children’s safety and welfare and compromise their ability to take appropriate protective action. (Response to Incidents)  The adverse effects for children living with long term parental alcohol misuse are well established and include both physical and emotional harm. Despite the fact that Adult S repeatedly presented or was reported to be intoxicated while caring for her children, there was considerable delay before professionals perceived this as evidence of neglect or considered the implications of her behaviour on her children’s emotional wellbeing.  How did this issue manifest itself in this case?  The concerns about Adult S’s problematic drinking first emerged in September 2013, following an allegation that she was often drunk and that she had been intoxicated while breastfeeding Child B. These allegations were discounted as malicious, partly on the evidence from the Health Visitor that Adult S was a ‘good mother’ who looked after Child B well.  Following the referral to CSC on 28th February 2014, a S.17 child social work assessment was completed, the outcome of which was that Adult S was a ‘good mother’ who attended well to her children’s basic needs but who was in need of help with her complex personal difficulties. There is no record that Adult S’s behaviour was considered neglectful.  There were two further serious incidents on 2nd and 20th April 2014, when Adult S was found to be intoxicated which required the children to be removed to members of the extended family. Neither of these incidents attracted a S.47 enquiry.  A single agency strategy meeting was held on 25th April 2014 which concluded that the case needed to be taken to a child protection conference. While the category of ‘registration’ was neglect the main cause for concern was Child B’s safety and there was no other reference to the issue of neglect. The minutes of the conference state “when not under the influence of alcohol there were no concerns regarding mother’s basic care, however under the influence of alcohol significant concerns have arisen regarding her capacity to provide safe care to the children”. There is no reference to the impact of Adult S’s chaotic alcohol misuse on the children’s emotional wellbeing and no recommendation in the plan to address these issues.   SCR Report-Child B – Final   Page 28  How do we know it is an underlying issue and not something unique to this case?  The representatives from the Health Services on the Case Group thought that this finding was a fair reflection of the current situation in Staffordshire. The CSC members believed that such practice was evident from time to time, but tended to reflect the practice of individual workers, rather than indicate a pattern of practice. It was noted that this practice is less likely when cases are managed within the Public Law Outline (PLO) process, though these by definition are the most serious cases.      How prevalent and widespread is this issue?  Information from the CSC Children in Need Census 2014-2015 indicate that 2,445 child social work assessments were completed within the period under review, out of which 350 were identified as evidencing the toxic trio (domestic violence, mental health issues, substance misuse).  There is no data on how many child protection plans there are for neglect due to alcohol misuse nor how many plans have strategies to address children’s therapeutic needs caused by living with alcohol.    What are the implications for the reliability of the multi-agency child protection system?  Child neglect is a complex and multi-faceted issue. If practitioners focus their attention solely on the ability of parents to meet their children’s basic care needs and keep them safe, then they risk failing to recognise and address the less obvious consequences for children living with neglect, particularly if it is associated with substance misuse.  Hidden Harm* refers to the multiple and cumulative adverse consequences for children living with adult substance misuse which can lead to a wide range of emotional, cognitive, behaviour and other psychological problems. It also emphasises the importance of listening to the voices of children and to help them deal with ‘the hurt, rejection, shame, sadness and anger they feel over their parents’ drug problems’.  The message from this is that it is not sufficient to ‘rescue’ children from neglect caused by adult substance misuse, but that it is necessary also to provide therapeutic support to help them overcome their abusive experiences. Without the routine consideration of the need to provide such support, the system could be accused of failing to fully address the needs of children neglected through adult substance misuse.  *See: Hidden Harm – responding to the needs of problem drug users (ACMD, 2003) SCR Report-Child B – Final   Page 29   Finding 2  The presentation of apparently episodic neglect caused by alcohol misuse makes it more likely that professionals will underestimate its adverse effects on children’s safety and welfare and compromise their ability to take appropriate protective action. (Response to Incidents)  When substance misuse is the root cause of children suffering neglect, it is important that practitioners see beyond the quality of their physical care and consider the emotional and psychological damage their neglectful experiences cause. The messages from Hidden Harm are clear and need to be embedded into practice across all partner agencies. The indications from this review suggest that this may not yet have happened. When this Finding is considered in the light of a recommendation from the NSI0 SCR in 2010 which stated:  “That the revision of the ‘Hidden Harm’ guidance becomes a strategic priority for the LSCB and encompasses not only awareness raising and training among professions but considers the commissioning of educational material to inform the general public.”  It would appear that there is further work to be done on this issue.   Questions for the Board   Is the Board aware of the extent of substance misuse based abuse and neglect across the County`?   Does the Board understand the barriers to the messages from ‘Hidden Harm’ being embedded in multi-agency practice?   Are there any additional measures that would help to achieve this objective?   Does the Board have a means to inform itself that the voices of children who experience substance misuse based abuse and neglect are heard and responded to appropriately?   Is the system adequately equipped to meet the therapeutic needs of children neglected through substance misuse?   How will the Board be assured that its remedial actions have been successful and progress maintained?    SCR Report-Child B – Final   Page 30  Finding 3  Is there a pattern of practice in the area the child lived whereby people don’t think to make contact with colleagues from other agencies to share or seek information that may have safeguarding implications which leaves some professionals unaware of concerns about children which impacts adversely on their ability to safeguard and promote their welfare? (Longer Term Work)  The first edition of Working Together published in 1991 to support the implementation of the 1989 Children Act emphasised the importance of inter-agency communication for an effective safeguarding system. This message has been repeated in every subsequent version of Working Together. In this case, despite the fact that there was multi-agency contact with Adult S and her children throughout the period under review, and apart from the referrals from the Police to CSC, there was virtually no inter-agency communication prior to the children becoming the subjects of child protection plans in May 2014.    How did this issue manifest itself in this case?  When the case was allocated for a S.17 child social work assessment on 28th February 2014, no lateral checks were completed and partner agencies were not informed of the concerns about the children. This pattern was repeated following the incidents of 2nd, 20th and 30th April 2014.  Adult S was visited by the Health Visitor on 9th April 2014 when she was informed of the events of 2nd and 3rd April 2014. At this visit the Health Visitor completed an EPNDS which scored 25/30* (an increase from 28th January 2014 when it was 23/30). Following the visit the Health Visitor did not contact the Social Worker to discuss the incident or to report Adult S’s EPNDS score nor did she share this information with Adult S’s GP.  Adult S was seen on a number of occasions by her GP during the period under review and she was prescribed anti-depressant medication. The GP also attempted to refer Adult S to the Peri-natal Psychiatry Service. The GP did not inform the Health Visitor of these actions. When the GP became aware of Adult S’s overdose on 3rd April 2014 he did not contact the Social Worker or Health Visitor.  Adult S received support from Pathway throughout the period under review. This was known to both the Social Worker and the Health Visitor, but there is no record of any communication between the agencies to share information.   *a score of 12/30 suggests the need for intervention.SCR Report-Child B – Final   Page 31 How do we know it is an underlying issue and not something unique to this case?  The response of Case Group members to this question was mixed. There was a view that inter-agency communication can be an issue and this can be due to capacity or the strength of the relationships between professionals from different agencies. Case Group members also felt that information sharing is often driven by CSC and there is frequently a mismatch between what information CSC want about a child and what they are prepared to share in relation to the concerns that have been expressed to trigger their enquiry.   There was some support for the view that the practice in this case was representative of practice generally and a belief that this issue is not confined to practice in the area the child lived in. This statement is at odds with the findings of the Ofsted inspection which found that ‘information sharing between agencies is effective’.  How prevalent and widespread is this issue?  The effectiveness of inter-agency communication is a difficult thing to measure or assess. There is evidence that problems with information sharing are a national issue as reflected in a fairly recent Ofsted report on SCR’s*  The report makes a number of comments about information sharing, including:   Agencies were found to have important information about the family circumstances but this was not shared early enough.   Most of the SCR’s identified sources of information that could have contributed to a better understanding of the children and their families.   What are the implications for the reliability of the multi-agency child protection system?  Effective information sharing is an essential element of a safe and fair child protection system.  With such arrangements in place, alerts about children at risk of significant harm are made in a timely fashion; the quality of assessment of risk and unmet need is improved; proportionate risk mitigation plans can be developed; the effectiveness of intervention strategies can be assessed and the ability to judge whether desired outcomes have been achieved (as a precursor to step-down or closure) is enhanced.  Without effective inter-agency communication all of the above are compromised with the potential to render the child protection system unsafe.  *See: Learning Lessons from Serious Case Reviews 2009-2010, Ofsted evaluation of SCR’s from 1st April 2009 – 31st March 2010 SCR Report-Child B – Final   Page 32   Finding 3  Is there a pattern of practice in the area the child lived in, whereby people don’t think to make contact with colleagues from other agencies to share or seek information that may have safeguarding implications, which leaves some professionals unaware of concerns about children which impacts adversely on their ability to safeguard and promote their welfare? (Longer Term Work)  Concerns about effective inter-agency communication pre-date the Ofsted report of 2010 and have been a feature of a number of high-profile reviews and reports since that time.  The need for effective inter-agency communication is well established and it is a state to which all LSCB’s aspire, yet it is a state which very few seem able to achieve.  The evidence to suggest that this is an ongoing concern in Staffordshire is not unequivocal, though the outcome of this review indicates that this issue is not wholly resolved.   Questions for the Board   Is this an issue which the Board would wish to explore further?   Are expectations about inter-agency communication and information sharing sufficiently clear?   Do the Board and member agencies have a means of gauging what the blockages to routine inter-agency communication might be or identifying when new ones emerge?   Does the Board need to offer additional guidance to support inter-agency communication and information sharing?   How will the Board assure itself that inter-agency communication and information sharing is ‘fit for purpose’ and supports a safe child protection system?    SCR Report-Child B – Final   Page 33  Finding 4  When decisions about safeguarding issues are being made, there is a tendency for some partner agencies to defer to CSC (who they believe ‘know best’) or assume that CSC involvement automatically means that safeguarding issues are being properly addressed. (Response to Incidents)  Working Together states that “Safeguarding is everyone’s responsibility: for services to be effective each professional organisation should play their full part”.  This review has suggested that the lead role of the Local Authority, as defined in statutory guidance, to co-ordinate the protection of children has been interpreted to mean that, in practice, the Local Authority owns the responsibility to protect children from harm, rather than this being a shared responsibility.    How did this issue manifest itself in this case?  There were at least three examples of practice in this case to illustrate this finding:   Following the incidents on 20th and 30th April 2014 the Police Officers in attendance were aware of the arrangements to secure the children’s safety following the incident on 2nd April 2014. They were minded to use S.46 powers on both occasions but did not do so on the basis that CSC wanted to place the children in the extended family secured with written agreements.  When asked in conversation about these actions, one of the Police Officers said he had some reservations about the proposed plan but “it’s their (CSC) decision”.   The Health Visitor was informed of the incident of 2nd April 2014 by Adult S in a home visit on 9th April 2014. The Health Visitor clearly recognised the safeguarding issues inherent in the incident, but did not contact CSC, as she assumed that appropriate protective action had been taken.   In the course of the mental health assessment on 2nd May 2014 (when Adult S was accompanied by Social Worker), the CPN was aware of the concerns about the children but did not speak to the Social Worker about these issues, as she assumed that the matter was in hand.   SCR Report-Child B – Final   Page 34  How do we know it is an underlying issue and not something unique to this case?  The Case Group members from partner agencies felt that though this practice was evident in this case, it was not representative of practice generally and made reference to escalation procedures if they are unhappy with CSC actions. They raised the interesting point about the tensions that exist between the need to challenge the decision making of professionals in all parts of the safeguarding system with the need to respect their professional knowledge and expertise.  The view of the CSC members of the Case Group was that, in reality, there was very little challenge in respect of day-to-day activity and the attitude of partners is often ‘I have told you about it, now it is over to you’. It was reported that very few formal escalation requests are received.    How prevalent and widespread is this issue?  This is a difficult question to answer locally, given that the finding relates to the attitudes and beliefs of practitioners about their relative roles and responsibilities and the ‘culture’ of shared responsibility.  However, there is evidence from a number of Serious Case Reviews that this is a regular occurrence in inter-agency working and is a national issue.  “Findings from the ‘Analysis of Serious Case Reviews’ demonstrate that the problem of joint responsibility has not yet been fully resolved. For example, the ‘silo’ working mentality continues to be a repeated feature of cases which go seriously wrong.  Achieving cultural change and getting agencies to work together is extremely challenging and requires cross-sector commitment”.*    What are the implications for the reliability of the multi-agency child protection system?  Statutory guidance and relevant procedures outline the responsibilities of partners in the safeguarding of children. Responsibilities are overarching and apply to all safeguarding partners.    *See: The Munro Review of Child Protection, Final Report: A Child Centred System Munro (2011) SCR Report-Child B – Final   Page 35  Ensuring the correct balance between the leadership role of the Local Authority, compared to the shared responsibility by partners, is a challenge for every LSCB.  The evidence from this review suggests that despite the existence of multi-agency processes and procedures, there is a belief amongst partner agencies that the final responsibility for safeguarding lies with Children’s Social Care. This can lead to a lack of ownership by other agencies, evident in a lack of multi-agency challenge of social care decisions and a lack of contribution of professional opinion in assessment, analysis and decision-making.  Shared ownership and responsibility between agencies and professionals that have different roles and expertise, and at different stages of intervention (including universal, targeted and specialist services) is required if children are to be protected from harm and their welfare promoted. To invest in one service alone the sole responsibility for owning how children are safeguarded is unsafe.   SCR Report-Child B – Final   Page 36   Finding 4  When decisions about safeguarding issues are being made, there is a tendency for some partner agencies to defer to CSC (who they believe ‘know best’) or assume that CSC involvement automatically means that safeguarding issues are being properly addressed. (Response to Incidents)  This finding is essentially about the “ownership” of the safeguarding system.  ‘Safeguarding is everyone’s responsibility’ is a meaningless statement unless it is evidenced by collective ownership of how children are safeguarded, both at practitioner and strategic levels.  The challenge of safeguarding children is multi-faceted. It presents challenges to individual practitioners, multi-agency teams and strategic managers and LSCB’s.  In this landscape a safe system depends upon partnerships characterised by shared ownership, professional challenge and debate across and within safeguarding partnerships. For this state to be achieved there needs to be clarity of expectation at the strategic level to ensure the correct balance is struck between the leadership role of the Local Authority, compared with the shared responsibility of partners in safeguarding work.  This finding raises questions about the extent to which this situation exists locally.   Questions for the Board   How effective is the SSCB in modelling shared ownership of the safeguarding system?   How can the SSCB promote dialogue and debate about what shared responsibility for safeguarding, led by the Local Authority, looks like in practice to ensure ownership is shared as fully as possible?   What steps can be taken to promote a culture in which challenge and debate across partner agencies at practitioner and managerial levels become the norm?   How can the Board evaluate how shared responsibility to safeguard children is put into practice?     SCR Report-Child B – Final   Page 37  Finding 5  There is a pattern of practice in Staffordshire where professionals routinely fail to engage with or challenge men in the safeguarding process, leading to untested assumptions about their role in promoting the safety and welfare of their children. (Family/Professionals Interactions)  There is a considerable body of evidence which refers to the need to engage with men in the safeguarding process both to assess their potential to introduce risk into the child’s life, but also their ability to promote the child’s safety and welfare. The danger of failing to engage with men and making assumptions about their role in children’s lives is well documented*. Despite the fact that Adult T and Adult U played a significant role in the case, particularly in the management of the periodic crises created by Adult S’s chaotic drinking behaviour, they were never involved in any assessments and were never questioned about Adult S’s behaviour and her relationship with her children.    How did this issue manifest itself in this case?  Adult T referred the concerns about Adult S to CSC EDS on 28th February 2014.  He alleged that Adult S frequently put herself in this condition and he took Child L and Child M to live with him. He had care of the children for the next three weeks but apart from one telephone call about contact, he was not spoken to by the Social Worker and there is no indication that he was involved in the assessment that resulted in a recommendation that the case could be safely held at CiN level.  Adult T raised concerns about the children again on 2nd April 2014 and again took Child L and Child M to his home. He was contacted two days later about signing a written agreement to retain the children in his care, but he wasn’t challenged about why he had returned them to Adult S (following the incident of 28th February 2014) without consulting with CSC (as agreed), nor was he asked about Adult S’s behaviour and her use of alcohol.  Adult T breached the written agreement of 2nd April 2014 by returning Child L and Child M to Adult S’s care without informing CSC and he did this on two further occasions, following the written agreements of 20th and 28th April 2014. He was never challenged about what he did or questioned about why he continued to return the children to Adult S’s care (and put them in harms way) when he was clearly aware of her issues with alcohol misuse.    *See The Child’s World: Assessing Children in Need Howarth (2001)  SCR Report-Child B – Final   Page 38  Adult U looked after Child B on the night of 2nd April 2014. He was not contacted after the incident and he was not involved in any planning in relation to Child B’s future safety. There is no record of any conversation between the Social Worker and Adult U, though he is referred to in the minutes of the strategy meeting on 25th April 2014 as a participant in the domestic abuse in his relationship with Adult S and is described as controlling and argumentative. Arguments with Adult U are identified as a trigger for Adult S’s drinking, but there is no record that these issues were ever addressed with Adult U.    How do we know it is an underlying issue and not something unique to this case?  It was the almost unanimous view of the Case Group and Review Team members that the failure to engage with and challenge the men in this case was representative of practice generally. The groups identified three principal reasons for this practice:   The personal challenges (and possible concerns about safety) of speaking to men about their risky behaviour.   Where there are a number of children in a family with different fathers (as in this case) professionals are more likely not to engage with any of them.   Problems that derive from working with families where there is regular movement of partners, often on a short timescale.    How prevalent and widespread is this issue?  It was the view of the Case Group and Review Team that this is a County-wide issue. Evidence from the now defunct DCSF* from as far back as 2007 would suggest that this is a longstanding, national issue.  There is no data available to indicate at what level men are engaged or involved in the child protection system in Staffordshire. The potential for involvement is however enormous, given that currently there are 640 children subject to child protection plans and 5356 children subject to CiN plans (as at July 2015).      *See: Understanding SCR’s and their impact: A biennial analysis of SCR’s 2005-2007 (DCFS, 2009) SCR Report-Child B – Final   Page 39  What are the implications for the reliability of the multi-agency child protection system?  It is axiomatic that all children have fathers and there is a body of evidence* which argues that the quality of fathering, as well as mothering, mediates the child’s psychological and emotional outcomes. It is also the case that men are often the source of risk of harm in families.  They are therefore significant figures in family life and the failure of professionals to engage with men leaves them uninformed about the nature of the relationship they have with their children and whether they are a source of safety or danger. A safe system requires practitioners to have a full and proper understanding of the roles that all significant adults play in safeguarding and promoting a child’s welfare. If men are routinely not included in the safeguarding process, it is possible that practitioners will come to erroneous conclusions about the role that they play in the lives of their children and make false assumptions about their ability or otherwise to keep them safe.                             *See: Fathers and Family Support Services: London Family Parenting Institute (O’Brien, 2004) SCR Report-Child B – Final   Page 40   Finding 5  There is a pattern of practice in Staffordshire where professionals routinely fail to engage with or challenge men in the safeguarding process, leading to untested assumptions about their role in promoting the safety and welfare of their children. (Family/Professionals Interactions)  The importance of engaging with men in the child protection process is self-evident.  It is clear from this review and from national data that practitioners find this difficult and do not routinely seek to make contact with men to enable them to become actively involved in the process of safeguarding their own children (or the children with whom they have contact). There clearly are barriers for professionals in achieving the desired outcome of greater involvement on the part of men that need to be acknowledged and addressed before any meaningful progress can be made on this issue.   Questions for the Board   How well does the Board understand the barriers to involving men in the child protection process?   What are the expectations of the Board in relation to professional engagement with men in the child care system?   Are there any criteria or standards against which to assess the engagement of men and are there means available to evaluate the impact (positive or negative) of such involvement?   What additional help can the Board offer to overcome the obstacles to improved practice?   What data would be helpful to the Board to understand the engagement of partner agencies with men in the child protection/childcare process?     SCR Report-Child B – Final   Page 41  Finding 6  Is there a pattern of practice in the area the child lived in, whereby some professionals are inclined to accept what parents tell them about their behaviour (without challenging them with available information that contradicts what they say), which leads to errors in assessment of risk to which children are exposed and compromises their ability to take protective action? (Family/Professionals Interactions)  For professionals to work effectively with adults to safeguard and promote the welfare of their children it is necessary to form meaningful relationships with them. However, professionals need to understand properly the dynamics of these relationships and be aware of the tendency of adults who are the subject of assessment to deny, minimise or distort the extent of their risky behaviour so as to reduce the level of professional concern about their children.  Adult S was the subject of a number of assessments by practitioners from different agencies during the period under review. The records indicate that she was never truthful about her use of alcohol and that at no point was she ever challenged over her denials and minimisations in her accounts of her drinking behaviour.    How did this issue manifest itself in this case?  When the case was allocated for a S.17 child social work assessment on 28th February 2014, it was known that allegations that Adult S “drank all the time” had been made in the referral on 3rd September 2013. The referral information on 28th February 2014 (provided by Adult T) reported that it had become a regular occurrence for Adult S to ‘pass out’ through drink. In the course of the assessment Adult S admitted that she had been drinking prior to the incident but she denied that she had a problem with alcohol and that she used it merely to ‘help her cope with difficult personal relationships’. She was not challenged about the discrepancy between her account and the reported concerns. Over the next seven weeks there were three incidents when Adult S was so intoxicated the children had to be removed from her care. In the course of those incidents Child L and Child M repeatedly said that Adult S drank all the time and frequently passed out but there is no record that the issue of Adult S’s chaotic alcohol misuse was ever revisited.  SCR Report-Child B – Final   Page 42  Adult S was the subject of a mental health assessment in May 2014, in the course of which she reported that CSC were involved and her children had been moved because she had been found ‘passed out’ while caring for her children. She said that “she hardly ever drinks” and that she did so on 3rd April 2014 in order to get some sleep. Adult S was not challenged about the discrepancy between these two statements. Also, it was known that when Adult S presented at hospital, she had drunk at least half a bottle of vodka and taken between 14 and 20 Diazepam and had said that ‘she wasn’t meant to wake up’. In the course of the assessment she said that she had not intended to kill herself, merely that she wanted some rest. This statement was not challenged, despite the fact that it was at odds with the referral information from the RAID assessment. In the course of the assessment the Social Worker was present and she did not challenge Adult S’s claim that she hardly ever drank nor did the assessing Mental Health Worker question why her children had been ‘removed’ if she did not have a problem with alcohol misuse.    How do we know it is an underlying issue and not something unique to this case?  Opinion was divided on this issue among members of the Case Group. While all agreed that there was evidence of such practice in this case some felt strongly that this did not represent practice generally, others believed that the finding was largely true and could be relevant on a County-wide basis. Members from the third sector pointed out the problems of being too robust in challenging ‘voluntary’ service users, as to do so can lead to them withdrawing from the service.  This issue has been flagged previously in Staffordshire and was captured in a recommendation from the Child A SCR in 2009 which stated:  “The LSCB and partner agencies should ensure that training and staff development activities have specific reference to and a focus on helping practitioners develop the skills and confidence they will need to maintain professional curiosity and respectful uncertainty when working with children and families”.    How prevalent and widespread is this issue?  This is another issue on which it is difficult to collect hard data. Anecdotal evidence from some members of the Case Group would suggest that the practice is quite prevalent and likely to be evident on a County-wide basis. The Ofsted report on Serious Case Reviews referred to earlier would tend to support the view that the practice is a national issue and quite prevalent when it states:  “Reviews found that there had been insufficient challenge by those involved.  The statements of parents or others in the family should not have been accepted at face value”. SCR Report-Child B – Final   Page 43  What are the implications for the reliability of the multi-agency child protection system?  When undertaking assessments in relation to safeguarding matters, it is generally in the interest of the adult being assessed (but not the child’s) that the person undertaking the assessment does not know the full extent of the issues and behaviours under assessment.  In order to manage the professionals’ access to this information, the person being assessed may misdirect, minimise, deny and lie about their behaviours and circumstances. In order to counter these strategies and offer appropriate challenge it is necessary for practitioners to approach assessments with a degree of healthy scepticism and to adopt the position of ‘respectful uncertainty’ recommended by Lord Laming in 2003*.  It is important that those responsible for managing the safeguarding system at a strategic level do not underestimate the difficulties and personal challenges that are inherent in this expectation, particularly for practitioners who may be newly qualified and relatively inexperienced. Arrangements need to be in place to help practitioners develop the necessary skills to do this difficult work and to ensure that they receive the support they need while doing so.  The failure to address this issue would make it more likely that professionals undertaking assessments will base their outcomes on partial or inaccurate information, making it more likely that they will reach false negative conclusions about children’s safety, with the consequence that children may be left at risk of avoidable harm.                     *See: Victoria Climbie Inquiry: Report of an Inquiry by Lord Laming (HMSO, 2003) SCR Report-Child B – Final   Page 44   Finding 6  Is there a pattern of practice in the area the child lived in whereby some professionals are inclined to accept what parents tell them about their behaviour (without challenging them with available information that contradicts what they say) which leads to errors in assessment of risk to which children are exposed and compromises their ability to take protective action? (Family/Professionals Interactions)  Fair, proportionate and effective safeguarding strategies can only be developed on the basis of accurate and comprehensive assessments of risk and unmet need. These can only derive from the professionals involved obtaining a true picture of the protective factors present in a family along with the risks to which a child may be exposed.   The obstacles to achieving such outcomes are manifest. A safe child protection system is one in which partner agencies have in place the necessary arrangements to ensure that practitioners develop the appropriate mindset for undertaking safeguarding work and receive the training and support they require to offer robust challenge to adults whose behaviour may pose a risk to children.   Questions for the Board   Is the Board aware of this as an issue facing practitioners?   Is there an adequate understanding at strategic level about the nature and role of relationships in safeguarding work?   Does the Board know what progress has been made with the recommendation about this issue from the Child A SCR?   How does the Board assure itself that learning from SCR’s is consolidated and retained?   What are the Board’s expectations of partner agencies in addressing this issue?   How might the Board help practitioners overcome this obstacle to effective practice?   How will the Board assess the effectiveness of any remedial action on this issue?    SCR Report-Child B – Final   Page 45  Finding 7  Is there a pattern of practice whereby neither multi-agency forums nor supervision in any agency are effective in challenging and disrupting a fixed view of a case (once established) as a means of checking its accuracy?  (Cognitive Biases)  There is a tendency for professionals, once they have come to a view about a situation or service user, to retain that view despite emerging evidence that it may be misguided or in need of revision.    Almost without exception, the professionals that were involved with Adult S had a positive view about her and regarded her as a ‘good mother’. This view did not change, despite mounting evidence that her behaviour presented a significant risk of harm to her children.    How did this issue manifest itself in this case?  Adult S was the subject of a number of assessments throughout the period under review. The records of these assessments are surprisingly similar. They all note that Adult S is pleasant, engaging, insightful and help-seeking. She presented as motivated to change and willing to accept whatever help she was offered. She never disagreed or argued with any of the professionals with whom she came into contact and she invariably accepted their recommendations about what she should do to improve her circumstances. The record shows that while she made contact with Pathway, Mental Health Services and GP, she never in fact engaged with these services in any meaningful way. The view of the professionals with whom she was involved was that she a ‘good mother’ who had her children’s interests at heart, but who was troubled with personal difficulties as a result of her complex relationships with Adult V, Adult T and Adult U.  When the concerns about Adult S’s drinking increased and it was necessary to move the children on three occasions, she attributed her behaviour to anxiety and low mood, brought on by her problems with Adult U. At these times she acknowledged the concerns of professionals and was co-operative in helping EDS make alternative arrangements for Child B. Despite these events, the professional’s attitude to Adult S and the belief that she was a struggling, but essentially ‘good mother’ did not change.  Within the period under review Adult S and her children were discussed in supervision by both Health and CSC practitioners on more than one occasion. Despite the evidence that Adult S had repeatedly put her children in harms way, had threatened to ‘slit her children’s throats’ and denied the older children a holiday at the very last minute because she had fallen out with Adult U the perception of Adult S as a ‘good mother’ did not change.  SCR Report-Child B – Final   Page 46  When the case went to conference on 12th May 2014, Adult S accepted, without argument, all the concerns that were expressed. She spoke to the conference about the arrangements she had made to obtain help and was very positive about the fresh start that a move to live near Adult W would offer. The minutes of the conference refer twice to the fact that there are no concerns about Adult S’s parenting while not under the influence of alcohol and she is urged to address the root cause of her drinking. The question about whether it was safe for Child B to remain in Adult S’s care was not raised.    How do we know it is an underlying issue and not something unique to this case?  Case Group members accepted the finding in relation to this case but largely felt unable to comment more generally. The CSC members felt that the practice in this case was attributable to the circumstances that prevailed in the area the child lived in at the time, but were not representative of practice generally.    How prevalent and widespread is this issue?  There is no data available on how prevalent of widespread this practice is.  However, it would appear that similar issues have emerged in the past in Staffordshire, reflected in a recommendation from the NSIO SCR, which stated:  “That the Directorate for Children, Young People and Families undertakes further work with its frontline managers to ascertain what, if any, are the barriers to the supervision of practitioners being a reflective process that enables them to consider the implications of new information”.    What are the implications for the reliability of the multi-agency child protection system?  The practitioners in this case (who had formed a positive view about Adult S at an early stage of their involvement) failed to recognise that she was engaged in a process of seductive coercion in her relationships with them, evidenced by her apparent willingness to engage and feigned co-operation.  In reality, Adult S did not properly engage with any of the services with which she had contact and did not change at all. In addition she repeatedly behaved in ways that put her children at ever increasing levels of risk. All of these things were known and the subject of discussion in both supervision sessions and the case conference with no apparent impact on professionals’ view of Adult S as a mother.  SCR Report-Child B – Final   Page 47  The quality of the safeguarding service for any child is directly related to the quality of the risk assessment of his or her family and circumstances. Two fundamental principles of risk assessment are:   They are prone to error and bias  They are dynamic (the level of risk changes as circumstances change)  When these two principles are considered in the light of the natural tendency of professionals not to revise a view about a family once a judgement has been formed*, the potential for unsafe practice becomes evident.  A safe child protection system needs to have in place arrangements (in the form of challenging, reflective supervision and robust child protection conference practice) to act as a check and balance against these normal practice errors.                                *See: Common Errors in Reasoning in Child Protection Work: Child Abuse and Neglect, Vol 23- Munro (1999) SCR Report-Child B – Final   Page 48   Finding 7  Is there a pattern of practice whereby neither multi-agency forums nor supervision in any agency are effective in challenging and disrupting a fixed view of a case (once established) as a means of checking its accuracy? (Cognitive Biases)  The task of completing risk assessments and carrying child protection cases is difficult. The task of providing oversight in the management of such cases, without direct contact with children and families, is probably more difficult.  There is an innate cognitive tendency on the part of practitioners to retain a view about a family or situation once it has been formed despite the emergence of disconfirming information. In order for the child protection system to be safe it needs strategies and processes in place (in the form of reflective supervision and independent multi-agency challenge) to ward against this.  A safe child protection system recognises this cognitive tendency as almost inevitable and has in place the means to routinely revisit initial formulations of risk to retest their validity.   Questions for the Board   Is the Board aware of progress made in relation to the recommendation in NSIO SCR?   Is the Board assured that multi-agency supervision arrangements are sufficiently robust to respond to the challenge this finding presents?   Are there any outstanding training needs for individuals charged with the responsibility of challenging risk formulations and intervention strategies?   Would the Board wish to develop a multi-agency best practice forum to address this issue?   How can the Board be assured that appropriate measures to address this issue are in place and working in partner agencies?     SCR Report-Child B – Final   Page 49  Finding 8  The way in which child protection conferences operate in the area the child lived in makes it more likely that they do not provide the necessary rigorous challenge to professionals’ assessment of parents’ capacity to safeguard their children’s welfare and do not produce sufficiently clear and risk focused child protection plans. (Management Systems)  The purpose of the child protection conference is “to bring together and analyse relevant information and plan how best to safeguard and promote the welfare of children”*. Implicit in this statement is the need for the conference to exercise rigour in the analysis of risk and demonstrate clarity in the development of risk management strategies.    How did this issue manifest itself in this case?  There was only one case conference held on Child B, which resulted in her (and her siblings) becoming subjects of child protection plans on the grounds of neglect.  The analysis of the information presented at conference lacked rigour, as evidenced by: the failure to challenge Adult S’s version of events that was clearly at odds with the seriousness of the events themselves; the failure to analyse in detail the risks posed by Adult S’s alcohol misuse; the failure to address the fact that the family had breached a number of safeguarding agreements; the failure to consider the increased risk to Child B caused by Child L and Child M living with Adult T; the failure to consider Child L and Child M’s therapeutic needs (having lived with Adult S’s alcohol misuse for probably their entire childhood) and the failure to consider the fundamental question about whether action was necessary to share parental responsibility to secure Child B’s future safety.  The child protection plan contained 17 recommendations, some of which related to risk, some to unmet need, some to monitoring arrangements and a statement that ‘parents should work in an open and honest manner with CSC’. The only reference to Adult S’s alcohol misuse was ‘whilst caring for any of the children, Adult S is strongly advised to refrain from any use of alcohol’.         *See: Working Together to Safeguard Children: DfE, 2015 SCR Report-Child B – Final   Page 50  How do we know it is an underlying issue and not something unique to this case?  There was broad agreement from the Case Group and Review Team that the quality of child protection plans is variable and that they would benefit from being SMARTER and more risk-focused.  The representatives from CSC disputed the suggestion that conferences do not present rigorous challenge to professionals’ assessments, while Health representatives believed that the finding was a fair reflection of practice generally.  While the evidence about whether this practice is a systemic weakness in Staffordshire is limited, the case conference is such an important part of the safeguarding process that the Board may, nonetheless, wish to explore this issue further.    How prevalent and widespread is this issue?  There are no arrangements in place currently to assess the quality of initial child protection plans in Staffordshire. The potential for this to be a significant issue for both initial and review conferences is evident from the sheer volume of child protection conference activity that takes place across the county annually (between 1st September 2014 and 22nd September 2015 there were 629 initial and 2171 review conferences across the County).    What are the implications for the reliability of the multi-agency child protection system?  At its heart, the initial child protection conference is the arena of risk management. It has two key tasks to perform:   To understand, analyse and make explicit the risks that are present – including drilling down into the information presented and challenging the assessments, views and perceptions of professional participants.   To develop proportionate outline risk management plans that clearly identify the sources of likely harm and what needs to happen to mitigate the identified risk.  At the conclusion of the conference all present, professionals and parents/carers alike, should be in no doubt about what are the causes for concern, how serious these are, what needs to be done, by whom, to effect change and within what timescales.  If the Case Conference process does not routinely yield these outcomes, then it cannot be regarded as ‘fit for purpose’. SCR Report-Child B – Final   Page 51   Finding 8  The way in which child protection conferences operate in the area the child lived in, makes it more likely that they do not provide the necessary rigorous challenge to professionals’ assessment of parents’ capacity to safeguard their children’s welfare and do not produce sufficiently clear and risk focused child protection plans? (Management Systems)  An effective child protection conference process is the cornerstone of a safe child protection system. The need for fearless and rigorous analysis of risk and the ability to develop clear, concise, risk-focused child protection plans are key elements of the process. A safe system is characterised by an adequately resourced child protection conference service populated with a trained and competent body of conference chairs who themselves have access to challenging reflective supervision.   Questions for the Board   Is the child protection conference service adequately resourced across the County?   Does the pool of Conference Chairs have any outstanding training or support needs?   Does the Board have a view about a preferred model for producing ‘outline’ child protection plans?   Are there any arrangements in place to ensure ‘consistency of product’ in terms of outline plans from initial child protection conferences?   What options are available to assess analytical rigour in the conference process?   How will the Board assure itself that the child protection conference process remains ‘fit for purpose’?             SCR Report-Child B – Final   Page 52 Appendix A: Glossary   ACRONYM MEANING CBT Cognitive Behaviour Therapy CiN Child in Need CP Child Protection CSC Children’s Social Care Services EDS Emergency Duty Service FSW Family Support Worker GP General Practitioner HV Health Visitor ICPC Initial Child Protection Conference KPE Key Practice Episode LSCB Local Safeguarding Children Board NFA No Further Action PLO Public Law Outline RAID Rapid Assessment Interface & Discharge SCIE Social Care Institute for Excellence SSCB Staffordshire Safeguarding Children Board SW Social Worker  REFERENCE MEANING Child  Anyone who has not yet reached their 18th birthday.  Safeguarding and promoting the welfare of children  Defined in Working Together to Safeguard Children (DfE) 2015 as:  • protecting children from maltreatment;  • preventing impairment of children's health or development;  • ensuring that children are growing up in circumstances consistent     with the provision of safe and effective care; and  • taking action to enable all children to have the best life chances.   Child protection  Part of safeguarding and promoting welfare. This refers to the activity that is undertaken to protect specific children who are suffering, or are likely to suffer, significant harm.  Abuse  A form of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm.  Neglect The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development.   Lateral checks ‘Lateral checks’ means information gathering between agencies. This involves the local authority contacting key partner agencies such as the Police and health services (this could also include adult services and any known voluntary and community agencies working with the child and their family) to both share information and request information for the purposes of promoting the welfare and safety of children.  SCR Report-Child B – Final   Page 53 Child Protection Conference An Initial Child Protection Conference (ICPC) must be convened when concerns of significant harm are substantiated and the child is judged to be suffering, or likely to suffer, significant harm. The conference must consider all the children in the household, even if concerns are only being expressed about one child.  There are two types of conferences; the first one to take place after a section 47 enquiry is called an ‘Initial Child Protection Conference’; subsequent conferences are called ‘Review Child Protection Conferences’ (RCPC).  Child Protection Plan If a decision is made at an initial or review child protection conference for a child to be made the subject of a child protection plan, the local authority might draw up a plan to protect the child. This is called a child protection plan. It names the members of the Core Group, sets out what the risks are, what needs to be done to reduce the risks and needs of the child (these must be specific and measurable); identifies who is responsible for what actions or changes; sets out what will happen if the plan is not kept to; and provides a date to review the progress being made.   Core Group If the conference decides that a child should be made the subject of a child protection plan, a group of professionals will be identified to work with the child and their family. The first meeting has to be held within ten days of the child protection conference. The child (where appropriate), their family and professionals will meet on a regular basis to discuss the child protection plan- this meeting is called a ‘Core Group Meeting’. The Core Group will always include the child (where appropriate), the parent(s) / carers, the social worker for the child (who is the keyworker); and other identified professionals involved in working with the child and their family. The Core Group has to meet on a regular basis and at a minimum of once a month. Its aim is to support working together arrangements to help to reduce the risks identified for the child in the child protection plan.   Section 17 of the Children Act 1989 Section 17(1) states that it shall be the general duty of every local authority:  (a) to safeguard and promote the welfare of children within their area who are in need; and  (b) so far as is consistent with that duty, to promote the upbringing of such children by their families.  by providing a range and level of services appropriate to those children’s needs.  Section 17(10) states that a child shall be taken to be in need if:  (a) the child is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of services by a local authority under Part III of the Children Act 1989;  SCR Report-Child B – Final   Page 54 (b) the child’s health or development is likely to be significantly impaired, or further impaired, without the provision of such services; or (c) the child is disabled.  Section 47 of the Children Act 1989 Section 47(1) states that:  Where a local authority:  (a) are informed that a child who lives, or is found, in their area (i) is the subject of an emergency protection order, or (ii) is in police protection; or  (b) have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm:  the authority must make, or cause to be made, such enquires as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.  Section 46 of the Children Act 1989 Under section 46 of the Children Act 1989, where a police officer has reasonable cause to believe that a child would otherwise be likely to suffer significant harm, the officer may:  • remove the child to suitable accommodation and keep him there; or  • take reasonable steps to ensure that the child’s removal from any hospital or other place in which the child is then being accommodated is prevented.   No child may be kept in police protection for more than 72 hours.    