Two siblings, Child A and Child B, both under 5-years-of-age, removed from the care of Special Guardians after the male partner was found to be seriously physically and sexually abusing them, in May 2015. There had been concerns for the welfare of both children throughout their lives. They both had special needs, as did their birth parents. There had been extensive involvement with health and social care agencies and the Family Court, which had placed the children with a couple, Mr K and Ms L, under a Special Guardianship Order. A number of criminal charges were brought against Mr K and he received a lengthy custodial sentence. Ethnicity or nationality is not stated. Findings: there were overall concerns about the way the local authority approached the task of planning the care of the children; neither of the Special Guardians had any experience of parenting nor with looking after children with disabilities; the particular vulnerabilities arising from these children should have been given greater weight; there were reported injuries which were not investigated. Recommendations for the LSCB: to highlight the particular vulnerabilities of children with disabilities; to require the local authority to look at its arrangements for working with families where there have been long standing child care concerns; the use of family group conferences; the arrangements for assessing whether siblings in care should be placed together or separately; and the use of Special Guardianship with particular reference to the involvement of the Permanent Placements Panel.
      
 Title:  Executive summary for Child A and Child B: serious case review. LSCB: Oxfordshire Safeguarding Children Board Author: Kevin Harrington 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.                              1 Serious Case Review, Published 01 03 17  Executive Summary for Child A and Child B Serious Case Review  Oxfordshire Safeguarding Children Board (the Board) conducted a Serious Case Review (SCR) after it emerged that two young children had been seriously abused by a man. He had been looking after them, with his female partner, under a Special Guardianship Order. The children had previously been in the care of Oxfordshire County Council (the Council) and the Council’s Children’s Social Care (CSC) services had been instrumental in arranging for the children to live with the Special Guardians. This report explains what happened and summarises the key findings of the SCR.   Key events Child A and Child B are siblings, both aged under five at the relevant times.. They have a range of physical and learning difficulties. Their parents have learning disabilities and have received social care services as a result. Child A and Child B have siblings who are not cared for by their parents. There is a background of significant contact with child care agencies across both parents’ extended families. Both Child A and Child B have been subject to Child Protection Plans.  Both Child A and Child B left the care of their parents as young children and the local authority in due course instituted care proceedings. Child A was then looked after in two foster placements and Child B was looked after within the extended family.  The local authority agreed to a family request that there should be a Family Group Conference (FGC) to discuss arrangements for the future care of the children. At this FGC the couple who were to become the children’s Special Guardians came forward. One of them has a distant family connection to the children and they expressed an interest in caring permanently for the children. They had no children of their own and had been together for about three years.  CSC assessed the couple and supported their application to the courts to care for the children. The outcome of the legal proceedings was that Special Guardianship Orders were made in respect of both children, with a Supervision Order of one year’s duration to the local authority.  The children lived with the Special Guardians for about a year. During that time the family received extensive and specialist services from the local authority and the NHS. At one point one of the children was seen to have bruising which specialist medical staff felt to be consistent with inflicted injuries. This was considered under formal safeguarding arrangements but it was decided that no further action be taken.  There were two other occasions when one of the children was seen to have facial bruising. On each occasion a day care provider contacted a social worker who advised that no further action was necessary because the children were exhibiting physically harmful behaviour and therefore likely to have bruises.  Eventually the female Special Guardian contacted police. She had found evidence that her partner was very seriously abusing the children, sexually, physically and    2 Serious Case Review, Published 01 03 17 emotionally. Her partner was arrested and subsequently received a lengthy custodial sentence. The children were removed from the Special Guardians and now live with foster-carers (where they are well and happy).  Findings of the serious case review A number of learning points and concerns about practice within and between agencies are identified in the SCR. However it is right to say at the outset that there was absolutely no indication that the children might be abused so seriously and extensively, within the Special Guardianship placement. It is also right to say that the SCR recognised that many individual staff across the agencies had displayed great commitment and compassion in their work with these children.  The SCR identified an overall concern about the way in which the local authority approached the task of planning the care of the children. There was an unevidenced optimism that various arrangements within the children’s family would meet the children’s long term needs, which were special and demanding. The review found that the option of removing them from their birth family should have been given greater weight at a much earlier stage. There was also a lack of rigour in the Council’s approach to determining what weight should be given to the importance of the children being placed together, when they had spent little time together before living with the Special Guardians.  Neither of the Special Guardians had any experience of parenting, nor any experience of looking after children with substantial disabilities and disadvantages, nor any strong, enduring relationships with the children. They almost drifted into the children’s lives yet became their legal parents. The SCR expressed some concerns about how this had happened, firstly in respect of the FGC. The FGC process may not have adequately challenged the emerging plan and in fact may have provided an unwarranted legitimacy to the proposed arrangements.  The legal proceedings which culminated in the Special Guardianship Orders were complex. This was related to associated developments across the extended family, and some differing professional views between the Council and the Children’s Guardian about various courses of action. Ultimately however it is agreed that all matters were considered fully and properly by the Court before making those orders. There is no indication that any agency failed to meet any significant statutory or good practice requirements in the legal proceedings.  While plans were being made for these children the government was also reviewing the use of Special Guardianship1. That review was prompted by a range of factors including evidence of some matters identified in this review  insufficient assessments of prospective Special Guardians  no reference to a Permanent Placements Panel when making an SGO plan  SGOs being awarded along with a Supervision Order, indicating an inappropriate degree of ambiguity in a permanent placement  inadequate support / intervention from agencies post-placement, particularly when new needs or concerns emerge                                             1 SGR_Final_Combined_Report.pdf    3 Serious Case Review, Published 01 03 17 The government has made a number of changes to the arrangements for Special Guardianship to address these issues.  The particular vulnerabilities arising from these children’s disabilities should have been given greater weight. Children with disabilities are known to be much more likely to be abused than non-disabled children. In this case there were concerning aspects of the children’s’ presentation after the placement with the Special Guardians which were noted by staff and might have given greater cause for concern. There was a tendency too readily to conclude that distressed behaviour was a consequence of early neglect and then the changes in the arrangements for the children’s care. Agencies need constantly to remind staff that children with special needs can display similar behaviour to children who are distressed as a result of abuse  There was one specific missed opportunity, when one of the children was found to have suspicious bruising and child protection arrangements were triggered. There were aspects of that episode, including medical evidence and concerns about the presentation of the male Special Guardian, which should have prompted a more thorough investigation. Police too quickly came to the conclusion that they could withdraw from the enquiries when there was still a clear possibility that the injuries were inflicted and when some further enquiries could have been made. There were too many attendees at a Child Protection conference. The carers were in attendance throughout which probably inhibited discussion.   There were then reported injuries which were not investigated. Overall the desire for the placement to be successful caused routine child protection processes to be disregarded or used with insufficient thoroughness.  Recommendations for the Board from the serious case review The Serious Case Review makes the following recommendations to the Oxfordshire Safeguarding Children Board: 1. The Board should use its arrangements for disseminating the learning arising from Serious Case Reviews to highlight the particular vulnerabilities of children with disabilities.  2. The Board should require the local authority to demonstrate that it has used the findings of this review to inform its arrangements for care planning for “looked after” children with particular reference to:   Working with families where there have been long standing child care concerns  The use of Special Guardianship, with particular reference to the involvement of the Permanent Placements Panel  The use of Family Group Conferences  The arrangements for assessing whether siblings in care should be placed together or apart 