Alleged sexual abuse of three siblings by their older brother in July 2015. Child FH lived with his mother, father and three younger siblings. The family is of dual heritage and had been involved with different services, including social services and CAHMS, for a number of years due to the complex needs of FH. From 2007 there were 7 social work assessments including one child protection inquiry. FH had a Statement of Special Educational Needs. There had been serious concerns about FH's behaviour from 2010 including violence to siblings and fire setting, and he was assessed by CAHMS and attended a Paediatric ADHD Clinic. In 2015 FH's mother told the school she was unable to cope and would not have him back after school. Later in 2015 FH's medication was changed and she felt better able to cope and their case was closed. Some weeks later the mother reported to the police that FH had raped his younger siblings. Learning includes: agencies should develop a pathway for the management of children with complex social and emotional needs, linked to aggressive behavioural difficulties or risk to others to address the needs of a small number of children, who do not easily match any diagnostic criteria and may not therefore meet the thresholds for any specific service. Recommendations include: more effective input by paediatricians and CAMHS staff to Child in Need meetings; multi-agency aspects need to be considered to ensure all relevant professionals are identified and invited to contribute to Child in Need meetings.
      
 Title:  Report of the serious case review regarding Family H. LSCB: Hertfordshire Local Safeguarding Children Board Author: Fiona Johnson 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.                           Final 14-Dec-17  1                     REPORT OF THE SERIOUS CASE REVIEW REGARDING Family H Author: Fiona Johnson    Final 14-Dec-17  2  CONTENTS 1. INTRODUCTION  1.1 Background to the review and summary of the case    P 3  1.2 Terms of Reference         P 3            2 SUMMARY OF FACTS         2.1 Family details         P 4 2.2 Earlier events         P 4 2.3 Agency Involvement during the review period     P 5  3. VIEWS OF FAMILY         P 11         4 ANALYSIS          P 12          5 CONCLUSIONS          P 25  6 RECOMMENDATIONS        P 28  Appendix 1: Methodology         P 29 Appendix 2: Glossary of Terms & Abbreviations     P 31 Appendix 3: Bibliography         P 32    Final 14-Dec-17  3  1 INTRODUCTION  1.1 Background to the serious case review and summary of the case 1.1.1 This serious case review (SCR) concerned a boy FH and his three younger siblings. FH was alleged to have seriously sexually abused his siblings. At the time of the review, prosecution was being considered however the decision was made by the Crown Prosecution Service that it was not in the public interest to pursue criminal proceedings despite the evidence meeting the threshold for prosecution.  1.1.2 There was agency involvement with the family from 2007 when FH (aged 4) was referred by to Children’s Social Care (CSC) by the primary school, because of aggressive and disruptive behaviour including attacks on a family pet. In subsequent years, several health agencies became involved and there was a high level of service input from other agencies.  1.1.3 This matter was referred to the Hertfordshire Local Safeguarding Children Board (LSCB) on 7/9/2015 and 16/11/2015 and was considered by the Case Review Group Meeting on 22/1/2016 which recommended that there should be a serious case review (SCR). The LSCB chair, Phil Picton, agreed the same day, that there should be a serious case review as the children had suffered serious harm and there were concerns about the way in which agencies had worked together1.   1.2 Terms of Reference Full details of the review process are included in appendix 2. In summary, an independent lead reviewer worked alongside a review team, composed of senior managers, and facilitated by the chairperson of the Case Review Group. The purpose of the SCR was to review the involvement of agencies involved with the family to understand how professionals had understood the cause and nature of the family’s difficulties, and how effectively they had responded. The focus of the review was to establish whether there were ways in which services for children could be improved in the future.    The SCR considered the work of the following Hertfordshire agencies:  Health agencies (including mental health, community health and GP services)  Schools  Police  Local Authority Services (including Children’s Social Care (CSC), Thriving Families and Fire and Rescue Services)                                                            1 (Working Together to Safeguard Children, 2015 4:18 p 76) Final 14-Dec-17  4   The time frame of the review was from October 2014, when there was a referral by Thriving Families2 that resulted in CSC undertaking a further assessment of the family’s needs, until late August 2015, when the younger children made the allegations about sexual abuse.       2  SUMMARY OF FACTS 2.1 Family details – all names have been changed for reasons of confidentiality  Age at time of allegations Mother 34 Father 50 FH 12 years Sibling 1 10 years Sibling 2 8 years Sibling 3 4 years Maternal aunt 31 years Maternal grandfather 62 years  The children have dual heritage, their mother is White British and their father was born in North Africa. Their religious affiliation is not known. Professionals were aware that the children were of dual heritage but there is no evidence that this directly affected professional practice. On occasion Mother explained FH’s behaviour as being in response to racism from peers. In 2014, the family were supported to move to a new house, because of these concerns however this did not resolve the neighbour disputes. FH lived with his mother and siblings in social housing. His mother was a single parent dependent on benefits, who received much support from her wider family. The father and mother separated prior to the review period. The children had no contact with their father and he did not live locally. He was not involved with the children during the period of the review.  2.2 Earlier events  2.2.1 FH and his family were first referred to the local authority in October 2007 when he was four years old. From 2007, there were seven local authority social work assessments (including initial assessments, core assessments and one child protection inquiry) but there was little continued involvement by social workers and the lead in service coordination came from support services including Family Centres, parenting programmes, Targeted Advice Service and, from Summer                                                            2 Thriving Families is a holistic, intensive, family intervention service It is an integral part of Hertfordshire County Council’s early intervention and prevention strategy. The Thriving Families teams work in partnership with agencies such as the police, housing associations and job centres, to improve the lives of the families they support. Final 14-Dec-17  5  2014, Thriving Families. FH had a Statement of Educational Needs3 and attended a specialist school for children with emotional and behavioural needs. He had been assessed by CAMHS in 2010 and was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)4 and was attending a Paediatric ADHD Clinic.  2.2.2 From 2010 there were serious concerns and risks identified about FH which included violence to siblings, fire setting and bizarre behaviour. FH was unpopular or scapegoated by children of neighbours at two addresses, frequently leading to police involvement. In 2011, there were concerns identified about sexualised behaviour between FH and Sibling1 which were assessed and considered to be within the range of normal sibling behaviour.   2.2.3 There were also unsubstantiated suspicions about the behaviour of a member of the wider family towards one of FH’s siblings, who used to stay with him occasionally. The family always denied that there was any cause for concern and say that the child later denied any inappropriate behaviour.   2.2.4 By autumn 2014 the family had moved to a new area, nearer to family members, and the problems with the neighbours recurred. The worker from Thriving Families, who had known the family for over a year, was concerned because there seemed to be little improvement in the family functioning and FH’s behaviour seemed to be increasingly detrimental to his siblings. This concern was intensified when mother reported that FH had tried to strangle his sibling when he was asleep. The worker felt that this action was a safeguarding matter and so made a referral to CSC.   2.3 Agency Involvement during the review period Initial referral and response October 2014 to December 2014 2.3.1 The initial referral from Thriving Families identified that FH was violent towards his siblings and mother and that Mother was saying that she could not cope with FH and that his siblings had started exhibiting difficult behaviour.  The duty team response was to undertake a child and family assessment. It was not considered that there should be a section 47 enquiry5.                                                            3 A Statement is a document which sets out a child's special educational needs and any additional help that the child should receive. The aim of the Statement is to make sure that the child gets the right support to enable them to make progress in school. www.specialeducationalneeds.co.uk/statement-of-sen.htm 4 Attention deficit hyperactivity disorder (ADHD) is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness. Common symptoms of ADHD include: a short attention span or being easily distracted, restlessness, constant fidgeting or over activity, being impulsive. www.nhs.uk/conditions/attention-deficit-hyperactivity.../Introduction.aspx  5 s.47 enquiry refers to section 47 of the Children Act 1989 which gives local authorities the duty to ‘make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare’ when they 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  Final 14-Dec-17  6   2.3.2 The assessment was undertaken by a social worker, involved the children and mother, and included consultation with a range of agencies. Information was requested from CAMHS who did not contribute, as the paper files could not be made available within the timescale of the assessment. The assessment identified sixteen risk factors including: the children’s sexualised behaviour; worries that FH would physically harm his siblings; that Mother had little insight into FH’s difficulties and concerns regarding the level of supervision she provided to the children. The social worker also identified factors that reduced the risks including: the support provided by the wider family; that home conditions were good; and that Mother had engaged with the assessment. The assessment included little information from the previous social care assessments, with minimal reference to the child protection investigation in 2012 and no reference to FH having previously been involved in fire-setting. The outcome of the assessment was that the social worker recommended further work with the family via a Child in Need (CIN) plan6 that was mainly focussed on support for mother and building a relationship with FH. There was also an expectation that the siblings would be seen regularly and that their health and educational needs would be met. The plan did not include any further assessment of the emotional and physical risk to the siblings from FH’s actions and there was no involvement in the plan by specialist services such as CAMHS or the paediatrician.   2.3.3 In December 2014 the family was allocated to a children’s practitioner. This worker did not have a social work qualification and was very inexperienced. This was in line with usual practice as CIN work was usually allocated to unqualified staff. The first CIN meeting was held in December and most key community agencies working with the family were invited and attended. The exception being that the community paediatrician was not invited.   Mother struggling to cope and risk of harm to children January – February 2015 2.3.4 The police were called out to the family home on four occasions during January and there was increasing evidence of violence from FH to his mother. The second CIN meeting was held halfway through the month and the school agreed to offer FH extended days as a support for Mother. At the meeting, there was also discussion of the risk that FH posed to the younger children and Mother was advised to call the police if she felt that she or the children were at risk and to request an emergency psychiatric assessment. The next time the police were                                                            6 A child is in need if s/he is under 18 and either s/he needs extra help from Children’s Services to be safe and healthy or to develop properly; or s/he is disabled. Children’s Services decide if a child is in need by assessing their needs. If they decide the child is in need they will normally draw up a plan setting out what extra help they will provide to the child and their family. This is called a child in need plan.  Final 14-Dec-17  7  called to an incident, FH was taken to Accident & Emergency which resulted in the CAMHS Crisis Assessment and Treatment Team7 (C-CATT) becoming involved. Their assessment was that FH did not have suicidal intent or psychosis so he was discharged home with a referral for longer term support from CAMHS.   2.3.5 In January 2015, Mother told both schools, on two separate occasions, that she could not cope with FH and said she would not have him back after school. Both times this information was shared with CSC and Mother was persuaded that FH should return to her care. The mother’s account is that she was not given the option of FH staying in care even for a short respite period.  On the second occasion, there was discussion about FH being accommodated in foster-care but the management decision was that this should not be agreed until there had been a psychiatric assessment. A final incident at the end of the month resulted in FH being held in police cells for five hours before being discharged to his grandfather’s care.   2.3.6 During February 2015 file records show increasing evidence that the younger children were experiencing harm and that Mother was struggling to cope and protect them from FH. Mother and maternal grandfather met with the children’s practitioner and the consultant social worker and described abusive behaviour by FH to his siblings which included FH biting Sibling2 and threats to burn the house down. On a separate visit the children’s practitioner observed FH bullying Sibling1 and Mother failed to intervene.  These incidents were discussed between the TYSS worker and the children’s practitioner who also informed the consultant social worker (CSW)8 who was her supervisor and some items were reported on to more senior managers.    2.3.7 In February the C-CATT decision was reviewed and a second Psychiatrist confirmed that FH did not have psychosis but recommended an earlier CAMHS appointment. Attempts by CAMHS to see FH were delayed by Mother cancelling an appointment and a letter offering an alternative date being sent to the wrong address. At the third CIN meeting held at end of month the school reported improvements in FH’s behaviour at school but the children’s practitioner reported the bullying incident and expressed concern about the impact of FH’s behaviour on the younger children. She reported that CAMHS had said that in-patient                                                            7 C-CATT is a multi-disciplinary community team of senior clinicians, providing a short-term, intensive and flexible assessment and treatment packages of care for children with complex and challenging mental health problems and at high risk of harm to themselves or others. 8 In Hertfordshire consultant social workers are experienced workers who undertake a senior practitioner role including holding a small caseload of complex work while transitioning into a management position. At this point they provided supervision for less experienced staff as well as being a role model for good social work practice. Final 14-Dec-17  8  assessment was not suitable and suggested that CSC would be seeking a second opinion. At this point the children’s practitioner was receiving minimal formal supervision and limited support because the CSW transferred to another team and there was a delay in the replacement CSW providing supervision.   Increased Professional involvement March 2015 2.3.8 During this month there was a significant increase in professional involvement with the family. Following a referral from Thriving Families, the Fire Service became re-involved in March and provided advice to Mother regarding fire safety. The worker from the Fire Service rapidly identified significant concerns about FH and shared them with her supervisor. It was agreed that she would remain involved despite the overall level of need and risk in the case being outside of their usual remit.   2.3.9 Early in March, FH was also seen by the Great Ormond Street Hospital (GOSH) team. He had been referred by paediatrician in September 2014 for a further assessment of possible autistic spectrum disorder (ASD). The staff there were very concerned about FH and the risk he posed to other children. Within two days of seeing him for the initial assessment the GOSH paediatrician had telephoned the community paediatrician and children’s practitioner sharing these concerns, following up the telephone call with an email to the community paediatrician. The community paediatrician replied advising that her concerns were being raised with CSC. The community paediatrician then telephoned, and wrote to the children’s practitioner, expressing concern about FH’s behaviour and the impact it was having on the entire family and suggesting that there was a need to consider residential placement for assessment of FH’s difficulties. Following this the community paediatrician made a referral to CAMHS asking for the transfer of the management of FH’s ADHD from Paediatrics to CAMHS as FH’s needs were more complex and needed input from a psychiatrist. GOSH saw the family again on 23rd March and following that appointment liaised with the CAMHS psychiatrist about a possible referral to the South London and Maudsley NHS Foundation Trust (the Maudsley).    2.3.10 On receipt of that referral the CAMHS psychiatrist contacted the children’s practitioner in mid-March asking for a professional who knew FH to attend an assessment appointment. Unfortunately, neither the children’s practitioner nor the TYSS worker could attend on the date chosen. This meeting was attended instead by the Fire Service worker who had known FH for many years. Following the assessment, the CAMHS psychiatrist changed FH’s medication and, because she was very concerned about the risks that FH could pose to others, she made Final 14-Dec-17  9  a referral to a specialist clinic at the South London and Maudsley NHS Foundation Trust (the Maudsley) for a forensic psychiatric assessment. This referral letter was copied to the children’s practitioner. At the end of the month FH was seen at CAMHS for a ‘Choice’9 appointment, however the outcome of this assessment was not shared with the local authority.  2.3.11 Early in March 2015 Sibling 2 was seen in school with a bruise, said to have been caused by FH. This matter was reported to the children’s practitioner who discussed it with the consultant social worker. Initially there was discussion about the need for a child protection investigation and medical examination however this was not pursued as the team manager’s decision was that no action was required because the injury was consistent with the explanation provided. A further CIN meeting was held at the end of March. CAMHS and the Fire Service were not invited to attend meaning that information shared at those meetings was not passed to GOSH or The Maudsley however Mother reported to professionals that FH had been seen by GOSH and the local CAMHS psychiatrist.   Mother reports improvements and case is closed April 2015 – June 2015 2.3.12 There was minimal agency involvement during April and there were fewer requests from Mother with regards to FH. Sibling2 however was observed in school with rope burns on his neck which the local authority came to believe had been caused during play with FH, though his mother told the review that this was not the case. Separately, Sibling2 was seen with a mark on his face, said to have been caused by FH with a lighter. Both matters were reported to the children’s practitioner and discussed at the CIN meeting. At that meeting, Mother reported that FH’s behaviour had improved since his medication was changed by CAMHS and suggested ending work with TYSS as she no longer saw a need for CSC involvement. The TYSS worker had no contact with the family during this month because of planned sick leave and the secondary school did not attend the CIN meeting so the information about FH’s behaviour improving was largely based on Mother’s report.  2.3.13 The final CIN Meeting was held in late June. Mother advised that she was now better able to manage FH because of his new medication. She reported that                                                            9 The Choice and Partnership Approach (CAPA; York and Kingsbury, 2009) is a clinical system that evolved in Richmond and East Herts CAMHS and is now being widely implemented across the UK, New Zealand and parts of Australia. New CAMHS users and their families are invited to an initial ‘Choice appointment’. This appointment is a face to face appointment aimed at identifying what they want help with and reaching a shared understanding of the problems. From there a range of alternatives open to them can be offered, including other services, strategies they can use to help themselves, and any appropriate specialist CAMHS interventions. https://www.mentalhealth.org.uk/sites/default/files/CAPA_PDF.pdf  Final 14-Dec-17  10  there was less violence at home from FH towards his siblings and told professionals that FH had been diagnosed by the GOSH team as having ASD, ADHD and hyperkinetic cognitive disorder.  The TYSS worker reported that their work with FH was complete. Mother had completed the ADD-vance10 course which she said supported her with managing FH’s Autism and ADHD. No agency formally opposed ending the CIN plan but the secondary school expressed concern and reported that FH’s behaviour in school was deteriorating. It was noted at the meeting that the reports from The Maudsley and GOSH were still awaited however it was still recommended that the CIN plan should cease. Following this meeting the social care team manager endorsed this decision and local authority staff finished work with the family at the end of June.  2.3.14 In June FH’s case was presented at an academic session for health clinicians in Hertfordshire that involved all the medical consultants involved with FH but no one from social care. The Maudsley, psychiatrist emphasised the need for a multi-agency approach and that social care input would be needed.   Health agencies express concern about CSC case closure 2.3.15 The GP became aware of the intention to cease the plan in June 2015 and sent a letter to County Hall addressed to the central Child Protection Unit11 expressing concern about the case closure however this letter was not received by the children’s practitioner. In late June, after the CIN plan had ended, the psychiatrist at The Maudsley sent a letter to the CAMHS psychiatrist, copied to Mother, GP and ‘social worker’. This letter described a diagnosis of childhood autism, along with previous diagnoses of hyperkinetic conduct disorder and ADHD.  FH was described as a high risk for repeating physically assaulting behaviour towards peers and adults both within the home and community contexts. The letter concluded saying ‘FH’s high level of complex needs and his risk management require a coordinated multiagency approach where his (and his families) needs are clearly identified and allocated. Good multiagency communication is the cornerstone to manage this level of risk and complexity’. This letter was received in CSC after the case was closed, it was uploaded to the system by an administrator in July 2015 but was not seen by social work professionals or managers.                                                             10 ADD-vance is a registered charity founded in Hertfordshire in 1996.  It provides specialist information, training and advice for professionals, as well as support for children, adults and families on issues relating to Autism, Attention Deficit Hyperactivity Disorder (ADHD) and related conditions. 11 The letter appeared to have been intended for the Child Protection Statutory Review Service which is the team responsible for chairing child protection conferences and Looked After Children Reviews. Final 14-Dec-17  11  2.3.16 In mid-July 2015 a letter was sent to the local authority from the GOSH team. This was a cover letter for a detailed assessment report that confirmed a diagnosis for FH of Autism Spectrum Disorder with callous and unemotional traits.  The letter stressed the risks and the need for close work between the school, CAMHS and paediatric team with continuing involvement by CSC. This letter was also received by CSC after the case was closed. The letter was date stamped in July, but the report was not uploaded to the system until September 2015. In mid-August, the CAMHS psychiatrist met with Mother, FH and the siblings and a further medication review was carried out. Mother informed the psychiatrist that the CIN Plan had ended in June. Mother said she was happy with this as she did not need further assistance. This was the first time that the psychiatrist had been informed of the ending of CSC involvement with the family. Following this appointment, the psychiatrist sent a letter to the GP informing her that CSC had closed the case and saying that she intended to contact them to voice her concerns (she had not done this before the children made their allegations very soon after). The same day she made a referral for PALMS (Positive behaviour, Autism, Learning disability, Mental health service) to work with the family.  2.3.17 Two weeks later Mother reported to the police that her son, FH had ‘raped’ his younger siblings.  3 VIEWS OF FAMILY  3.1 The Lead Reviewer and a member of the Review Team met with Mother, Maternal Grandfather and Maternal Aunt. The Lead Reviewer asked Mother to describe how it was caring for FH and his siblings. Mother described it as ‘a rollercoaster’. She went onto explain how ‘FH’s behaviour would turn when he would become ‘violent, aggressive, and verbally abusive, bite, and punch and kick making it a challenge to even to get him to school’. On one occasion he badly damaged her car. School had reported this behaviour but Mother said that Children’s Services refused to take him into care. Mother then explained that after FH saw the CAMHS psychiatrist and was prescribed new medication, Concerta, he was seen to have changed. ‘…he was hugging his siblings and had calmed down considerably…’  3.2 The Lead reviewer asked if the family had been helped by the Child in Need Plan. Mother did not feel that it provided much support and she and Maternal Grandfather expressed concern about inaccuracies in the Child in Need Assessment which they said they had tried to rectify but to no avail. They said that the family was looking for support but did not find that either the children’s Final 14-Dec-17  12  practitioner or the TYSS worker provided help. The most supportive service was ADD-vance and that they had learned a lot from their worker. Mother described that when she was under significant pressure in January 2015 and had asked for FH to be accommodated ‘she wanted somebody to listen but there was no contact for 3 days’. Nobody bothered to check up on FH ‘who was still in a hell of a mood’. The children’s practitioner and CSW eventually had come around in January but that visit was ‘just a welfare check’.  3.3 The Lead Reviewer asked what would have helped. Mother said that they wanted FH to be placed in a boarding school, he was statemented around 2011. He was permanently excluded in 2010. MGF said that it needed two adults to manage him. Mother said that she wanted somebody to take FH out of the house as she could not manage him on her own. MGF said he tried to give Mother a break by providing some help for a week. FH always listened to a man. He was ‘uncontrollable in the shops but when he was playing with Meccano he was meticulous and could concentrate for long periods’. Mother said that whenever he had appointments with doctors he behaved very well and that ‘professionals have not seen his behaviour when he has become aggressive’.  3.4 Mother felt that the police felt their hands were tied as it was for Children’s Services to support the family in relation to FH’s behaviour. Mother stated that the children resented speaking to social workers as they often were ‘pulled from their lessons’ and they ‘would not have anything to say’. Mother said that things had got better after FH’s medication was changed and because of this she wanted the CIN plan to end. Very few home visits were being done, between 4 to 6 weeks and not much was being done through the CIN plan. MGF said that there should have been a multi-agency approach and both Health and Children’s Services should have worked together.  3.5 The Lead Reviewer asked when the children first disclosed FH’s inappropriate sexual behaviour. Mother said that it was during the summer holidays in 2015 after CSC had ceased working with the family. She also confirmed that she had no concerns about sexual abuse prior to that time. She said that FH’s behaviour had got worse in July 2015 but because of the past lack of support she could not see the point in re-referring FH to the local authority.   4. ANALYSIS 4.1.1 Statutory guidance requires that serious case review reports provide a sound analysis of what happened in the case, why, and what needs to happen to reduce the risk of recurrence. The task for every review should be to answer the Final 14-Dec-17  13  following question: - What light has this case review shed on the reliability of our systems to keep children safe? This analysis should consider significant aspects of practice in the case and identify problematic areas. To understand their relevance to the wider safeguarding system, it is important that the analysis: -  identifies whether problems are specific to the case;  highlights any relevant information about how usual the problem is perceived to be locally;  is clear about why it is important for the LSCB to consider these matters relative to their responsibilities, the risk and reliability of multi-agency systems.  The following section considers the areas where analysis of practice in this case has identified problems that are relevant to the wider safeguarding system as it is probable that they are likely to be repeated as they have been described by practitioners as being ‘normal’ practice.  4.1.2 The reason for undertaking the serious case review was the allegation that FH had caused his siblings serious harm through sexual abuse. The extent to which professionals could have been aware of this risk is discussed in section 4.2 which considers the effectiveness of the professional response to child protection concerns about the risk that FH posed to his siblings.   4.1.3 The review has also considered practice within CSC regarding allocation, supervision and management of work. This is discussed in section 4.3 which examines the nature of work allocated to unqualified staff, the supervision provided to inexperienced staff and the distance between frontline staff and managers making casework decisions.   4.1.4 A significant feature of this review was the number of health clinicians involved with FH both in assessment and treatment of his needs. The complex routes to treatment within children’s mental health services and their impact on other professionals are discussed further in section 4.4.   4.1.5 One aspect of the professional work with this family was the absence of joint working between the health professionals directly involved with FH and the local authority staff who were working with all the children. The reasons for this are considered further in the section 4.5.   Final 14-Dec-17  14  4.1.6 A key aspect of multi-agency working is the quality of information sharing. In this case there were examples of very good information sharing between police and CSC but other occasions when information was not shared. The quality of information exchange between police and CSC is discussed in section 4.6.   4.2 Professional response to child protection concerns 4.2.1 A central concern of this review was whether professionals could have intervened to prevent the sexually harmful behaviour of FH towards his siblings. It is noteworthy that even with the benefit of hindsight no professional could identify actions or behaviour, during the period of the review, by FH or his siblings that pointed to a clear risk of sexual abuse and this was a view confirmed by Mother and grandfather. There had been concerns prior to the review period of possible sexually inappropriate behaviour between the siblings. These were assessed and, as all the children were young (under nine) at the time of the concerns, this behaviour was deemed to be within the realm of ‘normal’ sexual exploratory play. There was also an investigation into the potentially inappropriate care provided by an extended family member but this had not been substantiated. This review did not examine in detail these matters but there was no evidence (even with hindsight) that the judgements made at the time were wrong.  4.2.2 An interesting facet of the professional intervention with this family was that the agencies who had least direct contact with the family as a unit and no direct responsibility for the younger children were able to formulate most clearly their understanding of the risk that FH posed to their well-being. The professionals at GOSH and The Maudsley and the local paediatrician and CAMHS psychiatrist based their views on information provided by Mother about FH’s relationship with his siblings. Their assessment of FH identified explicit risks to the children of physical harm as well as broader concerns about emotional damage. Those who were most involved treated his behaviour as an extension of ordinary behaviour between siblings, whereas those who were more distant (or more expert) viewed it as being out of the ordinary.   4.2.3 One explanation for this may be that within society generally there is a greater acceptance of peer on peer violence within children than between adults and an assumption is made that such violence has less impact on their emotional well-being. Surveys suggest that ‘more than half of all children experience violence from a sibling in the course of a year,12 and furthermore that ‘…over half of the                                                            12 Finkelhor, David. Childhood Victimization: Violence, Crime, and Abuse in the Lives of Young People (Interpersonal Violence) (p. 92). Oxford University Press. Kindle Edition. Final 14-Dec-17  15  children under 10 years old hit by a sibling in the previous year had experienced five or more such episodes during that year’13.  4.2.4 Another aspect of violence within the home was FH’s attacks on his mother. When examining the police reports of the violence between FH and his mother the review team frequently noted that if an adult had acted in that way the alleged perpetrator would have been charged and there would have been a child protection assessment to consider the emotional impact on the children of witnessing such violence. That this was not considered argues that professionals focussed purely on FH and did not consider the impact of his behaviour on his siblings.   4.2.5 Local authority front line professionals were aware of the behaviour but felt unable to intervene. The initial decision to work with the family through a child in need plan may have been an over-optimistic decision however it was legitimate given the expectation of the Children Act 1989 that, where possible, social workers should work in partnership with families at the lowest level of intervention. The plan that was agreed however did not include any further assessment of the emotional and physical risk to the siblings from FH’s actions, despite this being the reason for the initial referral. The focus of the plan was on supporting Mother in parenting FH with little consideration of the potential risk that he posed to his siblings. Removing FH from the family home was considered but was rejected by managers who were probably unaware of the high level of risk because they were distanced from the front-line (to be discussed later).  Those professionals working most closely with the family also possibly became immune to the significance of the levels of violence, by virtue of experiencing it so frequently.   4.2.6 Managers did not progress a child protection investigation on one occasion as they considered they knew the cause of the injuries. This suggests that they thought the purpose of a child protection investigation was purely to identify what had happened rather than to assess the risk to the child. Child protection assessments and medicals should not solely describe ‘who did what to whom’ but should evaluate ‘context and cause’ and therefore how to prevent recurrence. It was known that FH had caused the injury to his sibling but a full child protection enquiry would have examined the context for the injury and considered whether and how a recurrence of the injury could be avoided.  There was, however, no proper consideration of whether there should be a section 47 child protection                                                            13 Finkelhor, David. Childhood Victimization: Violence, Crime, and Abuse in the Lives of Young People (Interpersonal Violence) (p. 97). Oxford University Press. Kindle Edition. Final 14-Dec-17  16  assessment undertaken by a social worker. Furthermore, there was also no consideration of whether the case should be re-allocated to a social worker to bring a greater level of skill and experience to bear on the case. Each incident was discussed in isolation with no evaluation of the overall picture.   4.2.7 It is not certain that if there had been better overall risk assessment the risk of sexual harm would have been identified. There is very little research about young people who sexually harm siblings. O'Brien (1991) found that sibling incest offenders were more likely than to have exhibited behavioural problems associated with ‘conduct disorders, including vandalism, fire setting, physical aggression, cruelty to animals, lying, stealing, and running away.14 In the UK similar small-scale research has identified similar data with Salter et al noting that ‘52% of sexual offenders had been cautioned or convicted for non-sexual offences’15. These studies involve small numbers and are retrospective focussing on young people known to have been involved in causing sexual harm. They show that some children who offend or are violent may present a risk of sexual harm but they do not identify a causal link. They therefore have limited use for the practitioner working with young people who have conduct disorders most of whom will not go on to develop sexually harmful behaviour.   4.2.8 Studies have shown that between one-fifth and one-third of child sexual abuse in the UK involves other children and adolescents as perpetrators and sibling sexual abuse is estimated is the most common form of intra-familial sexual abuse with one estimate indicating that half of all adolescent perpetrated offences involving a sibling. This abuse often goes unidentified with less than 20% of victims disclosing at the time and most of the prevalence data is based on survey information provided retrospectively by adults.16 It is therefore not unexpected that FH’s sexual abuse of his siblings was not identified. However, there was significant evidence of FH presenting a risk of physical and emotional harm to his siblings which was identified by professionals. Throughout the review period many professionals observed FH causing harm to his siblings. These events were recorded and discussed but there was no formal response and it was never                                                            14 Child Abuse & Neglect, Vol. 19, No 7, pp 811-819, 1995 Copyright © 1995 Elsevier Science Ltd Printed m the USA. All rights reserved SIBLING INCEST OFFENDERS NAOMI A. ADLER Department of Psychiatry, North Shore University Hospital-Cornell University Medical College, Manhasset, NY, USA JOSEPH SCHUTZ Department of Applied Psychology, New York University, New York, NY, USA 15 Development of sexually abusive behaviour in sexually victimised males: a longitudinal study (2003) Daniel Salter, Dean McMillan, Mark Richards, Tiffany Talbot, Jill Hodges, Arnon Bentovim, Richard Hastings, Jim Stevenson, David Skuse 16 An evidence-informed operational framework for children and young people displaying harmful sexual behaviours. NSPCC, Research in Practice and Durham University Publication details: [London]: NSPCC. pp 80 View report online http://email.nspcc.org.uk/c/1CpqbWE2fTZx3DTwcW6NRgym Final 14-Dec-17  17  assessed or examined as a child protection concern even though anxiety about this underlay the original referral to the local authority in 2014. A more active response to the risks of physical and emotional harm could have provided the opportunity of consideration of other risks that FH could have posed to his siblings but would not necessarily have led to the risk of sexual harm being identified.  4.3 Allocation, Supervision and Management in Children’s Social Care  4.3.1 At the time of the of the events under review, children’s practitioners (in the main unqualified and inexperienced) were supervised by consultant social workers, who provided guidance and advice but had no decision-making responsibilities. The children’s practitioners were also managed by the team manager who made decisions about casework, such as whether to initiate section 47 inquiries and case closure, and were responsible for applying for resources (via the HARP17 process). Actual decisions about resources and whether children should be accommodated were made by either HARP, Head of Service and or the Operational Directors of Children’s Services (for children 0 – 11 years old) and Director of Specialist Services (for children 12 to 17 years old). The role of staff and managers in the social work team was to provide the evidential basis for such requests. Senior managers report that such evidence is always provided by face to face discussion with e-mail confirmation of the request and decision. This perspective was not supported by more junior staff who reported sharing information with the team manager but having little direct knowledge of how decisions were then made by more senior management.   4.3.2 The decision to allocate an unqualified, inexperienced worker to be key worker for FH was in accordance with accepted practice at the time as child in need work was, on occasions, allocated to unqualified staff (some child in need work was also allocated to social workers). In this case, it failed to acknowledge the complexity of the case history or the clear child protection concerns that were explicit in the referral by Thriving Families. The assessment, furthermore, had indicated that working with this family would be challenging making it unsuitable for an inexperienced worker. An explanation given for this allocation decision was that the team was under pressure with high caseloads. Review of the team records indicates that during this time the team was holding 143 children. There were 6 Social Workers in post (1 CSW, 1 locum, 3 SW’s progressed through the                                                            17 Hertfordshire Access to Resources Panel (H.A.R.P) The Role of the Hertfordshire Access to Resources Panel is to make decisions on placements, Independent provision and support packages for Children and Young People Looked After or Children in Need Final 14-Dec-17  18  academy18 and 1 Social Worker who had stepped up from a children’s practitioner post). Objectively this is not a heavy team workload however there were a high number of newly qualified staff and certainly the children’s practitioner caseload was 25 which was very high given her level of experience. Recent annual workforce statistics produced by the Department for Education have for the first time included details about average children's social work caseloads in each of the 152 local authorities. While the average for England has been calculated at 16.1 cases per social worker, there is a wide variation across local authority areas and Hertfordshire was reported to have an average of 28 per social worker.19 Allocation of work for children’s practitioners has been reviewed and amended during the period of the review and current guidance now states that children’s practitioners should ‘Hold non-complex (low risk) CiN cases’ 20.  4.3.3 A further complication in this case was that the review has been told by staff at all levels that there were concerns about the performance of the consultant social workers (CSWs) which were addressed by them being aligned to new team managers which meant that they swapped their workloads. This decision was not in itself wrong however the implementation of the change, which did not include any formal supervision handover meetings, provided the potential for a loss of supervisory oversight of the children’s practitioner’s workload. Both CSWs were interviewed by members of the review team and it was clear that the CSW who was first involved had a different understanding of the risks within the case from that presented by the CSW who was involved in the latter stages. There was also a gap in the supervision provided to the children’s practitioner. The supervision file evidences that the children’s practitioner did not receive supervision from a CSW between 20.01.15 and 03.03.15 which was a significant period in this case history. It was during this period that the paediatrician from GOSH telephoned the children’s practitioner expressing concern about FH and the local community paediatrician wrote identifying risks and recommending a residential placement. There is no evidence that this contact or the community paediatrician’s letter was shared with managers.  4.3.4 A further significant weakness in the casework management systems was the absence of any professional or managerial input when copies of the reports from The Maudsley and GOSH were received by CSC on 30th June 2015 and 14th July 2016 respectively. These assessments were identified by the local authority early in the case history as being important in determining the nature of support for the                                                            18 Newly qualified staff with a limited caseload and requiring greater supervision 19 http://www.cypnow.co.uk/cyp/news/2003192/dfe  20 Hertfordshire Children’s Services PRACTICE GUIDANCE NOTE Final 14-Dec-17  19  family. Both reports gave very strong recommendations as to the need for continued children’s services involvement with the family; however, it appears that neither were seen by a manager or social worker although both were noted as being received and uploaded onto the data-base by administrative staff. It is surprising and concerning that reports of such importance could be received by the Local Authority but not reviewed by any professional. Administrators processing documents without professional oversight is also evident in the response to the letter from the GP expressing concern at the case closure. This letter was sent at the end of June but was not uploaded onto the system until the end of July and again there is no evidence that it was reviewed by any professional. During the process of the review it was confirmed that this all of this was possible because there was no system and process in place for vetting the contents of such letters. It has been reported to the review team that measures have been taken to prevent such correspondence being uploaded without the knowledge of the Social Work Team and a more comprehensive system will be put in place to ensure that a manager has sight of such letters when they are received. 4.3.5 There were three other decisions made by managers that had a significant impact on the progress of the case. The first was the decision by the service manager to refuse Mother’s request for FH to be received into care. This decision was influenced by concerns about whether there was sufficient understanding of his needs, hence the decision to defer until a psychiatric assessment (referred to in the previous paragraph) was completed. This perspective may have been valid however there was no follow-up by the service manager or team manager to check the progress or outcome of this assessment.   4.3.6 The second intervention was regarding whether to progress a child protection investigation and medical when Sibling2 was seen to have bruising caused by FH. The decision made by the team manager not to progress the investigation via a child protection medical appeared to be a focus on FH’s needs with less consideration of the risks to the siblings (see para 4.2.5 above).    4.3.7 The third intervention was the decision by the team manager to confirm that the CIN plan should be ended in June and the case should be closed to CSC prior to receipt of either of the assessments from GOSH or The Maudsley. Given the previous decision that FH could not be accommodated until such assessments could be completed, this action is surprising. It was driven by Mother’s consideration that she no longer needed support with caring for FH and argues a significant lack of focus on the needs of the younger children. At this time there was little direct contact between the team manager and the children’s practitioners when making such decisions yet the team manager was responsible Final 14-Dec-17  20  for decision-making on all their cases. The expectation was that the team manager would read all CIN meeting minutes and when necessary access case records to inform their decision-making. At this time, she had overall responsibility for over 100 cases, so it is unlikely that when considering closure, she would have recalled the significance of the two outstanding psychiatric assessments and would only have identified this from the minutes of the meetings after a very detailed examination of the file. In any case by the time the team manager was involved, two professionals had endorsed the recommendation for closure reached at the CIN meeting so there was little likelihood of meaningful challenge. The process of case closure thus became a ‘rubber-stamping’ exercise.   4.3.8 The structure of the managements systems in Hertfordshire meant that there was a long chain of command and the CSW was providing guidance to the children’s practitioner without any real authority as all the key decisions were made by the team manager or service manager at some distance from the frontline. There have been changes made to this structure since this time and team managers now chair all first and last CIN meetings and this has been described by practitioners as much safer.  4.4 Care pathways for children with complex conduct disorders 4.4.1 Both local health and local authority professionals told the review team that there was not an effective care pathway for children with complex behavioural problems that may include aspects of ADHD and ASD. It is significant that over a six-month period FH was assessed and treated by five consultant-led health teams. All the teams had separate and significant functions but this case does raise the question as to whether this very complex route to treatment could be improved. This complexity required strong communication within the health system and presented significant challenges for understanding by agencies outside. This was a significant cost to public resources. There was strong communication about concerns between GOSH and the local health teams however there was less positive communication between the local health teams and the wider local multi-agency network. At times, the priority for the local teams appears to have been the search for a definitive medical diagnosis, although this would not have provided a better understanding of the potential risk to the child or his siblings, or aided case management. Achieving a definitive diagnosis for FH (if such a thing existed) offered no guarantee that the safeguarding risks within the family would be resolved and the suggested management plans suggested by the tertiary centres amounted to basic interagency coordination of safeguarding activity that should have been occurring anyway. Final 14-Dec-17  21  4.4.2 Each of the local health teams involved was clear about their role in assessing risk from the point of their service however this sometimes became a process of saying that the child did not meet their criteria rather than contributing to a discussion about how his overall needs could best be met. Thus, CCATT were clear that FH did not have a psychiatric disorder and would not benefit from an inpatient psychiatric admission but did not provide guidance as to what support they could provide or who else could provide suitable services. The local community paediatrician wrote to the children’s practitioner saying that she felt FH would be best cared for in a residential setting but without indicating what sort of provision that might be. The GOSH paediatrician was clear that she felt there were risks to FH’s siblings if he remained at home and advised that there should be consideration of residential provision by the local teams but this was not addressed by CSC or CAMHS in a multi-disciplinary way and each agency approached the issue using their individual thresholds for accessing such service. The fragmented approach FH’s problems rather than the development of an overall solution meant that FH was passed on for further and further assessment whilst effectively leaving his day to day care with the family, and by default, CSC. Overall there was too much focus by the local teams on diagnosis with insufficient consideration of how to manage his care and within that the risks to the siblings.  4.4.3 Within CSC, there was limited knowledge of referral processes in CAMHS and the wider health service, leading to misunderstanding about what services could or should be made available to FH and his family. Even some months after the event, CSC staff understood that the referral of FH to CAMHS had been declined because CAMHS wasn’t the right service for him. In fact, following FH being seen for his CHOICE appointment in April, the consultant psychiatrist took on the care of FH. There was no shared or mutual understanding of how to work with young people with conduct disorders. Local authority staff felt that unless there was a clear diagnosis of a mental illness then CAMHS were resistant to becoming involved and would determine the problem to be best resolved by CSC or the school. CAMHS practitioners confirmed that they considered that as conduct disorders were not immediately life threatening (unlike children with psychiatric problems who were self-harming) and it was also known that they had poor outcomes from CAMHS treatment options, so they would often suggest alternatives to their service.    4.4.4 The reasons for the absence of effective care pathways for children with complex conduct disorders are many however it is likely that a significant factor is that many of these young people are extremely difficult to work with and are often Final 14-Dec-17  22  resource intensive. Effective responses for such young people require, from the start, a multi-agency approach. The needs of these young people can rarely be met from established provision but require packages of support and care that are adapted from within existing resources. This in turn, requires trust and confidence between agencies in order that front line managers and professionals can develop creative and innovative solutions. This requires cultural change within and between agencies with improved mutual understanding of agency thinking and acknowledgement of the limitations of each organisation. From this can come the flexibility in budgets and organisation that is required to develop a range of solutions that go beyond the limitations of any single organisation.  4.4.5 Without this trust and support between professionals and agencies it is probable that there will be resistance to becoming involved and professionals will use thresholds and assessment criteria as a mechanism for avoiding intervention. These responses are often based on criteria that are internally valid but do not assist in addressing the overall needs of the child and family such as the decision by C-CATT that an in-patient admission for FH was unlikely to achieve good outcomes for him. This was a valid decision but it did not make the risk go away and so needed to be supported by a rapid planning process, by all involved agencies, to consider how to best meet FH’s needs whilst enabling the safety of his siblings to be achieved. An approach such as this requires a significant cultural change within all organisations and needs to be underpinned by a shift in service planning at the highest level.   4.5 Joint working between health professionals and local authority practitioners 4.5.1 Throughout the review period two strands of agency intervention with the family progressed in parallel. Local authority staff supported the family via the child in need planning process focussed on support to mother in coping with FH whilst local health professionals pursued a clinical diagnosis for FH via referrals for highly specialist assessments based on family attendance at two hospitals in London.  Professionals at GOSH had a very accurate sense of the issues and risks and clearly documented and communicated these to the local health professionals. They understood that the health team were working closely with CSC to address the problems. GOSH only once had direct contact with the children's practitioner at the start of their assessment and except on one occasion did not copy CSC into later communications with the local health team. Two months after the final appointment with FH the local authority was sent a copy of the assessment report. By then the local authority had closed the case. Final 14-Dec-17  23  As a result the report and the covering letter (which urged the local authority to continue to work with other agencies) was not read.    4.5.2 The CIN planning meetings were convened by CSC staff and attended by school staff, health visitor and school nurse, TYSS, and Thriving Families. These are the usual agencies that attend CIN meetings but they did not reflect all the health agencies that were working directly with this family and particularly did not include CAMHS or the community paediatrician. This meant that there was no input to these meetings from the health practitioners directly responsible for managing FH’s treatment for ADHD. A clear focus of any CIN meeting should be consideration of any safeguarding risks for the whole family however as there was great dependence on Mother providing information about the outcome of specialist assessments it is likely that this may not have included full detail about professionals’ perspective about the risks that FH was perceived to present to the other children.  4.5.3 There was no consideration of inviting CAMHS or the paediatrician to attend the meetings despite their involvement being known by the children’s practitioner and there being some communication between the agencies. One explanation given by CSC for not inviting CAMHS professionals to the CIN meetings was that CAMHS did not usually attend such meetings and furthermore the relevant professional would have been the psychiatrist who would not have had capacity for this because of other work commitments. When this was discussed with CAMHS professionals they acknowledged that it was unusual for a psychiatrist to attend CIN meetings however they said that it was possible. Similar views were expressed about the likelihood of a paediatrician attending a CIN meeting.   4.5.4 There were attempts from both sides to work jointly. The CAMHS psychiatrist contacted the children’s practitioner and asked her to attend the initial assessment meeting. This was not possible due to prior commitments. The fire service staff member who did attend, and knew FH historically, was not part of the CIN meetings so did not have recent information about FH’s behaviour towards his siblings. There was no consideration by the CAMHS psychiatrist that she or another CAMHS worker should attend the CIN meeting and similarly whilst it was often identified at the CIN meetings that there was a need for a report from CAMHS this was never achieved. When consulted as part of the SCR CAMHS staff were clear that they could attend CIN meetings but rarely did because their work processes involved clinical appointments that did not easily allow for attendance at outside meetings. There was evidence that the children’s practitioner had attempted to contact the CAMHS psychiatrist but had found this Final 14-Dec-17  24  difficult and informal communications with CSC staff indicate that staff do not invite CAMHS staff to meetings because they have developed such low expectations as to their attendance and input. Whilst the paediatrician did write to the children’s practitioner requesting a ‘professionals meeting’ this was not followed up when the meeting was not arranged nor was there any consideration to a health professional convening such a meeting.  4.5.5 In their work with the family health professionals followed their separate care pathways all of which focussed on clinical appointments. Health interventions often lagged slightly after the crisis that had precipitated increased agency input. At no point did any health clinician convene a multi-agency meeting; instead they passed information to other agencies via telephone or copy letters summarising the outcome of the clinic appointment. This meant there was little direct communication between health professionals and children’s social care professionals at the time that FH’s behaviour was seen to be most problematic. Furthermore, the contact that took place at that time was largely negative and concerned thresholds for service delivery. For professionals in CSC the most difficult period with this family was between January and March 2015. Their main contact at that time was with CCATT and CAMHS and focussed on what service could be provided to resolve the family crisis. This in the main involved clinicians (some of whom had never met the family) telling CSC professionals why they could not offer FH a service. Social care staff also lacked an understanding of possible mental health resources available and the absence of clear multi-agency care pathways meant that social work staff felt powerless to intervene. In this situation, it is unsurprising that when Mother reported improvements in FH’s behaviour there was little energy to question that report. Rather professionals were relieved that an unsolvable problem appeared to have been resolved whereas in fact this was repeating the historical pattern of cyclical interventions.  4.5.6 There is evidence that there was confusion then between agencies about respective roles and responsibilities. The children’s practitioner was thought to be a social worker by the CAMHS staff and the C-CATT Nurse was thought to be a psychiatrist by local authority staff. There was a lack of clarity from CSC staff about the remit of the C-CATT service which is referred to as CAMHS and there was no understanding that the service was separate from CAMHS with different thresholds for intervention. Local authority staff did not understand that the local paediatrician’s referral of FH to CAMHS was to transfer responsibility for managing the ADHD and was not a further request for a psychiatric assessment of FH’s mental health needs. Similarly, there was confusion by local authority staff about the reasons for the psychiatrist’s referral of FH to The Maudsley. Final 14-Dec-17  25  Some of these confusions reflect the inexperience of the children’s practitioner and may have been resolved with closer supervision however most of them would also have been resolved if professionals had explained more clearly to one another what they were trying to achieve, but sadly this was never achieved.  4.5.7 Discussions with both CSC and CAMHS front-line staff identified that there were not many opportunities for direct conversations between agencies which was a limitation of current arrangements. It was acknowledged that this limited professionals’ opportunities for specialist knowledge to be shared and for greater understanding of each other roles and responsibilities.   4.6 Information sharing between Police and Children’s Social Care 4.6.1  Generally it was clear that there was close working between CSC and the Police and when the family was in crisis there was good communication between the CSC Emergency Duty Service and the Police. Scrutiny of the records identified however that whilst the Police often provided good information reports regarding incidents involving FH it was evident that on some occasions information was either passed late or not at all. In early January, there were three police visits to the family because of FH assaulting Mother. These were not reported to CSC until the 20th January when following a further call-out it was decided that a referral to CSC for support should be made and details of previous visits dating back to November 2014 were included in the referral form.  4.6.2 The reasons for this appeared to be that it was for each individual police office to judge whether the information about an event should be shared.  In the main it appears that with regards to children the police only report safeguarding concerns and only pass information about wider welfare concerns where there is evidence of domestic abuse. An example that highlights this distinction is that in 2015 and 2014 there were three occasions when FH was assaulted by a peer and none of these incidents was reported to CSC.    4.6.3 The issue for discussion is how the individual police officers identify the information that should be shared. It is likely that all domestic abuse incidents that involve children are reported to CSC. This contrasts with practice in this case where some incidents of assault of Mother by FH were reported and others were not. It is known that in some police forces any incident where the police have contact with a child who they believe needs additional support is reported to CSC. This approach does risk overloading CSC but equally does enable social workers to cross-reference facts that may not in themselves appear to be child protection concerns but in context may indicate risk. In other local authority Final 14-Dec-17  26  areas, there are agreed protocols about what information is shared which is often linked to the MASH arrangements.  5 CONCLUSIONS  5.1 This review was initiated because three children had suffered serious harm because it was alleged that they had been sexually abused by their brother and there was concern about the ways in which agencies had worked together. The review has shown that whilst there was no evidence that professionals had not responded to indicators of sexual abuse there were other aspects of safeguarding practice that could be improved and these are detailed below.  Operational Practice Matters 5.2 The review has identified that it can be hard to secure the attendance of senior health clinicians, such as consultants in community paediatrics and CAMHS, at multi-agency meetings about children. Consultation with staff suggests that this reflects a wider pattern and is not limited to this case. Staff indicated that the current pattern may be a consequence of the priority that is given to clinic attendance and the management of waiting lists. The absence of key people from meetings reduces the effectiveness of work with some of the most complex children and undermines collaboration. Social care staff appear to have low expectations about the attendance of certain groups of professionals at child in need meetings and strategy meetings which means that on occasions health staff are not invited to attend.  5.3 During the review several key reports and letters were received by Children’s Social Care and were uploaded onto the client record system without being read by the children’s practitioner or by managers (some while the case was open, others shortly after it was closed). There was no evidence of a system to identify important correspondence and bring it to the attention of managers. It is not known whether this would apply to other cases but as it happened on three separate occasions on this case it seems probable.  5.4. The review has also highlighted the complex nature of management and supervision arrangements within Hertfordshire Children’s Social Care. It is reported that since the period when the events described in this report took place caseloads for children’s practitioners are significantly reduced and that they all receive regular group case supervision and one to one supervision. There have also been changes in the direct involvement of team managers in case work decisions. These changes are relatively recent and may benefit from further review once they have become embedded in practice. Final 14-Dec-17  27  5.5 CAMHS clinicians consulted during this review have indicated that their work would be assisted if children who are subject of a Child in Need plan could be readily identified at the point when a referral is being assessed. This would enable decisions to be made about allocation in a more informed way and could improve prevention of more serious mental health problems.    5.6 Police officers had many contacts with FH during the period under review. This included involvement because of his behaviour in the home and in the wider neighbourhood. On occasion, he was the perpetrator of violence and sometimes he was a victim of crime. Some contacts were reported to the local authority, but others were not and there appeared to be no consistent pattern or criteria (i.e. apparently similar incidents were treated differently) about how and when information was shared.  Wider Operational and Commissioning Matters 5.7 Within the local health service there was no clear care pathway for this child who exhibited aggressive and risky behaviour. The focus of family and local health professionals was on obtaining a diagnosis, rather than addressing the day to day risks presented by his behaviour. During the period of the review five paediatric / psychiatric services worked with the child and his family. There was a clear rationale for the involvement of each separate service however when examining the overall pattern this is hard to justify and was confusing for the family and other professionals. Referrals were made for specialist assessments in tertiary centres. This resulted in lengthy assessment reports and diagnostic labels (ADHD, Autistic Spectrum Disorder, and Conduct Disorder with callous and unemotional traits). There is a danger that once a child is referred for an expert assessment, local health professionals will rely on its outcome and do less to resolve the problems. In fact, the care plan that emerged from these assessments was ‘to be aware of the risk and to manage it through close collaboration and information sharing across agencies including the local authority’. Unfortunately during the time it took for the assessments to take place local collaboration and dialogue (which was already not strong) had been closed down. Ironically the time taken for the assessment and the complex nature of the care pathway directly militated against that recommendation from being implemented.  5.8 No pathway can be effective unless culture and attitude support working together and the review has identified that at present there is a significant gap between CAMHS clinicians and CSC staff with regards to joint working and that for this to improve requires a shift in culture on both sides. 5.9 One reason for the number of services and clinicians being involved was that there was no local capacity within the CAMHS services in Hertfordshire to Final 14-Dec-17  28  undertake this assessment or to put in place the treatments recommended by NICE for such children (e.g. multi-systemic therapy). CAMHS services are currently under review which provides an opportunity for developing locally based services that are more flexible and able to be responsive to individual needs in cases such as this.   Final 14-Dec-17  29  6 RECOMMENDATIONS 6.1 HSCB to require that Commissioners and health providers should consider how service working arrangements can be revised to enable more effective input by paediatricians and CAMHS staff to CIN meetings. Multi-agency aspects of the problem (including scheduling, invitations, administration) should be considered in developing a solution. The local authority should ensure that all relevant professionals are identified and invited to contribute to CIN meetings and should persist in challenging agencies when there is no input to the CIN planning process. 6.2 HSCB to ask the local authority to provide concrete assurance on its arrangements for the management of correspondence including professional oversight of reports and letters regarding service users. 6.3 HSCB to seek assurance from Hertfordshire Children’s Social Care on the quality of supervision and management arrangements in Child in Need and Family Safeguarding services. 6.4 HSCB to request that the local authority and HPFT should explore a means of providing confirmation that a child is the subject of a CIN plan for CAMHS and other professionals. The arrangement should comply with data protection arrangements.  6.5 HSCB to ask Hertfordshire Police to review the criteria for reporting incidents to the local authority when officers have contact with children whose welfare could be promoted by the provision of services. There should be discussion with the local authority to achieve agreement as to the sort of incidents that should be reported and a mechanism whereby this can be achieved. 6.6 HSCB to require that commissioners across all agencies develop a pathway for the management of children (including young children) who have complex social and emotional needs, linked to aggressive behavioural difficulties or risk to others (these would include those whose histories feature sexualised behaviour, fire setting, sexual abuse and, chronic exposure to domestic abuse). This must address the needs of a small number of children, who do not easily match any diagnostic criteria (or might accumulate numerous diagnoses) and may not therefore meet the thresholds for any specific service. Their needs may be so specific that they cannot be addressed within a traditional pathway. Meeting their needs will require flexibility and the ability to talk and cooperate to create a bespoke solution in each specific case. This must be accepted as a shared responsibility, which must not be avoided because the child falls outside the remit of a particular team or service. 6.7 HSCB to ask commissioners to explore the possible use of CAMHS transformation funding to implement the proposed pathway, to include assessment and development of locally based treatment expertise, in line with NICE guidance.   Final 14-Dec-17  30  Appendix 1 Methodology 1 Review process  1.1 The review was conducted in accordance with Working Together 2015 guidance that:   recognises the complex circumstances in which professionals work together to safeguard children;  seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings’. (HM Government, 2015 p74)  1.2 This report was completed based on information provided by staff and managers directly working with the family, who were interviewed by Review Team members. The lead reviewer also had telephone conversations with senior specialist clinicians from Great Ormond Street Hospital (GOSH) and The Maudsley Hospital and was given copies of their assessments. Following comments being received on the final report there was further information received from GOSH and the report was further amended. The review team also had access to reports and recordings from local authority and health staff including the assessment completed by the social worker in October 2014.  1.3 Frontline practitioners were also involved in two meetings where the Lead reviewer shared initial findings from the review. There were productive discussions between the lead reviewer and practitioners about whether the practice identified in the review was usual and how any problems could best be addressed.   1.4 The Panel considered at all stages how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately, when possible.   2 Parallel processes   At the time of the review there was consideration of prosecution of FH for the sexual abuse of his siblings. There were also care proceedings with regards to FH and his siblings who became the subject of full care orders in 2016. At this point, FH was receiving support in a residential treatment unit and his siblings were in foster-care.  Final 14-Dec-17  31               3 Family input to the review  The lead reviewers and a member of the review team met with the mother, the maternal grandfather and the maternal aunt. As the father had no contact with the children or professionals for the period covered by the review he was not consulted. He was advised however that the review was taking place and will be given the opportunity to see the final report prior to publication. Consideration was given to involving the children in the review, however the criminal proceedings, and their age, made that problematic so, following discussion, it was agreed by the review team that this would not happen, but that the review would critically evaluate the steps that agencies had taken to establish their wishes and feelings. Prior to the publication of the report representatives of the safeguarding board met with FH’s mother and other family members and shared the report with them. They asked for a number of minor changes to be made to the report on matters where their understanding of events differed from the professional records. None of these have affected the findings, learning or recommendations of the report.        4 Methodological comment and limitations  The process of the review was comparatively smooth and, despite an active police investigation, it was possible for the Review Team to interview all the front-line staff involved with the family. There were follow-up meetings with front line staff to share immediate findings and whilst these progressed smoothly with CSC staff there were significant difficulties in arranging a meeting with health professionals. This mirrored the difficulties experienced by CSC staff in involving health professionals in case planning. In part this reflects the different nature of clinical work where staff diaries are committed for weeks ahead and professionals are required to give six weeks’ notice prior to changing the date of a clinic.    Final 14-Dec-17  32   Appendix 2: Glossary of terms  ADD-vance ADD-vance is a registered charity founded in Hertfordshire in 1996.  It provides specialist information, training and advice for professionals, as well as support for children, adults and families on issues relating to Autism, Attention Deficit Hyperactivity Disorder (ADHD) and related conditions. ADHD Attention Deficit Hyperactivity Disorder is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness. ASD Autistic Spectrum Disorder CAMHS Child and Adolescent Mental Health Services C-CATT CAMHS Crisis and Treatment Team a multi-disciplinary community team of senior clinicians, providing a short-term, intensive and flexible assessment and treatment packages of care for children with complex and challenging mental health problems and at high risk of harm to themselves or others. CHOICE The Choice and Partnership Approach (CAPA; York and Kingsbury, 2009) is a clinical system that evolved in Richmond and East Herts CAMHS and is now being widely implemented across the UK CIN Child in Need - A child is in need if s/he is under 18 and either s/he needs extra help from Children’s Services to be safe and healthy or to develop properly; or s/he is disabled. CSC Children’s Social Care  CSW Consultant Social Worker GOSH Great Ormond Street Hospital HARP Hertfordshire Access to Resources Panel LSCB Local Safeguarding Children Board Section 47 Enquiry Refers to section 47 of the Children Act 1989 which gives local authorities the duty to ‘make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare’. Statement of Educational Needs A Statement is a document which sets out a child's special educational needs and any additional help that the child should receive. Thriving Families Thriving Families is a holistic, intensive, family intervention service. TYSS The Targeted Youth Support Service  Final 14-Dec-17  33    Final 14-Dec-17  34  Appendix 3: Bibliography Naomi Adler a. & Joseph Schutz, Sibling Incest Offenders, Child Abuse & Neglect, vol. 19, no 7, pp 811-819, 1995 copyright © 1995 Elsevier Science Ltd  David Finkelhor, Childhood victimization: Violence, crime, and abuse in the lives of young people (interpersonal violence) (p. 92). Oxford University Press. Kindle edition. Working Together to Safeguard Children, 2015 Daniel Salter, Dean Mcmillan, Mark Richards, Tiffany Talbot, Jill Hodges, Arnon Bentovim, Richard Hastings, Jim Stevenson, David Skuse, Development of sexually abusive behaviour in sexually victimised males: a longitudinal study. NSPCC, Research In Practice and Durham University, An evidence-informed operational framework for children and young people displaying harmful sexual behaviours. Publication details: [london]: nspcc. http://email.nspcc.org.uk/c/1cpqbwe2ftzx3dtwcw6nrgym  