15-year-old child, Perry, who suffered a serious injury in April 2015 as a result of poor physical care and hygiene. Perry's father was convicted on four counts of neglect and sentenced to four years imprisonment in February 2017. Perry and three siblings went to live with their mother and received support as children in need. Perry's parents separated in 2008 and the children lived with father who refused to allow them any contact with mother. Siblings were subject to a child protection plan for neglect between December 2010 and July 2012. Referrals in 2014 resulted in further involvement by social workers and other professionals through a child in need plan. There were allegations of sexual assault of one of the siblings by a young adult male living in the household and concerns around poor living conditions and the physical care of the children. Key findings include: the need to recognise the potential for harm from neglect; the need to have high expectations; collating evidence about risk, vulnerability and resilience more systematically; having strategies to respond to parental resistance; identifying who is living in households; avoiding the use of euphemistic language which obscures professional communication and understanding; and listening to the views of children and assessing their level of understanding. Makes recommendations for the LSCB to consider including: do they have sufficient information about the use and effectiveness of local assessment resources, including guidance on identifying and responding to children at risk of significant harm from neglect?
      
 Title:  A serious case review under Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006: ‘Perry’: the overview report. LSCB: Nottinghamshire Safeguarding Children Board Author: Peter Maddocks 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.                           FOR PUBLICATION Page 1 of 56            A serious case review under Regulation 5(1) (e) and (2) of the  Local Safeguarding Children Boards Regulations 2006  ‘Perry’  The overview report   Commissioned by the  Nottinghamshire Safeguarding Children Board  August 2017   FOR PUBLICATION Page 2 of 56 Index  1 Introduction ................................................................................................... 4 1.1 Context of the serious case review ............................................................... 4 1.2 Rationale for conducting the serious case review............................................ 5 1.3 The methodology and scope of the serious case review ................................... 6 1.4 Information about Perry and the family ........................................................ 8 2 Summary of contact by services and significant events ......................................... 12 2.1 Summary prior to January 2013 ................................................................. 12 2.2 January 2013 and CAF ............................................................................. 12 2.3 Referral to MASH and social work assessment ............................................. 13 2.4 Referral to the Supporting Families Service.................................................. 15 2.5 Involvement of MAT and education welfare service in Derbyshire ................... 16 2.6 Referral to Nottinghamshire MASH from Derbyshire MAT .............................. 19 2.7 Completion of assessment and allocation as CIN December 2014 .................... 20 2.8 February 2015 concerns increasing about neglect and Perry feeling scared of males in the house ............................................................................................ 21 2.9 Contact by school with children’s social care services .................................... 22 2.10 Perry presented at hospital by school ......................................................... 22 2.11 Referral to GP ........................................................................................ 24 2.12 Strategy meeting .................................................................................... 24 2.13 Decision that children cannot remain with father ......................................... 24 2.14 School report further concerns and Perry presented at hospital ...................... 25 2.15 Summary of contact with Humberside social care services ............................. 26 3 Appraisal of professional practice in this case ..................................................... 28 3.1 Responding to neglect ............................................................................. 29 3.2 Voice of the child and understanding their personal and family history ............. 31 3.3 Risk from inappropriate contact and relationships ........................................ 32 3.4 Communication between professionals ...................................................... 34 3.5 Use of legislation and safeguarding pathways .............................................. 35 3.6 Quality of assessment and plans ................................................................ 39 3.7 Parental resistance ................................................................................. 41 3.8 Use of the local escalation processes .......................................................... 43 4 Analysis of key findings for learning and improvement ......................................... 44 4.1 Cognitive influence and human bias in processing information and observation . 44 4.2 Family and professional contact and interaction ........................................... 46 4.3 Responses to information and incidents...................................................... 47 4.4 Tools to support professional judgment and decision making ......................... 48 4.5 Management and agency to agency systems ............................................... 49 4.6 Issues for the Nottinghamshire Safeguarding Children Board to consider in regard to learning and improvement ............................................................................. 51 4.7 Recommendations .................................................................................. 51 4.8 Issues for national policy .......................................................................... 52 Appendix 1 Terms of reference identified by the serious case review team for further investigation by the key lines of enquiry: .................................................................. 53 Appendix 2 Membership of the case review team ...................................................... 55 FOR PUBLICATION Page 3 of 56 Appendix 3 Biographical summary of the independent reviewer ................................... 56  FOR PUBLICATION Page 4 of 56 1 Introduction 1.1 Context of the serious case review  1. This serious case review examines the appropriateness of professional support given to a 15 year old child (referred to as Perry for the purpose of the review1) who was diagnosed with a serious injury in April 2015 arising from emotional abuse and neglect.  2. Finalisation of this serious case review and publication of this overview report was postponed pending the outcome of the parallel criminal process associated with the events and information described in this report. The father, with whom Perry and the three other siblings were living up until 2015, was convicted in January 2017 on four counts of neglect and was sentenced to four years imprisonment in late February 2017. Up until that point it had not been possible for the independent reviewer or for any other member of the review panel to have any contact with Perry or any sibling or with either of the parents. This was at the request of the Crown Prosecution Service and of the police to avoid compromising what had been a long investigation. After the criminal proceedings had been concluded, Perry and mother agreed to a meeting with the independent reviewer and the Nottinghamshire Safeguarding Children Board Development Manager in late April 2017 and the finalisation of this report.   3. In the spirit of candour, the nature of the injury to Perry, occurring as result of extended poor physical care and hygiene that was in plain sight of several people and organisations, put this into the category of an injury that could and should have been prevented. Several professionals recognised that neglect was a serious threat and several individuals were working diligently and beyond the remit of their professional roles to improve Perry’s circumstances over several months. Some other professionals did not share the same level of concern as others.   4. The review’s task, in compliance with government guidance set out in Working Together to Safeguard Children (2015), is to address why, despite concerted effort on the part of individual professionals, it was not more effective and what can be done to improve future arrangements and inter-agency working and to better safeguard and promote the welfare of children.   5. A key learning message from this review is the importance of all professionals understanding and having the confidence to use and to navigate the relevant escalation processes to ensure that the most appropriate response is being given by the correct professionals in a timely fashion. Individual professionals can become overloaded or disorientated by a variety of factors that can include workload pressures as well as for example the cognitive and emotional challenges associated with dealing with the complex and chronic neglect2. This was a parent who appeared                                         1 To help give confidentiality and privacy to the children, there is no reference to the gender of any of the siblings. Perry is a unisex name. The usual pronouns of ‘he’ or ‘she’ are substituted with ‘they’ or ‘their’ for example (and the subsequent impact on grammatical convention is acknowledged).  2 Chronic neglect being is defined and understood as one or more needs basic to a child’s healthy development not being met, the neglect is perpetrated, by commission or by omission, by a parent or caregiver and the neglect happens on a recurring or enduring basis. FOR PUBLICATION Page 5 of 56 to the various professionals to love his children despite his haphazard parenting, the quality of which he appeared able to improve temporarily when sensing there was an escalation of likely intervention, for example through the possibility of court action or other measures.   6. Another key learning message is that whatever the motive or circumstances of a child’s neglect, it can pose a serious threat of emotional and physical harm, and in a minority of cases can even be life threatening.   7. The review describes and analyses the extent and quality of contact and involvement of services with Perry and the three siblings who had been the subject of historical concerns about neglect. There had been a child protection plan between 2010 and 2012 as well as involvement through child in need plans up until December 2012 and the case being formally closed by children’s social care services in January 2013.    8. For the purpose of clarity the use of acronyms is kept to a minimum that is possible. Family members are referred to by their relationship to Perry such as mother, father or sibling.  The eldest sibling is Sibling 1 and the youngest of the four siblings is Sibling 3. Perry is the second eldest. Professionals are referred to by their roles such as teacher, school nurse, GP, police officer or social worker for example. Four adolescent males (Boy 1 through to Boy 4) are also referenced in the report and their relationships and the significance for including in the report is described at the relevant points.  9. Two areas are identified in the report. Nottinghamshire is where the children lived with their father and the majority of services contributing to this review are located in that county. School 1 is a primary school and School 2 is a secondary school both of which are located in Nottinghamshire. Derbyshire is the second area identified. Sibling 2 attended a secondary school (School 3) in Derbyshire and there was involvement by the multi-agency team (MAT), education welfare and school nursing services.   10. A third area is generically referred to as Humberside. This is the area where mother lives and where the siblings have moved to. In the interests of giving the siblings confidentiality in their new location and the fact that the review is not focussed on any significant input from that area, the particular local authority is not identified in this report.  1.2 Rationale for conducting the serious case review  11. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires local safeguarding children boards to undertake a review in accordance with the criteria and procedures that are set out in chapter four of Working Together to Safeguard Children (2015).  12. A local safeguarding children board should always undertake a serious case review when a child has been seriously harmed and abuse or neglect is either known or is suspected and there is cause for concern as to the way the authority, the local safeguarding children board or other relevant persons have worked together.  FOR PUBLICATION Page 6 of 56  13. The circumstances of Perry’s injury and admission to hospital was discussed by the serious incident review sub group of the Nottinghamshire Safeguarding Children Board on the 9th September 2015.  The panel agreed that the criteria for a statutory serious case review were met. The serious harm to Perry appeared to be the result of neglect and there were issues to be examined in regard to what different organisations had known about Perry.   14. The recommendation was ratified by Chris Few, the independent chair of the Nottinghamshire Safeguarding Children Board, on the 14th September 2015. Ofsted and the National Panel were advised of the review being commissioned on the 16th September 2015.  15. The expected timeline for completion of a serious case review described in national guidance is six months from the date of commissioning. The timeline for completion of the review is determined by the independent chair of the local safeguarding children board who can take account of factors that may have an impact on the timeline. This includes parallel processes such as the police investigation of the circumstances of Perry’s injury described earlier in the report.    16. The overview report is the property of the Nottinghamshire Safeguarding Children Board as the commissioning board and will be the final and public record when it is published.   1.3 The methodology and scope of the serious case review  17. The review was conducted from the outset on the basis that this overview report would be published in full and without redactions.    18. The methodology used to conduct the serious case review draws on best practice in proportionately balancing the need for sufficient rigour in regard to investigating the circumstances of professional involvement with Perry and siblings given the public interest issues associated with the case3, taking account of the parallel criminal investigation and securing the level of appropriate and informed reflection about the complex human, legal and organisational systems for the purpose of learning and improvement.   19. The methodology combined an investigatory model for collating information from agencies with elements of a learning review model for analysing the latent underlying conditions and contributory factors that are influencing local systems and practice and reflected in the final chapter of the report which describes findings and recommendations.                                           3 The public interest relates to the circumstances under which the injury developed over time to a child who was the subject of extensive multi-agency contact and there had been longstanding concerns about neglect that had involved the use of child protection plans historically and is the subject of a statutory serious case review.  FOR PUBLICATION Page 7 of 56 20. The timescale of the review is from the beginning of 2013 when Perry and the three siblings were no longer subject of either a child protection or child in need plan until Perry’s admission to hospital in April 2015.   21. All services who had contact with Perry were required to provide a chronology of relevant and significant contact or information.   22. Organisations who were identified as having significant involvement with Perry were required to provide a written account of contact and agency analysis against terms of reference set out in the appendix that included an appraisal of learning for that service together with any action for implementing learning and improvement. These reports were provided by the following agencies:  a) Nottinghamshire Healthcare NHS Foundation Trust (NHCFT) regarding the provision of school nursing services;   b) Nottinghamshire Police in regard to contact with the family and associated people and the criminal investigation of the circumstances of Perry’s injury;  c) NHS Nottingham West Clinical Commissioning Group (CCG) in relation to the delivery of GP based health care services;  d) A report was provided on behalf of the three schools and associated educational support services in relation to Perry and siblings;  e) Nottinghamshire Children, Families and Cultural Services Children’s Social Care in relation to contacts, referrals and assessments in relation to child in need and child protection plans;  f) Nottinghamshire Supporting Families Service who attempted to provide support in the summer of 2013;  g) Nottinghamshire Youth Service in regard to Sibling 1, Perry and Sibling 2’s respective participation in activities at a local young people’s centre between January 2013 and November 2014;  h) Nottingham University Hospitals NHS Trust (NUHT); provided hospital treatment to one child in January 2013 (Sibling 3) for a broken toe before the admission of Perry in April 2015.  23. CAFCASS4 provided a summary of information about their brief contact in 2010 when father made a private law application to the family proceedings court in 2010. Information was sought from the multi-agency team (MAT) and school nursing service in Derbyshire. Information was also provided by the school in Derbyshire.                                           4 The Children and Family Court Advisory and Support Service. FOR PUBLICATION Page 8 of 56 24. Information was collated about;  a) The extent to which circumstances of the children were sufficiently known about and understood in regard to the needs, views, wishes and feelings of the children commensurate with their age and understanding;  b) The extent to which evidence of neglect was observed, recognised and understood by professionals in regard to promoting the safety and well-being of the children; this includes the clarity of understanding and knowledge about any relevant and significant history in regard to similar concerns over a longer time period;  c) The quality and rigour of professional response at a single and multi-agency level; this will include how significant information or incidents were dealt with through contact, assessment or enquiry and action planning;  d) The level of understanding about any factors related to culture, cognitive understanding or disability that had a bearing on engagement and interaction between the children and their father with different professionals;  e) The quality of advice, support and supervision for professionals and the oversight of arrangements for children at risk of significant harm;  f) Identification of any issues in regard to the capacity or resources of agencies across the continuum from delivering appropriate early help through to more assertive and statutory intervention when required.  25. The panel supporting the work of the review was comprised of senior and specialist agency representatives to oversee the collation and analysis of information and outcomes of the review and reporting to the Nottinghamshire Safeguarding Children Board. The panel representation encompassed senior and specialist professionals from children’s education and social care services, criminal justice and health organisations. Information is included in an appendix to this report along with the relevant biographical details of Peter Maddocks the independent reviewer and author of this report.   1.4 Information about Perry and the family 26.  Perry has three siblings, one of whom is older and two are younger. Father is long term unemployed. The area that Perry was living when with father is a predominantly white population as is Nottinghamshire as a whole compared to England. The area does not have a high concentration of deprivation.  27. Surprisingly, and in spite of the statutory involvement through a child protection plan and child in need plans, little information had been recorded by local services regarding the family circumstances before moving to Nottinghamshire or about the mother or the reason for the separation and her absence from the children’s lives. The school nursing service in Derbyshire who saw Sibling 2 at drop in sessions at the school FOR PUBLICATION Page 9 of 56 had the only record of any of the children regarding contact with mother which described them as having occasional contact which they looked forward to.   28. The parents have been separated since 2008/09 (the exact date is not recorded in documentation provided to the review) when the children were brought to live in Nottinghamshire in a rented house by their father who has an extended family living in the county. The parents had met when father was working in the Humberside area. The circumstances of the separation were not recorded in any assessments; mother told the independent reviewer that father left Humberside with the children after their relationship had broken down. Mother was staying with friends when father took the children to Nottinghamshire. According to mother the relationship had been in difficulty for several years and the pregnancies and birth of the children had been an effort to keep the relationship going. Father refused to allow any contact and had, according to Perry and to mother, told the children that mother did not want any contact with them. He threw away any birthday and Christmas cards sent to the children. He would visit friends in Humberside but never made arrangements for the children to see their mother during those visits. Perry and sibling 2 who met with the independent reviewer say that they just stopped asking about their mother.  29. Mother was living on benefits at the time of the separation and says that she had no help from any agency to secure a large enough property to be in a position to have the children returned to her. When the children returned to mother’s care in April 2015 she was able to acquire a four bedroom property within weeks.   30. While Perry and the siblings were living in Nottinghamshire mother was sent minutes of meetings such as the child protection conferences but no direct contact was discussed. Mother was told that services were working with the children and their father in Nottinghamshire; no help was provided to promote contact or to seek the views of the children or explore returning them to Humberside. Mother had contact with several different social workers although felt that it was only the final social worker in Nottinghamshire who spoke to her in clear terms and made things happen.   31. Perry’s family’s cultural and ethnic heritage is white British and English is their language. There is no record of any religious affiliation. There is no record of any assessed learning or physical difficulty or disability on the part of either parent (although in November 2014 father referred to having learning difficulties but this does not appear to have been followed up and explored). Apart from some mild post-natal depression for mother, there is no record of any mental health difficulties or illness and neither parent have any record of misusing alcohol or drugs (although there are references later in the report to some unresolved queries about father’s possible use of alcohol and drugs).   32. The children were the subjects of a child protection plan for 18 months between December 2010 up to July 2012 when the plan was stepped down to a child in need plan that ended in December 2012 (although the case was not formally closed by children’s social care services until January 2013). Concerns were focused on neglect. More recent referrals in 2014 had resulted in further involvement by social workers FOR PUBLICATION Page 10 of 56 and other professionals through a child in need plan. There had been allegations of sexual assault of one of the siblings by a young adult living in the household and there were concerns about the continuing poor condition of the home and the physical care of the children.   33. Sibling 1 the eldest sibling left School 2 in July 2014 and was not in employment or further education. Perry attended the same school. Sibling 2 the third sibling attended School 3 (located in Derbyshire) having transferred in September 2013 from School 2. Sibling 3 the youngest sibling attended a junior school (School 1) in Nottinghamshire.   34. When Sibling 1 arrived from Humberside they came with a partially completed formal assessment of special educational needs. Nottinghamshire ‘adopted’ this assessment and issued a statement of special educational needs describing Sibling 1 as having ‘significant learning difficulties in all areas.’ Sibling 1 was placed at School 1 with additional support. At transfer to secondary school father expressed a wish that Sibling 1 went to School 2 and this was agreed. At School 1 and School 2 the SENCOs5 worked with class teachers and education support services to plan and monitor Sibling 1’s educational progress. Sibling 1’s progress appears to have been in line with their abilities. Sibling 1’s statement was discontinued in April 2011 but additional support continued to be made available.   35. Perry also has general learning difficulties. Perry was given support throughout their time at School 2 and appears to have made educational progress commensurate with their abilities. The implications of Perry’s learning difficulties on the events leading to their hospital admission are discussed later.  36. Sibling 3, the youngest sibling, has moderate learning difficulties and followed an individualised curriculum at school with both academic and social targets. Sibling 3 had substantial support within school and Sibling 3’s needs were planned and monitored through an individual education plan. School maintained an individual education plan that was regularly reviewed and Sibling 3 had additional support funded from the High Level Needs Panel.  37. Sibling 2 the second youngest sibling is described by staff at School 3 as a child of around average ability. With appropriate attendance and support the school expected Sibling 2 to be capable of achieving five GCSEs at A-C level.   38. All four siblings appeared to enjoy attending their respective schools although there were concerns about Sibling 2’s late arrival (when taking the younger sibling to their school).  There were attendance issues for Sibling 2 in 2014 and for Perry in March 2015 in the weeks prior to the diagnosis of injury which is described in the narrative of the next chapter of this report.                                           5 Special education needs coordinator (SENCO) is a teacher who is responsible for special educational needs at school. All schools have a SENCO and they work with other teachers and with parents to make sure that pupils with special educational needs get the appropriate support and help they need at school. FOR PUBLICATION Page 11 of 56 39. There have been three different young males living in the household. Limited information was recorded about any of these males in regard to Perry and the three siblings although there was significant involvement by children’s social care services with two of the males. In addition, the siblings had contact with unknown adult males outside of Nottinghamshire via social networking websites. Further information is included in the following narrative summary.  FOR PUBLICATION Page 12 of 56 2 Summary of contact by services and significant events   2.1 Summary prior to January 2013  40. Historical records held by the universal health services describe a history of concerns about children’s developmental delay, neglect and not going to health appointments for the children when they were living with both parents in the Humberside area before the parents separated and father and the children moved to Nottinghamshire in 2009. Further information is included at the end of this chapter given to the independent reviewer as a result of inquiries for this review through the Humberside area’s local safeguarding children board.  41. Perry and the siblings have been known to universal and specialist services since coming to live in Nottinghamshire. There were recurring concerns about the quality of father’s parenting and the poor home conditions and services attempted to work with father.   42. In December 2010 the circumstances of the children were discussed at a child protection conference which decided that the children were at risk of significant harm due to the poor physical conditions of the home and the emotional neglect of the children. In July 2011 the continuing lack of improvement led to a decision to invoke the public law outline (PLO) process with a view to putting the matter before a court6. Legal advice was that an emergency application would fail for lack of evidence. There is no comment recorded in regard to an application by notice.   43. The invoking of the public law outline (PLO) and the prospect of legal proceedings apparently generated some progress and in July 2012 it was judged appropriate to step down from a child protection plan to a child in need. The review child protection conference that made this decision was not quorate being attended only by the social worker, a SENCO from one of the schools and father7. A child in need meeting was scheduled for September 2012. No minutes are recorded for this meeting although there is evidence of the meeting having taken place.   2.2 January 2013 and CAF  44. In January 2013 children’s social care services formally closed their involvement on the basis that father had achieved ‘sustained significant improvements’. There was                                         6 The PLO is a national procedure for when social workers concerned about the welfare of a child may be thinking about taking the case to court so that they can ask the court to make orders to protect the child. In most cases (that do not involve emergency protection for example) the Public Law Outline requires the social workers to arrange a meeting with the parent(s) to see if it is possible to reach agreement about what needs to happen to protect the child from harm, so that court proceedings can be avoided if appropriate and if not will then begin a formal process of giving notice. The PLO falls outside of the scope of the review’s timeline although comment is made later in the report. 7 The NSCB procedure requires as a minimum that at every child protection conference there should be at least two other professional groups or agencies in addition to children’s social care that have had direct contact with the child who is the subject of the child protection conference. FOR PUBLICATION Page 13 of 56 continuing support primarily through the school using what was then called the common assessment framework (CAF). Nationally, the CAF has subsequently been replaced by early help arrangements. These are usually, although not exclusively, deployed before difficulties escalate to requiring more intensive involvement such as child in need or child protection. The use of CAF in long-term neglect cases can unwittingly disguise inadequate care.  45. The CAF was opened on the 14th February 2013 by the SENCO at School 2. This described father as ‘caring, loving but struggling with domestic chores’. The siblings were described as ‘self-sufficient and able to take care of themselves in terms of washing and dressing’ although it was noted that one of the siblings had ‘matted hair and grubby clothing’.   46. A multi-agency meeting at School 2 on the 14th February 2013 was attended by the school nurse and was informed that the youngest sibling (Sibling 3) was needing help with self-care such as showering and hair brushing and that father was amenable to this help through School 1.   47. The meeting was told that the case was closed to social care and that school were going to lead on a CAF. It was agreed that a CAF review would be held on 27th March 2013. That review appears to have been postponed until the meeting in June 2013 that is described in the later paragraph below.  2.3 Referral to MASH and social work assessment  48. On the 5th June 2013 a youth worker made contact with the MASH (multi-agency safeguarding hub) to discuss concerns about the neglect of Perry and Sibling 1 whose spectacles had been broken for six weeks; both of the siblings’ clothing was dirty which made them the target for bullying. Father had also cut Sibling 1’s hair. Sibling 1 was also talking with a 60 year old male on a social networking website. The school was reported as having similar concerns.   49. There was discussion in the MASH with the former allocated social worker who advised the MASH that there was an ongoing CAF in place with the school acting as lead professionals. It was recorded that contact could not be made with school (although no reason is recorded). It was judged that the information was not ‘new’, the situation was of a ‘chronic nature’ and that the family function at a ‘low but adequate level’. It was recommended that the CAF would continue.   50. On the 10th June 2013 the MASH wrote to School 2 informing them about the concerns passed on by the youth worker regarding ‘Sibling 1’s unkempt appearance and possible contact with an older male’. The letter confirmed that MASH had decided to take no further action and asked the school to ‘address these concerns within the CAF’.   51. Two weeks later on the 19th June 2013 the youth worker made a second enquiry with the MASH. Sibling 1 had disclosed being hit by father the previous evening and had FOR PUBLICATION Page 14 of 56 also been pushed down the stairs. The spectacles were still broken. The siblings were suffering bullying and there were concerns about ‘mild learning difficulties and head lice’.   52. Three days later, on Friday the 21st June 2013, the team manager agreed that an assessment was required. The referral information recorded in MASH included a ‘copy and paste’ of the original concerns at the initial child protection conference in 2010 (and therefore querying the sustainability of father’s ‘improved parenting’). There is no reference to the social network contact with a much older male (and the implications for whether this was an indicator of potential abuse; it represented an inappropriate contact given the absence of any other apparent relationship).   53. A CAF meeting on the 27th June 2013 discussed ongoing concerns about the cleanliness of the siblings’ clothing. Father was invited and expected to attend the meeting but did not and neither did children’s social care services. The school nurse had phoned father to remind him about the meeting although had not got an answer. The school nurse was identified as the lead professional for the CAF. The school nurse updated the information in the CAF to create a ‘family CAF’ which was sent to all the professionals on 3rd July 2013. A further meeting was scheduled for 12th September 2013.   54. A social worker made a home visit on the 4th July 2013 for the purpose of speaking to father and the children in regard to the assessment that had been decided by the team manager two weeks previously. The social worker reported that that there was no disclosure of physical harm during the visit and that the children stated that father did not hit them. It is not clear if all the children were spoken to or whether father was present throughout during their discussion.   55. The social worker spoke with the school nurse on the same day and described finding the home cluttered and bedding that was dirty with mattresses that needed replacing. The school nurse had already been helping to clear clutter from the home (and is an example of a professional going beyond the remit of their role and considering the size of caseload for a school nurse). The social worker raised a query about Sibling 1’s level of learning and understanding. Father had raised whether Perry’s two other siblings had ADHD (attention deficit hyperactivity disorder) although the school nurse had no information about such a diagnosis although there was ‘global developmental delay’. The social worker planned to recommend that a core assessment should be completed; this would require allocation to the area social work team.   56. Coincidentally, father consulted the GP on the same day (4th July 2013) in the company of his mother presenting with symptoms of tiredness and a low mood. His mother suggested that he needed anti-depressants. Blood tests revealed no physiological illness and although he was offered a follow up consultation with the GP he did not attend. There was no contact between children’s social care and the GP and indeed no requirement for such contact to be made.   FOR PUBLICATION Page 15 of 56 2.4 Referral to the Supporting Families Service  57. A referral was made on the 5th July 2013 to the Supporting Families team (which was the targeted support service which no longer exists but had then just been established in October 2012. It is now a Family Service incorporating early help functions)8. The social worker apparently made the referral, in consultation with the health visitor, in regard to improving home conditions, developing boundaries and guidance, social isolation, developing routines and providing advice and support in regard to sexual health and development.   58. A joint visit was made to the home by the Supporting Families district co-ordinator and the social worker on the 23rd July 2013. They found the house to be ‘cluttered, dirty and untidy’. Father agreed that improvements needed to be achieved in regard to the children’s hygiene and he agreed to work with the Supporting Families service.   59. The core assessment was to be undertaken by an area based social worker who, according to a phone discussion on the 24th July 2013 with the school nurse, planned to close the case when the assessment was completed feeling that a CAF should be an appropriate level of help for the family. The school nurse did not know what the circumstances of the referral had been or who had made the referral.   60. On the 29th July 2013 the first visit to the home by the Supporting Families service found the home to be even more untidy than on the initial visit with litter and food debris in the lounge. All the children were present with their father and the siblings were described as being ‘adequately presented’. All of the siblings were seen on their own as well as with their father and they discussed improvements they wanted to achieve. When the family support worker made the follow up scheduled visit to the home on the 5th August 2013 they could not get a response but left a card. The worker attempted a further visit the same day but again with no response. The worker informed the social worker and apparently there were further unrecorded and unsuccessful attempts made to visit.   61. In July 2013, according to school nursing records, a transfer out to another school was completed for eleven year old Sibling 2 to move from School 2 to School 3 in Derbyshire in September 2013.   62. This was confirmed when the assessment was completed on the 23rd August 2013. The assessment noted that school attendance was good, there were no concerns about the siblings’ physical presentation and there was ‘acceptable’ improvements in the home conditions. The assessment noted that a referral had been made to the                                         8 The Supporting Families Service had a prescribed remit to deliver improvements to families with children who presented with at least three of the four factors that were being targeted by the government’s Troubled Families programme. The factors were; receipt of state benefits as a result of not working; children persistently absent/excluded from school; children involved in anti-social behaviour; a local criteria which in Nottinghamshire included social care involvement. The Troubled Families service has continued into a second phase and been incorporated into early help provision.  FOR PUBLICATION Page 16 of 56 Troubled Families’ Service (which father never engaged with). The assessment recommended that a CAF was appropriate.   63. When the children returned to school in September 2013, although there was some improvement in the cleanliness, some clothing was ‘inappropriate’ (this apparently referred to size). Hair cleanliness also remained an issue.   64. On the 9th September 2013 the siblings (with the exception of Sibling 2 who at their request was now attending school in Derbyshire) were discussed with the GP at a ‘Red Card’ multi-agency family liaison safeguarding meeting9. There are no written records of that discussion.  65. On the 18th September 2013 the Supported Families service spoke to the head teacher for the junior school who confirmed Sibling 3 was attending regularly although there were continuing concerns about hygiene.   66. On the 4th October 2013 children’s social care services were informed by the Supporting Families service that they had closed the referral as the father had not responded.   2.5 Involvement of MAT and education welfare service in Derbyshire  67. On the 6th March 2014 Sibling 2’s school (located in Derbyshire) requested support from the Derbyshire education welfare officer located within the multi-agency team (MAT) for the locality (there are local MAT services located across Derbyshire). Sibling 2’s school attendance had been poor for some time and had declined to just over 70 per cent by the end of February 2014. The Department for Education define school attendance of less than 85 per cent as representing persistent absence and therefore a matter for concern.   68. The referral from the school reported that they had tried to provide support to father who had told them he had three other children to look after and had admitted finding it ‘hard’. The school reported that no improvements had been achieved and that father was not responding to telephone calls or to letters. The school stated in the referral that they had been in contact with School 2 to inquire if they had observed any concerns in regard to Sibling 1 or Perry. School 3 had been told that there were no concerns about the older siblings (this contact had been made in February 2014).  69. The education welfare officer made an unannounced home visit on the following day to discuss the possibility of Sibling 2 moving to a school closer to home. There is little                                         9 The multi-agency family liaison safeguarding meetings (also referred by some people to as Red Card meetings) are held between GP’s, health visitors and school nurses to discuss children where there are identified concerns and take place within agreed timescales that are held at least quarterly and are deemed as good practice.  Practice nurses should be involved and any discussion should be documented within the child’s electronic patient SystmOne record and for this record to be flagged. There is further guidance being developed in the county which is discussed in the final chapter.  FOR PUBLICATION Page 17 of 56 detail recorded of that visit or even who was present. There is no record about home conditions, adverse or otherwise.   70. The education welfare officer made a follow up home visit ten days later on the 17th March 2014 and spoke with father about achieving an improvement to the morning routines in regard to Sibling 2 arriving at school on time. There was another discussion about the option of Sibling 2 moving to a school closer to home. Father was warned that if school attendance did not improve there would be further action. The record is unclear about what action was proposed although the inference is enforcement action through the court. There is no record of what the condition of the home was like. There was no further contact by the education welfare officer before they closed the case on the 19th June 2014 after Sibling 2’s school attendance had improved.   71. Just over three weeks later the school emailed the education welfare officer to report further concerns about Sibling 2’s attendance at school which had again declined (to 86 per cent) and homework was not being completed. The case was reallocated to another education welfare officer. There is no explanation about why a different officer was allocated the referral given the recent contact in June 2014. School 3 reported that Sibling 2 was not attending school due to stomach pains and headache and had been throwing their lunch away. An attendance warning letter was issued to father on the 8th July 2014.  72. The letter was followed up by a prearranged visit to the home by the education welfare officer to discuss attendance and strategies for getting Sibling 2 to school on time. Perry was seen during the visit and was described as being well presented.  There was no further contact with the education welfare officer until late October 2014 when school again were reporting attendance issues.   73. On the 13th September 2014 (a Saturday), the emergency duty team (EDT) received a fax from the Nottingham City EDT. The fax concerned a referral from an anonymous referrer who knew the family, believing that Sibling 2 was in a relationship with an 18 year old male and that on a social networking internet site there had been a mention of rape.   74. The Nottinghamshire EDT worker telephoned the referrer in order to clarify details. The referrer stated that Sibling 2 was 12 years old and that her boyfriend (Boy 4) was 18 years of age and had previously been in a relationship with Sibling 1. The referrer stated that there were pictures on the social networking site of Boy 4 and Sibling 1 and of Boy 4 and Sibling 2, and that there were comments about rape and ‘ragerape’.   75. The EDT worker looked at the internet pages and felt that the words were used in ‘the context of slang’. There were photographs but ‘they were not of concern and there was nothing to suggest rape or a relationship between Sibling 2 and Boy 4 although Sibling 2 did have a picture of a male asleep’ with a caption ‘Boy 4 sleeping awww’. The matter was discussed with the EDT team manager who stated that the case needed to be investigated further by the district team.  FOR PUBLICATION Page 18 of 56 76. On 15th September 2014, the team manager of the district team recorded that the social worker needed ‘to triage, speak with parents’ (sic) and it was rated amber priority as there was ‘no evidence to believe that Sibling 2 was at risk of immediate harm’. Attempts were made that day to telephone the father but were unsuccessful. It was therefore agreed with the team manager to write to father asking that he make contact with the team. It was recorded that there was ‘not enough evidence to progress otherwise’. No further action was taken and father did not make contact with the team.   77. Perry who had been a regular attendee at the local young people’s centre since December 2012 stopped going to the centre in October 2014. Sibling 1 who had also been a regular attendee since January 2013 stopped her attendance in November 2014. Sibling 2 had been a less regular attendee.  78. On the 28th October 2014 the education welfare officer and a MAT worker (multi-agency team) from Derbyshire made a home visit. The education welfare officer had attempted to visit four days previously but the door was not opened despite people being thought to be inside.   79. Sibling 2 had a bandaged knee and was limping. The lounge was described as cluttered, the carpets were dirty and the house smelt musty. Father agreed to let the two practitioners look around the house. Sibling 3’s ‘bed’ was a dirty mattress with a duvet and no cover. Sibling 3 said one of the siblings slept on the settee in the lounge. During the visit, Sibling 2 and Sibling 1 were in a bedroom with ‘a male friend’ who was not identified playing a computer game.   80. Sibling 3 was dirty and their hair was matted. In addition to the general clutter and dirt there were trip hazards all around the house. Father showed little engagement with the concerns. He did not want support and he declined subsequent contact with the early help service that was arranged after the visit.  81. A further visit on the 31st October 2014 by the education welfare officer raised ‘further concerns about conditions’. This was discussed with a manager in the MAT who instructed that a referral should be made to the MASH in Nottinghamshire. This was not actioned until the 13th November 2014.   82. The head teacher for the youngest sibling asked the school nurse to see Sibling 3 on the 11th November 2014 because of concerns about home conditions, poor hygiene and persistent head lice. Sibling 3 reported that conditions at home had got ‘messy again’ and that Sibling 2 was doing all the clearing up and Sibling 1 was bringing Sibling 3 to school. Sibling 3 was dressed in clean clothes although their hair was greasy and there was still evidence of head lice. According to the school nurse’s record the school were aware that the Derbyshire Targeted Support Service had made a referral to MASH (two days later on the 13th November 2014).   83. The following day, 12th November 2014, Sibling 2 told staff at School 3 that Sibling 1 had been raped by their boyfriend (Boy 1) during the summer school holiday (when FOR PUBLICATION Page 19 of 56 aged 16 years old). He had been allowed to stay in the house by their father. Boy 1’s sibling (Boy 2) had also been staying at the house and the two males had been ‘going out’ with Sibling 1 and 14 year old Perry. It was reported that initially Boy 1 had been going out with Perry but had turned his attention to Sibling 1.   84. Sibling 2 also reported that a pair of 11 year old Sibling 3’s knickers had been found in father’s car after Boy 1 had been working on the vehicle.   85. When the assistant head (who was also the safeguarding lead for the school) phoned father he had said that he believed that there had been ‘consensual sex’ involving 16 year old Sibling 1. Father said that that the matter had been dealt with by the parents and that the police had not been informed.   86. The school reported this information to the MAT and to the Nottinghamshire MASH on the 12th November 2014. The school also reported concerns about the home conditions. The school’s referral also reported that one of the siblings had been seen (by a targeted support work during a home visit) to kiss father ‘inappropriately on the mouth’. Children’s social care services decided that an initial assessment was required.   2.6 Referral to Nottinghamshire MASH from Derbyshire MAT  87. A referral by the Derbyshire MAT to the Nottinghamshire MASH was sent by secure email on the 13th November 2014. The referral states that the parents had separated six years previously. Father reported that he had learning difficulties and was taught how to do things by his father. Father had also described Sibling 1 and Perry having learning difficulties and that Sibling 3 had ‘global delayed learning’. The referral described a range of concerns in regard to neglect and father’s lack of engagement with help and support.   88. On the 17th November 2014 a youth worker had reported that Sibling 1 had disclosed that Perry had taken naked photographs of them self and sent the images to a 19 year old in the south west of England.   89. The social worker who made a home visit to speak to the children on the 19th November 2014 was prevented from speaking to Sibling 1 by father on their own. Very poor home conditions were described, and it was difficult to access the downstairs rooms. The social worker discussed with father the concern regarding Sibling 2 having reported that 16 year old Sibling 1 had been raped. Father stated that Sibling 1 was not raped but that there had been ‘sexual activity’ with a 17 year old who was a boyfriend. Father insisted that he had spoken to the boy’s parents and had ‘sorted’ the situation. He refused to allow the social worker to speak to Sibling 1 and asked the social worker to leave the property.  90.  On the 25th November 2014 a strategy discussion between the police and children’s social care services agreed that children’s social care services should undertake a single agency enquiry ‘unless Sibling 1 wished to speak with the police’. It is not apparent that the obstruction of the social worker by father was discussed. FOR PUBLICATION Page 20 of 56  91. On the 2nd December 2014 a parent of another child at the school reported an online posting by Perry on a social networking website about having sex with dad. The social worker spoke with Perry who reported that it was only Sibling 1 who used the account (the siblings apparently all had access to each other’s online accounts).  92. On the 6th December 2014 a referral was sent to Nottinghamshire Police from Derbyshire to report an historical allegation that Sibling 3 had been indecently assaulted. The allegation had originated with Boy 2 telling his then girlfriend (Sibling 1) in September 2014 that Boy 1 had indecently touched Sibling 3.  93. This information was logged against the name of the male rather than Sibling 3 and therefore was not known about until the review identified the third party reference to it. There is a discrepancy in the record of information between the police and children’s social care services about this information. The police have described written and telephone communication about the allegation of indecent assault which was not explicitly recorded in children’s social care services. What has been established is that Sibling 3 along with the siblings were interviewed by a social worker and no disclosure or allegation was made about Boy 1. It is also apparent that the specific allegation was not explored in any interview.   94. The information was the subject of a strategy discussion between the police and children’s social care services although there was not an agreed record of what was discussed and agreed.    95. The police and children’s social care services concluded in December 2014 that Sibling 1 had not been raped although had experienced sexual contact that had ‘caused distress’. Children’s social care reported that all of the children had been spoken to individually at school although there is no detail recorded. Sibling 1 and father did not want the police to be involved.   2.7 Completion of assessment and allocation as CIN December 2014  96. The core assessment that was completed on the 22nd December 2014 following the s47 enquiries noted the number of previous assessments in regard to neglect and poor home conditions and that it was a persistent and continuing cycle of limited improvement. There is reference to Sibling 1 and Perry using the internet (although no detail is recorded or evidence of referencing back to the transfer of inappropriate photographs over the internet). Father was also said to be using cannabis although, again, no detail is recorded.   97. It was decided that an initial child protection conference should be convened if there were ‘any issues with engagement or concerns regarding home conditions and parenting boundaries’.   98. The assessment recommended that a child in need (CIN) plan should be developed; this was written the same day and apparently as a desk based activity (as opposed to FOR PUBLICATION Page 21 of 56 working with father, children and others). The plan identified the following requirements; the siblings to be ‘presented appropriately in order for them to feel confident and prevent social isolation and resolve recurring head lice, self-protection on the internet, self-protection around relationships, self-esteem and vulnerability, building trusting relationships to gain the children’s wishes and feelings via direct work, to supervise the children on the internet, to attend school on time, consider father’s low mood and his learning capacity, management of the home conditions to an acceptable level and promoting contact with mother’. All of the actions were to be reviewed in six weeks.   99. The case was transferred back to the area social work team where it was allocated on the 29th December 2014. Other professionals were informed of the transfer almost two weeks later on the 12th January 2015.   2.8 February 2015 concerns increasing about neglect and Perry feeling scared of males in the house  100. There was no contact by children’s social care services with the family until February 2015. A letter sent on the 11th February 2015 to arrange a social worker’s visit to the home for the 20th February 2015 referred to attempted contact by phone although there are no dates recorded. Father refused to allow the social worker into the home on the 20th February 2015 because he ‘had company’. There is no further information about who this was.   101. A follow up visit on the 23rd February 2015 found the home conditions to be poor. The smell in the house was ‘very strong’ with a general body odour and the children were all in dirty unwashed clothes. The social worker attempted to go through the child in need plan that had been written by the social worker in December 2014 but father minimised the concerns.  102. Further concerns that were recorded during February 2015 included Sibling 2 arriving late at school, the children being in dirty clothing and smelling and being socially isolated by peers, being hungry and their (unsupervised and unrestricted) use of the internet. Father was also reported to be misusing alcohol (although nothing specific is recorded). He made clear he had no intention of working with social workers and would not attend meetings. He initially gave consent for the social worker to work with the children although later stated that the children wanted nothing to do with the social worker. The concerns were discussed at an ‘informal’ multi-agency meeting on the 4th March 2015 that was not attended by father.   103. A supervision discussion between the social worker and their manager on the 12th March 2015 agreed that if father was unwilling ‘to address the concerns a strategy meeting would take place’.  104. On the 24th March 2015 a member of School 2 raised concerns because Perry was smelling strongly of urine and had greasy hair. Perry was walking ‘as if in pain’.  Perry reported that Sibling 1’s boyfriend (Boy 3) was always at the house and ‘lies on top of FOR PUBLICATION Page 22 of 56 the bed with Sibling 1’. Perry said that he was calling Perry names and alleged that he was asking Perry to have sex with him. Perry disclosed feeling scared of him and hated going home when he was there.   2.9 Contact by school with children’s social care services  105. The information was reported to children’s social care services by the senior teaching assistant. The social worker was on leave and the teaching assistant therefore asked to speak with the duty manager who was ‘not available’. It was a support officer who dealt with the telephone contact and advised the school that the social worker was scheduled to visit on their return from leave in nine days’ time and that there were plans to convene a child protection conference.  This reference to plans to convene a child protection conference does not appear to have been based on advice or direction from a social worker or a manager.   106. Later the same day the deputy head teacher who was on gate duty at the end of the day observed Perry ‘clearly in pain, appeared to be shuffling along’.   107. Perry returned to school the following day and was still in considerable pain. Perry had not washed or changed their clothing and was walking with difficulty. Perry said that they had a pain in their stomach and confirmed that father had not given them any medication to manage the pain or made arrangements for Perry to see the GP.   108. The school decided that Perry needed to be taken to the hospital emergency service by a teacher for assessment and treatment and informed father accordingly.   2.10 Perry presented at hospital by school  109. Perry, accompanied by a teaching assistant, was presented at the hospital with abdominal pain and was at the hospital for some nine hours having first of all been seen in the emergency department and then transferred to the paediatric ward to provide further time for assessment. Perry was examined around the abdomen but no clothing was removed. Perry was diagnosed with a urinary infection and prescribed anti-biotic medication. Perry was examined by a consultant paediatrician who also saw father as well as Perry and discussed the current involvement of social work services. Father who was described as unkempt ‘was unclear’ about why children’s social care services were completing an assessment.  There was telephone contact between the hospital and children’s social care service duty social worker although, as previously mentioned, the allocated social worker was on leave. The consultant paediatrician asked to ensure that the social worker made a home visit on their scheduled return from leave four days later.  No referral was made to children’s social care. There was no contact between children’s social care services and the school until the 31st March 2015.   110. Perry did not attend school the following day; a home visit was made by the school attendance officer who saw Perry at home with father. Sibling 1 answered the door. FOR PUBLICATION Page 23 of 56 Perry returned to school on the 1st April 2015 saying that they felt better but ‘did smell really awful’. A teaching assistant took Perry home to have a shower and a change of clothing. The teaching assistant spoke with father to point out the very poor hygiene and advised that Perry should be seen by a doctor. Perry was expected to return to school later that day.  111. Children’s social care services undertook a visit to the home the following day, 2nd April 2015, and found the home conditions to be poor and father ‘taking no responsibility’ and was unwilling to work with social workers and refusing to allow contact with the children. He was advised that there would be no option other than to ‘escalate to an initial child protection conference’.   112. A subsequent discussion with the team manager over a week later on the 10th April 2015 agreed that a joint visit would be made to the home with a view to convening a legal meeting to discuss options through the court. The team manager agreed to speak with the service manager.  113. The social worker made a home visit on the 17th April 2015. Perry was in the shower and was not seen by the social worker. The social worker was told that Perry was off school with a urinary infection. Father confirmed that he had not taken Perry to the GP stating that he had bought over-the-counter ‘remedies’. He was advised to contact the GP.   114. The joint home visit that had been agreed over a week earlier on the 10th April 2015 was made on the 20th April 2015 by the team manager and social worker who found conditions to be ‘exceptionally poor’, describing debris everywhere, an infestation of flies, food on the floor, dirty crockery and their feet ‘sticking to the floor’. The smell of urine was ‘overpowering’. The team manager was particularly shocked by the amount of flies in the house. There was nowhere to sit in the living room and there were a number of trip hazards, including a chainsaw on the kitchen floor. The team manager tripped in the hallway. The level of uncleanliness in the kitchen was ‘extreme’; no work top was clear and it looked as if rubbish had just been thrown around the room. One ground floor room was totally full with furniture and clothing and was not accessible. Only the front room and kitchen were accessed during the visit.   115. The social worker stated to the author of the agency report that the father’s demeanour changed during that visit and that the social worker had felt quite intimidated by him. The social worker recalled that the home conditions had deteriorated since the previous visits.  116. Perry had not returned to school effectively since the 25th March 2015 when they had been taken to hospital from school and had not been taken to the GP or any other health centre.   117. Father maintained that he did not need to change anything and was in denial that any of the children were being neglected. He was asked to consider having the children FOR PUBLICATION Page 24 of 56 looked after under a voluntary arrangement (s20 of the Children Act 1989) and was informed that legal advice was to be sought about securing court orders.   118. The team manager and social worker contacted the police to request that photographic evidence was secured; they were advised that taking photographs was not a service provided by the police10. It was agreed that the team manager would convene a strategy discussion. This was done the following day, 21st April 2015 and arranged for the 22nd April 2015.   2.11 Referral to GP  119. Perry was taken to the GP on the 21st April 2015 prompted by the home visit the previous day as well as contact from the school nurse who had phoned to check on whether father had taken Perry to see the GP given the non-attendance at school since the Easter break. The social worker ensured that a GP booking had been made and informed the practice about the home visit and concerns which were entered on to the electronic patient record system. Perry was not physically examined by the GP during the consultation.  120. Perry was unable to produce a sample of urine to be tested (not unusual in itself) and arrangements were made for Perry to bring a sample in the following day. In the event it was delivered by the social worker when father had failed to bring a sample in; (there is of course no way of knowing if this was actually a sample from Perry and it is highly unlikely given the condition that it is now known that Perry was in by this stage). According to the receptionist, the smell from Perry was ‘like nothing (the receptionist) had smelt before’. The GP claims not to have smelt an odour.   2.12 Strategy meeting  121. The strategy meeting on the 22nd April 2015 agreed that a joint enquiry would be conducted by the police and children’s social care services. The meeting felt that an initial child protection conference would be of little value given father’s attitude and should proceed with a legal strategy meeting.   122. Father refused permission for social workers to look around the home when they visited on the 23rd April 2015. He claimed that Perry was better. He would not allow any photographs to be taken of the conditions in the house.   2.13 Decision that children cannot remain with father  123. The team manager discussed the case with the service manager on Thursday the 23rd April 2015 and agreed that making arrangements for the children to be placed with                                         10 If there had been a strategy discussion the police could have been party to the investigation and the collation of evidence including photographs.  FOR PUBLICATION Page 25 of 56 mother in Humberside should be pursued otherwise a legal planning meeting should be arranged. The checks with Humberside did not begin until the following week.  124. On 27th April 2015 a police check on the mother was returned to children’s social care. It stated that on 14th August 2001 there was a child abuse record following an anonymous caller reporting having seen various bruises on Sibling 1; that the house was chaotic, lots of dirty nappies had been seen and the caller felt that Sibling 1 lacked supervision. No action was taken by the police in 2001.  125. There is a discrepancy between Humberside and Nottinghamshire social care services about when checks in Humberside were started in April 2015. According to Nottinghamshire on the 28th April 2015, the Humberside social care service were telephoned following the emailed request for information. Due to a shortage of staff in Humberside no information was exchanged. According to Humberside the first contact was not until the 29th April 2015.   2.14 School report further concerns and Perry presented at hospital  126. On the 28th April 2015 the school contacted the social worker. Perry had returned to school; this was the first attendance since the 25th March 2015; she had a smell described as being ‘like sewerage’ and ‘rotting fish’. Perry was very pale. It was agreed that father would be asked to take Perry to the hospital.   127. Father took Perry to the hospital. He also smelt. Perry was wearing several layers of clothing and was resistant to removing any. Perry was admitted and the following day was persuaded by the school nurse who visited Perry at the hospital to allow a proper examination and the removal of clothing. Perry told the school nurse that a fear of being in trouble was the reason for the reticence in allowing an examination.    128. Perry had to be taken to an operating theatre for the removal of clothing and examination.  Perry was wearing multiple layers of clothing and underwear, and had been urinating and defecating through them for several days (the exact number is unknown).  Perry had head lice, was unkempt, and had very poor hygiene.  Extensive and severe wounds were uncovered encircling the tops of both legs, cutting through skin/tissue/fat down to the muscle layer, with the underwear completely embedded and stuck in to the wounds. Paediatric staff have commented that the condition of Perry was outside of anything they had previously observed in a child and were very distressed by the severity of the injuries.   129. Perry remained an inpatient, requiring plastic surgery, intravenous morphine and antibiotics until ready for discharge several days later.  130. On 29th April 2015, Humberside social care were again contacted. They stated that a response would be made that day. A police check was also requested on the mother’s partner, and it was confirmed that there was no trace of him on police systems.   FOR PUBLICATION Page 26 of 56 131. On 30th April 2015, the social worker transported Sibling 1, Sibling 2 and Sibling 3 alongside their mother to Humberside. The home address was seen, as were the sleeping arrangements. The home conditions were recorded as being ‘not of concern’.   2.15 Summary of contact with Humberside social care services  132. In interview with the agency reviewer for children’s’ social care services in Nottinghamshire the social worker stated that it was difficult to get information from Humberside social care services but that the information shared by Humberside was that the case had been opened and closed due to ‘low level s17 concerns’ (reference to section 17 of the Children Act 1989 and child in need) with some mention of head lice and smacking but a lack of evidence.  This information exchange was not recorded in the file but the social worker confirmed in interview that they knew this information prior to taking the children to Humberside on 30th April 2015.   133. The author of this overview report has made his own inquiries of the Humberside social care service through the local safeguarding children board. In a letter from Humberside the independent reviewer was told that the first contact from Nottinghamshire was on the 29th April 2015, to outline the circumstances of the case and ask whether there were any concerns known about the children’s mother who lived in Humberside.   134. Humberside say they were told that in view of the serious neglect suffered by Perry and the three siblings there was a possibility that the four children would move to Humberside to live with her. There is no reference to the contact by email and phone prior to the 29th April 2015 recorded by Nottinghamshire.  135. Humberside say that their worker provided what information was known to them at that time, which was limited to three contacts in 2000, 2004 and 2007. Supporting information was only available in relation to the 2004 and 2007 contacts, both of which were initiated by school services.  136. On 19th March 2004 Sibling 1 and Perry’s head teacher had contacted Humberside children’s social care to express concerns about both children. They were said to have some learning difficulties, appeared unkempt and regularly suffered with head lice. Sibling 1 was described as often being late for school and had said that this was because the parents slept in. The head teacher making the contact felt that the parents were not coping, having phoned the family at 11.00 and they were all still in bed. This information reflects the pattern of concerns that had been evident when the siblings were in the care of their father.   137. The children’s mother, had told the head teacher that Sibling 1’s behaviour was difficult (damage to house, swearing and drawing on the walls) and that Sibling 1 was sent to her bedroom in response to this behaviour.  The head teacher also said that other parents had informed the school that Sibling 1 was sometimes locked in the garden and that the siblings had been seen hanging out of a bedroom window. Advice FOR PUBLICATION Page 27 of 56 was offered to the school, but there is no further detail in the record in relation to the content of this advice.    138. On the 4th July 2007 the Behaviour & Educational Support Team (BEST) contacted Humberside social care services in relation to Sibling 1 with whom they had involvement. The  BEST team had visited the family following an incident which was described by Sibling 1 as resulting from mother brushing Sibling 1’s hair due to Sibling 1 having itching of the scalp.  The brushing was hurting Sibling 1 who was trying to get mother to stop. Mother pushed Sibling 1 who fell. The BEST worker stated that both mother and Sibling 1 were ‘ok’, the worker had addressed the issue with mother and she had agreed that this should not happen again. The BEST team were ‘to continue to offer support to the family if needed’ and agreed to make further contact with the social care service if there were any further problems.     139. There were no further contacts or referrals about the family, and Humberside social care services have no knowledge of the circumstances surrounding the children’s move from Humberside to the care of their father in Nottinghamshire.   140. According to the letter, following the contact from Nottingham on 29th April 2015, and in view of the seriousness of the children’s circumstances, Humberside children’s social care was ‘very keen to be as fully involved as possible in planning for them if they were to return to live with mother on a permanent basis’. They arranged for a consultant social worker (a specialist and experienced social work practitioner) to attend a multi-agency strategy meeting that was scheduled in Nottingham on 7th May 2015, where further information was to be shared. However, Perry’s three siblings were transported to Humberside on 30th April 2015 by the Nottinghamshire social worker to live with their mother; therefore by the time this strategy meeting took place three of the children were already living in Humberside.  Perry was still in hospital in Nottinghamshire.  141. Humberside social care services say that they were not asked to make any further checks, neither were they invited to be involved in making or assessing these arrangements. The position was subsequently clarified by Nottinghamshire social care services as one in which the mother had ‘exercised her parental responsibility in respect of the children, as opposed to social care services having placed the children in their mother’s care’.  Perry joined the siblings in Humberside when Perry was discharged towards the end of May 2015.   142. Following the strategy meeting on the 7th May 2015 the consultant social worker and the Humberside locality group manager were in contact with the Nottinghamshire social care team in relation to the details of the assessment of mother carried out by Nottinghamshire. There was no record of an assessment being completed by Nottinghamshire. A transfer meeting between Humberside and Nottinghamshire was held on 8th June 2015, since which time the children have been supported by Humberside children’s social care as children in need.    FOR PUBLICATION Page 28 of 56 3 Appraisal of professional practice in this case   143. Several people from different services tried hard to provide support. Good relationships were made between the siblings and particular professionals. All of the children went to schools with good pastoral care and all of the schools were active in making contact with other professionals. They were prepared to take action when they became very concerned about Perry’s physical health and presentation.  There was for example a good working relationship between School 2 and the school nurse who also took a close interest in the family and at one stage took responsibility for the CAF.   144. The youth workers made relationships with three of the siblings and made them feel welcome. These are the universal services that are so important in helping create resilience for children like Perry living in adverse circumstances and are in a position to raise concerns with specialist services.   145. There was effort to give support to father on several occasions and the referral to the Supporting Families service was an example of a service reaching out to work with father in spite of rather than because of any legal or service thresholds.   146. Although all of these services contacted children’s services at different times, this did not lead to action that was prompt and rigorous enough in really dealing with the neglected circumstances of Perry and siblings. None of the people who had concerns and were reporting these apparently knew how to escalate them when they were not getting the response they felt was required11. An example is the teaching assistant who despite asking to speak with a duty manager was only able to speak with a support officer. Similarly a consultant paediatrician who wanted to speak with the social worker (who was on leave) left a message and was neither informed about the background concerns of Perry or making a referral about Perry’s condition.   147. Some of the initiatives by professionals in daily contact with the siblings, well intentioned as they were and with Perry’s interests at heart, did not have the outcome that was required. Examples include using the CAF so soon after the CIN arrangement had been closed by children’s social care. The CAF, undertaken by professionals who had little or no previous contact or involvement, was undertaken on the premise that father was able to take concerns seriously, that he was ‘trying’, a ‘devoted and loving father’ and was putting his ‘needs ahead of the children’. In truth, the CAF helped disguise the fact that neglect was entrenched and that father was displaying resistance to professional concerns over many years. When contact was made with children’s social care early in 2013 the prevailing mind-set expressed through the MASH referral was that nothing had changed to require an escalation, at least initially.   148. A mind-set that saw neglect as a lower order concern, combined with the evident workload issues in children’s social care at the time created latent conditions in which                                         11 None of the services appear to have been aware of these processes despite recent communication strategies in the form of briefings to schools for example. FOR PUBLICATION Page 29 of 56 at every point that a contact was made the response lacked urgency, even in March and April 2015 when it was increasingly clear that children’s social care professionals were becoming concerned enough to raise the possibility of the siblings being looked after (although only with the consent of father). This slowness also characterised the making of referral for example from Derbyshire in October 2014.   149. The decision to take Perry to hospital in March 2015 to have medical treatment was a clear recognition about the extent of worry at school. The fact that this was done outside a safeguarding pathway involving the statutory agencies meant that the hospital staff were not sure who or what they were dealing with. A clear request for a safeguarding medical was what was required at that time with a summary of the background concerns. This required children’s social care to be taking a lead.   150. The assessments that were undertaken at different times were not detailed enough in several important respects and are described later on. Significantly, the neglect was never defined and analysed clearly enough; this had already an impact on the PLO proceedings back in 2011.   151.  The primary focus remained on physical neglect and missed a better more holistic enquiry into the emotional care of the siblings. The significance about information suggesting inappropriate and abusive relationships with non-related adults was not recognised within children’s social care and was not apparently shared with the police. The obstruction by father of social work inquiries was not discussed with the police. Children’s social care did not initiate strategy discussion with the police to discuss the concerns being reported and allow an opportunity to plan joint investigations.   152. A combination of factors that include the impact of long-term neglect on professional cognitive processing of information, flaws in how professionals escalate concerns effectively, the use of euphemistic language and workload contributed to the response given to Perry and the other siblings not being effective in preventing the injury.    3.1 Responding to neglect 153. Occasional lapses in hygiene have a distressing consequence for any child but are of a different order to the persistent and chronic neglect that erodes self-confidence, isolates a child and for Perry resulted in what should have been a preventable injury (or at least prevented its severity).   154. The consequence of neglect for Perry and the siblings was not sufficiently assessed and analysed by the services that had the statutory power and responsibility to intervene. In this case the police were given limited opportunity to consider the information that children’s social care were receiving.   155. Social care professionals not in daily contact with the children or their father, were less able to understand the significance of emotional and physical neglect in this household and the impact that it was having on the children. Knowledge of the family over several years developed a mind-set that this was a family that straddled the FOR PUBLICATION Page 30 of 56 boundary of just good enough care. Rather than seeing further reports of neglect in the context of cumulative abuse for a child it was initially processed as being consistent with the known and established history. This is important because it is social workers who are in a position to escalate intervention, using the courts if necessary to present evidence to secure legal powers and authority, and ultimately assume greater control and responsibility for children when parents cannot or will not address legitimate issues of concern. The use of legal proceedings is not restricted to circumstances when a child needs to be removed but can for example involve the use of supervision orders. When social care recognised that they needed to escalate their response it was delayed more than once.   156. Looking back through the information collated for the review it is difficult to determine what  had ever changed in regard to the conditions of the children and the attitude of their father to any of the help provided by such a variety of professionals over several years and it seems had begun before the children ever came to Nottinghamshire. Although there were marginal improvements, made usually as a result of threatened escalation in regard to school attendance for example, these marginal improvements were only ever short-lived.   157. Associated with this was the evidence of father becoming less co-operative and more confident about obstructing certain professionals such as social workers particularly from December 2014 onwards. These factors were not recognised at the time. These are issues that are regularly identified through reviews such as this.  158. The discussion and processing of information about neglect generally focussed on the physical condition of the children and of their home. In itself not very surprising given this is the tangible and observable evidence. It is less apparent how the emotional care of the children was inquired into and assessed. Too much reliance was given to the children not disclosing anything untoward and father giving positive reassurances on important issues such as the reports of sexual activity.   159. Superficially, the children and father were observed to have a good rapport. There is no record of exploration about what the children meant to father and what had motivated him to bring them to Nottinghamshire.  160. There is little information about the quality of emotional attachment of the children to their father (or to the absent mother) and what either parent meant to each of the children.   161. There is information that father found the emotional care of his four children as challenging as giving them good enough physical care. He does not appear to have been very engaged either in the physical care of his children, meeting their needs in regard to routines such as feeding them and getting them to school or in supervising them in the house. There is no information about social activities that he encouraged although there is evidence he used withdrawal of social activities such as the young people’s centre as a sanction.   FOR PUBLICATION Page 31 of 56 162. The children showed considerable resilience in spite of the deficient parenting they received. Some of that deficit in parenting was apparently ameliorated by the children, and in particular Sibling 2, taking on care tasks abrogated by their father. Sibling 2 does not have the level of additional needs that the three other siblings have in regard to cognitive and learning difficulties and it was Sibling 2 who was seen to be taking on adult responsibilities such as getting a younger sibling to school that involved a walk of several miles and contributed to Sibling 2 often being late for school.  Given Sibling 2’s quasi-carer responsibilities that were having a direct impact on important aspects such as educational attendance and participation, this deserved discrete assessment.    163. The children were often dirty and did not have regular meals. They lived in what is described as dirt and clutter. They were unsupervised at home, had unregulated access to the internet and some of the siblings were exposed to inappropriate sexual behaviour by young males allowed unsupervised access to the house.  There is evidence that some of the siblings were vulnerable to sexual abuse and exploitative behaviour in regard to issues such as the transmission of inappropriate images over the internet. The siblings were socially isolated and subject to some bullying.   164. An important factor in dealing with child neglect is exploring the tangible aspects of care being given (or not given) to children. A recurring theme in this family is the extent to which throughout the children’s lives they have been denied appropriate access to health care when required. The GP for example had very little contact with father or the children. This in turn also meant that there was little recorded base line information about the children’s physical health and development.   165. Denying access to appropriate health care throughout childhood in regard to routine developmental checks and immunisations as well as to consultation and treatment in regard to illness or injury is evidence that should have been considered in regard to neglect.    3.2 Voice of the child and understanding their personal and family history  166. Children and young people generally face internal and external barriers in talking openly about their feelings or disclosing difficult information about themselves or their circumstances. Additional complications arise when there are additional levels of difficulty associated with learning and cognitive functioning and the implications this has in achieving clear accounts.    167. The children’s difficulty in communication is referred to on more than one occasion although it is less clear how these were then considered in the organisation of important disclosure discussions. There is no record of an assessment of the respective learning and cognitive ability of the individual children and their respective level of understanding for example in regard to what are appropriate and inappropriate relationships. Too much reliance appears to have been given to the absence of disclosures (for example regarding allegations of sexual assault) and on more than one occasion a child refers to not wanting to get into trouble for sharing FOR PUBLICATION Page 32 of 56 information. It is not so much what children actually say, but rather what they are not willing to talk about.   168. Often, the behaviour of children and their physical presentation (clothing, cleanliness, weight, and demeanour) reveals what they might be experiencing, thinking, feeling or hoping for rather than any more explicit statements or disclosures. Children who suffer chronic neglect are far more likely to have feelings of low self-esteem, of feeling unloved and unwanted and this also has implications for disclosure.    169. The physical presentation of the siblings has been described in some detail already. There has also been reference to the developmental delays observed in the early years of the siblings and the ongoing global and learning difficulty of three of the siblings. Evidence about the degree of isolation the children appeared to experience has also been referenced.   170. Most if not all of the professionals who had contact with the siblings were largely unaware of any significant history of the children. There was an apparent absence of curiosity about the children’s relationship with their mother or her circumstances since the children moved to Nottinghamshire. Despite mother routinely receiving copies of minutes of meetings there was no other work or enquiries with mother. When the children were reunited with their mother in April 2015 it took place at the hospital where Perry had been admitted. The three children who met with the independent author described that meeting as very rushed.   171. Access to the children at important moments was controlled by father. For example when allegations about unwanted sexual behaviour or the use of the internet for transmitting inappropriate images were being reported. There was contrast between what the children disclosed away from home and how they presented when at home or when interviewed by a social worker for example.   172. Father was highly influential in persuading the siblings were doing nothing that was without their consent. There is little recorded evidence about how professionals developed an understanding about how far each of the siblings had an understanding about consent taking account of their respective ages and cognitive development.   173. High reliance was given on the children having a ‘warm relationship’ with their father but less sceptical attention given to other indicators such as his control of the children and their access to key professionals and the children’s ability to speak freely.   3.3 Risk from inappropriate contact and relationships  174. Several occasions when information was recorded indicated that the siblings could be at risk from inappropriate contact or relationships via the internet or in regard to young adults having access to their home. This information was shared with the police investigation during the review.    FOR PUBLICATION Page 33 of 56 a) The youth worker reporting information on the 5th June 2013 to the MASH (multiagency safeguarding hub) that Sibling 1 was talking with a 60 year old male via a social networking website;  b) The enquiry on the 13th September 2013 to the EDT about 13 year old Sibling 2 possibly being in a relationship with an unknown 18/19 year old. c) Sibling 2 telling staff at School 3 on the 12th November 2014 that her sibling, Sibling 1, had been raped by Sibling 1’s boyfriend (Boy 1). Sibling 2 also referred to his younger brother (Boy 2) who was also living in the household and was described as being in a relationship with 14 year old Perry. Father refused to allow social workers to speak to Sibling 1. The strategy discussion between the police and children’s services in December 2014 concluded that Sibling 1 had not been raped but ‘had experienced sexual contact that caused distress’.  d) Sibling 2 also reported that Boy 1 had been working on father’s car and afterwards a pair of Sibling 3’s (youngest sibling) knickers were later found in the vehicle.  e) School 3 reported on the 12th November 2014 that one of the siblings had been seen (by a targeted support worker during a home visit) to kiss father ‘inappropriately on the mouth’. f) The youth worker reported on the 17th November 2914 that Sibling 1 had disclosed that Perry had taken naked photographs that had been sent to an unnamed 19 year old living in the south west of England. There was further reference to concerns about the use of the internet in late 2014. g)  A parent of another child at the school reported on the 2nd December 2014 a posting by Perry on a social networking website a comment about having sex with dad. The social worker spoke with Perry who reported that it was only Sibling 1 who used the account. h) On the 24th March 2015 Perry who was smelling strongly of urine and was walking as if in pain at school told school staff that Sibling 1’s boyfriend (Boy 3) was always at the house and lies on the bed with Sibling 1. Perry said that this boy was calling them names and alleged that he was asking Perry to have sex.  Perry reported feeling scared of him and hated going home when he was there.  175. Father’s obstruction of social workers in talking with the siblings was not discussed with the police and the majority of the incidents or information summarised in the previous paragraph were not reported to the police until this serious case review had collated information. Father claimed that at the time any sexual relationships were consensual although this was contradicted by his assertion that he had spoken to the family of a young male to warn him off.   176. The allegation of rape by one of the boys was discussed by the police and social workers although it was only social workers who undertook any formal enquiries that were obstructed by father. Given the nature of the criminal allegation the police should have ensured they were leading the enquiries; it was inappropriate to delegate it to social workers.  FOR PUBLICATION Page 34 of 56  177. There is no recorded evidence about the circumstances of the respective incidents were investigated and no recorded evidence about how the different siblings cognitive and learning difficulties were considered in regard to issues about consent. It is apparent that at least two of the siblings were the subject of behaviour that made them feel afraid and upset.   178. The possibility that the siblings were at risk from potentially inappropriate contact and relationships was not recorded in any assessment or enquiry.   3.4 Communication between professionals  179. Achieving clear enough communication between busy professionals working different shift patterns using different IT and other information systems and across several different worksites is a recurring theme in reviews.   180. Significant communication between professionals is described in the previous chapter. This included the schools who had day-to-day contact with Perry and siblings and who recorded their concern about the physical neglect of the children and attempted to engage father with support from the school nurse. Sibling 2’s school involved the education welfare officer and MAT service.  The school that Perry attended with a sibling communicated a great deal with education support services. The youth service also contacted children’s social care services to report information.   181. The status of the information sharing was not always explicit. Was a specific phone a call an enquiry, a contact or the intention to make a referral? There is a pathway to provision framework that guides decision making which is intended to guide and inform all professionals about how decisions will be made in regard to information. However, some professionals probably assume that if they have contacted children’s social care and it is their intention to make a referral that this is how it will be managed. In fact, the decision as to whether information is to be processed as a contact or referral by the MASH or by children’s social care lies with that service. It is for this reason that clarity about the use of escalation processes are important and is discussed later.   182. The manner in which information was categorised and managed by children’s social care was influential on more than one occasion.   183. The referral in June 2013 was regarded by children’s social care services as not being new information. Some of this reflected a difference of view between social care services and other professionals about the seriousness and significance of neglect. Information about the children being subjected to unwelcome and inappropriate contact by adults was not sufficiently recognised partly because of the assurances that father gave.   184. The phone call on the 24th March 2015 made by the senior teaching assistant to children’s social care services provides an important learning point. Despite asking to FOR PUBLICATION Page 35 of 56 speak with a duty manager it was a support officer who took the call. The issue was not apparently escalated to the designated senior in school to pursue and equally there was no formal escalation to children’s social care services.   185. The police should have been party to the escalating pattern of concerns about the physical condition of Perry in March and April 2015. The condition of the children constituted a potential offence for the police to be aware of and the father’s pattern of obstructing access and enquiries with the children should also have been discussed with a view to the police supporting the investigation.   186. The home visit made by the social worker and team manager that resulted in a request to the police to take photographs should have instead have been a referral to the specialist public protection unit with a view to agreeing a strategy for joint investigation. If there had been a strategy discussion with the police prior to that home visit there would have been an opportunity to discuss whether a joint visit by police and social workers was appropriate.  187. The GP service was never approached for information during the assessments. The GP service should have been aware of the child protection plan that had been in place historically although would not have been updated about the subsequent referrals and assessments. If the GP practice had been updated, and if the GP had consulted those records, would there have been a different mind-set to the consultation in March 2015 for example. The level of contact by the youth service with three of the siblings was apparently unknown and they were not invited to participate in any multi-agency discussion.   188. The referral from the MAT in Derbyshire to the MASH in Nottinghamshire was almost two weeks after the home visit in October 2014 despite the manager in MAT issuing an instruction that the referral should be processed. There was change in management between the instruction being made and the new manager recognising that the referral was still outstanding two weeks later.   3.5 Use of legislation and safeguarding pathways   189. The decision to step down to a child in need plan in March 2012 was taken at a child protection conference that was not quorate; it was only attended by the social worker, the SENCO from School 2 and father (and chaired by an independent reviewing officer). Information provided by children’s social care services appears to have been more optimistic about conditions compared to the views of other professionals.   190. After children’s social care services closed their involvement in January 2013 the school and school nurse became the primary professional support to the children through a CAF. Arguably, this helped to disguise the significance of the neglect at least initially. None of these professionals had been part of the previous core groups. This contributed to a new set of professionals starting afresh with father who gave them an optimistic impression of a parent who was a ‘devoted and loving father’ and ‘was putting the needs of his (children) first’. It remains unclear the extent to which any of FOR PUBLICATION Page 36 of 56 the professionals who were directly in contact with father and the children from January 2013 onwards had a good enough knowledge about prior history.   191. In order to protect children, important powers are given to police and social workers in particular to conduct formal enquiries and take action to ameliorate any identified risk to a child. The effective implementation of those legal powers relies on a good understanding and application of the relevant frameworks and pathways for the police and social care professional staff to follow.   192. Some of those powers require authorisation through an application to court whilst others describe duties to make enquiries and in the case of the police will allow temporary removal of children12 when there is immediate concern about the safety or well-being of children. The point has been made that the police were not sufficiently informed by social care services about relevant information and therefore were not involved as much as they should have been in the enquiry processes in this case.  193. The spirit and the structure of the relevant legislation and statutory guidance is upon professionals exercising their powers when required in a timely manner. In examining Perry’s circumstances there was significant inertia during critical periods.   194. In November 2014, when a decision was made that a strategy discussion was required to discuss the allegation of rape made on Sibling 1’s behalf by Sibling 2, it was six days before the strategy discussion took place that decided on a single agency investigation by children’s social care rather than a joint investigation. The decision to conduct a single agency investigation was not appropriate given the nature of the allegation. There was a further week before the siblings were talked to individually by the social worker at their schools. A delay in undertaking any disclosure work with a potential victim and particularly for a child reduces the likelihood of information being given for any number of different reasons. More than once, one of the children referred to their concern about getting into trouble over information being given.   195. The delay to the making of enquiries has implications in regard to important issues such as any forensic evidence as well as increasing the likelihood of vulnerable child witness with a learning difficulty not being able to provide information.  196. The section 47 enquiry which only involved social workers was not completed for a month. Given the history of neglect and other information indicating inappropriate and unwelcome contact from young adults, it seems perverse that an initial child protection conference was not considered appropriate. It is not confirmed if a manager’s advice and direction was sought on this; none is recorded. The absence of a child protection conference removed an important opportunity to bring different                                         12 Section 46 of the Children Act 1989 provide police powers of protection (PPOP) to remove a child to a place of safety for up to 72 hours. The powers are intended to be used for exceptional circumstances that by definition are unforeseen. They are not intended to be used as an administrative convenience of not having to make an emergency application to a magistrate.  FOR PUBLICATION Page 37 of 56 services including the police to a round table discussion about the various risks to the children.   197. The decision to transfer the case to an area social work team in order to provide statutory help through a child in need plan was a continuation of involvement although nothing happened until March 2015 when there were further concerns being raised primarily by the school.   198. Although the case was promptly allocated to an appropriately experienced and qualified social worker it took their personal caseload up to 25 cases, 13 of which were children already subject to a child protection plan. Additionally, the social worker was on leave at the beginning of January 2015 when the case was transferred in to the team. Shortly after their return to work the social worker was allocated a further complex case which resulted in the child being removed, and it was this other case became the focus of the social worker over those weeks. There is further analysis in the findings later in the report.  199. Although it is apparent that a decision to undertake further section 47 enquiries was made in late March 2015 in response to the information coming into children’s social care these did not start until the 22nd April 2015.   200. The police were not party to the escalating concerns about neglect and were therefore not primed to participate in the process of making enquiries and collecting of evidence. This is not procedural convention; it is about jointly considering what information or evidence has been discovered so far and planning a strategy for making further enquiries and investigation.   201. The purpose of a strategy meeting between the police and social care professionals is intended to highlight the nature of concerns and risk and to agree a strategy for conducting enquiries and to review information from those enquiries.   202. If the police had been party, through a strategy discussion or meeting, to the concerns in March and April 2015 they would have in a better position to allocate resources to secure evidence in the home. Warranted police officers have powers to overcome obstruction that are not available to other professionals such as a social worker. In April 2015 that father prevented social workers from seeing Perry when they visited the home. Perry had also not been sent to school and father was reluctant to seek medical attention for the child. In cases where there are concerns regarding sexual abuse the on-call paediatrician for sexual abuse should be involved in the strategy discussion. This is a concern that has been raised in audit and in a previous serious case review (IN14) and has been raised at the Board.  203. Although social workers and other professionals clearly wanted to secure the engagement of father, this approach had shown little progress over several years. If social workers are unable to get sufficient cooperation and engagement by an adult with parental responsibility in making required improvements to keep a child safe, the social workers can seek additional powers through the court and involve for example FOR PUBLICATION Page 38 of 56 acquiring shared parental responsibility through a care order. These are usually done by giving notice and using the public law outline framework although there is provision for emergency applications ex-parte without notice.   204. There were two significant episodes where the use of legislation was considered by social workers prior to the diagnosis of Perry’s injuries in late April 2015. On both of those occasions it was apparent that there was concern about the children remaining in the care of their father.   205. The first occasion occurred outside the time line for the serious case review but is nonetheless relevant to later events and identifying learning for professional practice.   206. Legal advice was sought in July 2011 and it was agreed that the legal threshold for neglect was met although a court would need evidence regarding the impact on the children. The fact that evidence could not be identified reflected a weakness in the quality of information being collated and the analytical rigour in understanding the implications on the children rather than a lack of evidence. It highlights a weakness in how assessment of the neglect was undertaken at that time (information is provided in the final chapter about the subsequent work on assessment in the county).   207. The second episode occurred in April 2015. It began on the 2nd April 2015 when the social worker had returned from leave having been told about the school taking Perry to the hospital emergency service on the 25th March 2015.   208. The social worker clearly felt that the situation had reached the point of requiring a more authoritative approach through the safeguarding procedures although did not apparently discuss the concerns with the team manager until the 10th April 2015.   209. The social worker had a complex workload and was involved in legal proceedings with one of the other allocated cases. Whether it was the social worker having other more urgent demands or whether it was the unavailability of the manager for example is not clearly established. Information from the service has not clarified the reason for this delay. The agreement to make a joint home visit was not executed until the 20th April 2015. It was during this visit that the team manager and social worker attempted to persuade father to allow the children to be looked after.  210. An option available to the team manager and social worker would have been to consult a solicitor about grounds for either an emergency protection order or seeking an order by notice given they had clearly wanted to have the children taken out of the household. Other legal orders could also have been considered. In order to do this it also requires consultation with a senior manager. As events over the next few days demonstrated, their concerns were well founded although at the time they did not have evidence from other professionals or their own contact to suggest that any of the children were at immediate risk of significant harm. If there had been legal consultation it is unlikely that an emergency application would have been supported; the injury to Perry had not been diagnosed that that stage.  FOR PUBLICATION Page 39 of 56 211. The police, having not been involved in any strategy discussion about the evidence of neglect that was becoming more concerning by the end of March 2015 were not in a position to support an investigation and collate evidence until after a strategy meeting two days later. Arguably, an emergency strategy discussion should have happened on the same day as the visit had taken place. The lack of apparent urgency infers a degree of disconnect between the original objectives of creating procedural pathways that promote timely liaison between services that can then become routine and viewed as an administrative function.   212. After Perry had been diagnosed with an injury the local authority arranged for the children to go to their mother. Although there were checks with the other local authority, these were the minimum and there was no other assessment undertaken. Given the information provided in some agency reports for this review about historical concerns about neglect, combined with the fact that the siblings had all experienced neglectful care over several years, further information about the mother’s circumstances and capacity to meet the needs of her children should have been sought before the children moved to Humberside.    3.6 Quality of assessment and plans  213. Assessment of a child’s needs and circumstances is the foundation upon which effective statutory professional help is provided when a child is in need or requires safeguarding from significant harm.  Several assessments were completed at different times and by different social workers. The fact that the assessments did not identify sufficient history about the children including their relationship with their mother, did not identify more clearly the significance of neglect and the father’s resistance has to invite reflection about the adequacy of assessment practice. Were the deficiencies due to workload pressures or do they reflect the expectations and standards expected of social workers?  214. A starting point for the assessment has to be securing a sufficiently complete narrative about the history of the child and family which should include the personal history of significant adults taking responsibility for caring or parenting. There were gaps in the narrative for Perry and siblings that have already been commented upon.  215. An assessment cannot just be a narrative. It requires professionals to analyse the significance of information that is collated (and the significance of any information that is not available or cannot be verified).   216. The point has been made that the family history of Perry is largely unknown in spite of extensive statutory involvement for child protection and the conduct of assessments.  In developing an insight into the level and nature of risk there has to be an exploration of what protective factors or sources of resilience can be identified alongside the factors that indicate vulnerability for a child.  217. For example, research indicates that older children with good attachment, good self-esteem and a good relationship with a sibling combined with a higher IQ will indicate FOR PUBLICATION Page 40 of 56 higher levels of resilience compared to another child. In this case the assessments have not revealed and explored this sort of information clearly enough.   218. Similarly, parental history of domestic abuse, significant substance misuse, chronic psychiatric illness, isolation, experience of being abused as a child, having been looked after and had multiple placements or are fearful of the stigma or suspicious of statutory contact are contra indicators to consider alongside protective factors that include positive social support, a positive parental childhood, good parental health (mental and physical), education including workplace qualification and stable employment. The assessments do not provide sufficient information on these various factors.  219. Family and environmental factors that are significant in regard to indicators of vulnerability include a run-down neighbourhood, a poor relationship with school, poor social support, poverty and social isolation. The factors in regard to protection and resilience include a committed adult for the child, a good school experience, strong community and good services and support. The assessments do not provide sufficient information about these various factors.   220. Assessment, as described in national guidance, should be a dynamic and ongoing process that has the capacity to analyse information and respond to the changing needs or risk faced by children. A good assessment helps avoid delay in providing help and can monitor and record the impact of any services delivered to the child and family.  The focus should be on the child. The assessment needs to show appropriate rigour in checking relevant information and providing a record of evidence that can demonstrate appropriately balanced judgments are being made.   221. The assessments were characterised by being episodic, did not establish a clear enough history of the children, focussed on physical presentation of the children and their home conditions and did not describe clearly enough the views, wishes and feelings of the individual children about their circumstances and about important issues such as their mother or about the presence of unrelated young adults in the household.   222. The children had discernible differences regarding their development, their personal level of understanding and the roles they had in the family. Sibling 2 for example was clearly taking on carer responsibilities for aspects of her siblings’ daily routines and father was abrogating tasks and responsibilities he had as a parent.   223. The assessments were limited in collating evidence from outside of children’s services and do not appear to have sought information from important professionals such as the GP or other professionals such as the youth service who had significant contact with three of the siblings. If health professionals had been approached this could have shown up the extent to which the siblings had not been seen by health services.   FOR PUBLICATION Page 41 of 56 224. Neglect was a persistent feature in the presentation of the children at school and for three of them at the local youth centre, along with the poor conditions of the home although this was not explored in regard to the impact it was having on the children.  The children suffered isolation, showed evidence of developmental delay, lacked important social and emotional skills, were often hungry and were exposed to sexual activity that was unwelcome for Perry, was opportunist and exploited the siblings’ vulnerability. It was this type of information that an assessment should have been collating.   225. Although workload has clearly had an impact on some aspects of how the case was managed, the case has identified other issues for development and improvement.   226. Neglect is notoriously difficult for professional practice and makes assessment even more critical. There is the dilemma of different professionals having their own thresholds and frameworks for making judgments about what constitutes neglect. Neglect is persistent and rarely has one catastrophic and defining event that can clearly push professional judgement over a multi-agency threshold of common concern.  227. The threshold of concerns relating to the neglect of children therefore can and do differ between different individuals and organisations. Some of this reflects different types of knowledge and expertise. An example might be a paediatrician having a much clearer medical understanding about the impact of neglect on very young children’s neurological and physical development compared to another non-medical professional for example.  Neglect requires a different approach in regard to how enquiries and assessment is conducted. For example, it has to establish what the deficits and identify how it is having an impact on the child. Neglect can also appear to represent less urgent risk compared to other forms of abuse when for example social workers and the police are having to prioritise how they will respond to individual incidents of information and the amount of resource in terms of professional experience and time is allocated.   228. The issues highlighted in regard to assessment are contributory to the plans more often than not being characterised by an absence of clear enough objectives or tasks. The final child in need plan written in December 2014 is described as being very long and was not implemented.   3.7 Parental resistance  229. Serious case reviews consistently comment upon the importance of professionals being able to distinguish between families who are genuinely engaged in a necessary process of change and intervention and those that are resistant to professional concern and interventions.   230. The evidence of research and from reviews of practice identify three broad types of uncooperative behaviour.   FOR PUBLICATION Page 42 of 56 a) Hostile and threatening behaviour; which produces damaging effects, physically or emotionally, in other people including professionals; b) Non-compliant behaviour; involves proactively sabotaging efforts to bring about change or alternatively passively disengaging; c) Disguised compliance (manifested as disguised resistance); involves significant adults in a child’s parenting and care not admitting to their lack of commitment to change but working subversively to undermine the process.  231. The types of behaviour are not entirely or necessarily exclusive from each other in their use by resistant adults although the first two behaviours are more explicit and discernible. Accepting the need for change in response to concerns about significant harm to a child is often a complex journey. Tony Morrison (2006)13 adapted Prochaska and Di Clemente’s (1984)14 model of change by describing seven sequential elements of motivation, which, he argued, are necessary for genuine and lasting change to begin:  a) I accept there is a problem; b) I have some responsibility for the problem; c) I have some discomfort about the impact, not only on myself, but also on my children; d) I believe things must change; e) I can be part of the solution; f) I can make choices about how I address the issues; g) I can see the first steps to making the change/can work with others to help me.  232. Parental non-acceptance of the stages identified by Morrison produces different forms of resistance and, indeed, even parents within one household may respond differently to accusations of maltreatment. In several works, Bentovim (198715 and 200416) argues that parents’ failure to take responsibility for their children’s maltreatment, their dismissal of the need for treatment, their failure to recognise their children’s needs and the maintenance of insecure or ambivalent parent and child attachments are all key indicators of a poor prognosis in regard to a diagnosis that a child has or is at risk of significant harm.  233. To complicate matters considerably, parents may say that they accept the need for change, and can even appear motivated towards that end, whereas, in reality, they are actually opposed or indifferent.                                            13 Morrison, T. (2006) Staff supervision in social care: making a real difference for staff and service users, third edn, Brighton: Pavilion. 14 Prochaska, J.O. and DiClemente, C.C. (1984) The transtheoretical approach: crossing traditional boundaries of therapy, Homewood, IL: Dow Jones-Irwin. 15 Bentovim, A., Elton, A. and Tranter, M. (1987) ‘Prognosis for rehabilitation after abuse’, Adoption and fostering, vol 11, no 1, pp 26–31. 16 Bentovim, A. (2004) ‘Working with abusing families: general issues and a systemic perspective’, Journal of family psychotherapy, vol 15, no 1/2, pp 119–135.  FOR PUBLICATION Page 43 of 56 234. Father never accepted that any of the siblings were at risk from neglect and minimised the concern of professionals. His level of understanding was not explicitly explored. The lack of sustained improvement in his parenting and his obstruction of social workers in particular was not discussed in multi-agency meetings with the police or with other services.   3.8 Use of the local escalation processes  235. As with all human behaviour and interaction, people can make ill-informed judgements or do not take the correct action for a variety of reasons. A great deal of child protection work and especially in regard to issues such as neglect and emotional abuse rely on nuanced professional judgment. The same legal system that gives powers and responsibilities to protect children also sets out legal protection for parents and families on matters such as privacy. A great deal of child protection work is not about gross acts of cruelty that can be seen for what they are but rather are far more nuanced and opaque.   236. The Nottinghamshire Safeguarding Children Board recognises that professionals can disagree about a judgment or decision and has published a policy and pathway for professionals to escalate their concerns if they believe another professional is taking a wrong decision and is unwilling to discuss it17. The procedure sets out the following advice.   237. ‘Problem resolution is an integral part of interagency working to safeguard children. It is often a sign of developing thinking within a dynamic process and can indicate a lack of clarity in current procedures or approach. Professional disagreement is only dysfunctional if not resolved in a constructive and timely fashion.  238. Effective working together depends on an open approach and honest relationships between agencies and a commitment to genuine partnership working. As part of this there needs to be a system in place to enable disagreements to be resolved to the satisfaction of practitioners and organisations involved. The aim should be to resolve difficulties at practitioner level between organisations, where this is possible, but where not the disagreement should be escalated until a resolution is achieved. Disagreements should not be left unresolved.  239. Disagreements could arise in a number of areas, but are most likely to arise around thresholds, roles and responsibilities, the need for action and communication.  240. Although it is apparent that several professionals had misgivings about the slow pace of response at critical moments, none of them used the escalation procedure which was updated in July 2015.                                          17 Resolving Professional Disagreements (Escalation Procedure)  FOR PUBLICATION Page 44 of 56 4  Analysis of key findings for learning and improvement  241. Meaningful analysis of the complex human interactions and decision making processes that are integral to multiagency work with vulnerable children and troubled family’s has to understand why things happen and the extent to which the local systems (people, work processes, organisational arrangements) help or hinder effective work locally within ‘the tunnel’18.   242. In keeping with models of best practice for conducting serious case reviews, the findings use a systems based typology developed by SCIE to identify some of the underlying patterns that appear to be significant for local practice:  a) Cognitive influence and human bias in processing information and observations; b) Family and professional contact and interaction; c) Responses to significant incidents and information; d) Tools and frameworks to support professional judgment and practice; e) Management and agency to agency systems. 243. The aim is to use this particular case to reflect on is revealed about gaps or areas for further development in the local systems for vulnerable children and young people.   244. In providing any recommendations, reflections and challenges to the Nottinghamshire Safeguarding Children Board there is an expectation that there will be a response to the key findings in regard to the following:  a) An indication as to whether the Nottinghamshire Safeguarding Children Board accepts the findings; b) Information as to how the Nottinghamshire Safeguarding Children Board will take any particular findings forward; c) Information about who is best placed to lead on any particular activity; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported.  245. The Nottinghamshire Safeguarding Children Board will determine how this information is managed and communicated to relevant stakeholders. The formal response should form part of the publication of the serious case review.   4.1 Cognitive influence and human bias in processing information and observation Dangers of a mind-set that cannot recognise the potential for harm from neglect; not seeing information with fresh eyes; neglect that can prove fatal; dangers of low expectations and professional overload; professional open mindedness and vigilance; understanding the                                         18 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. FOR PUBLICATION Page 45 of 56 significance and risk of neglect for particular children requires knowing the child well; guarding against flight from judgement  246. Neglect can be life threatening or cause significant physical injury, as demonstrated in this case, and needs to be treated with as much urgency as other categories of maltreatment. The possibility that in a very small minority of cases neglect will be fatal, or cause grave harm, should be part of any practitioner’s mind-set. This is not to be alarmist and is not suggesting that predicting or presuming that where neglect is to be found, the child will be at risk of death. However, practitioners, managers, policy makers and decision makers have to be discouraged from minimising or downgrading the harm that can come from neglect and discouraged from allowing neglect cases to drift especially in busy services dealing with competing categories of abuse and concern. Drift was a significant issue in this case and although workload (discussed later) was a significant factor it is unlikely to have been the only ‘latent condition’.   247. The age of children can also have an impact on the sense of urgency that professionals give to information. Older children can be seen to have more opportunity to take care of themselves compared to a younger more dependent child. Age related bias was apparent in how for example the role of one of the siblings as a carer for a younger child was not the subject of any significant enquiry and assessment.    248. It should remain a key objective for professionals to ensure that a child is living in a sufficiently healthy environment and has appropriate relationships that promote the child’s proper development and well-being. Professionals should be striving to do this in partnership with parents and care givers using mechanisms such as early help (historically CAF) where and when it is appropriate and does not require a more authoritative and assertive strategy.   249. However, it is essential that professionals are able to recognise the significance of neglect either in regard to extreme forms such as in this case from the spring of 2015 and when it is persistent and long-term (and also demonstrated in this case).   250. Professionals are expected to form judgements about what is good enough care and this is different and distinct from being judgmental. Some professionals can struggle to reconcile what they feel might be imposed standards when working with families from socially or economically challenged circumstances.   251. It would be foolish to adopt a stance that says any child who has recently been subject of a child protection plan or been a child in need should not then be supported through an early help plan but Perry’s case invites reflection as to whether anybody was adopting a sufficiently robust mind-set that queried what had really happened to the neglect that had been talked about for so long.   252. In this case there was a distinct difference between professionals who were able to see the neglect for what it was and others who exhibited a lower threshold of expectation and were distracted by the parent’s general disguised resistance FOR PUBLICATION Page 46 of 56 (discussed later) and the belief that the siblings had a positive relationship. This led to some professionals to optimistically interpret the siblings’ behaviour when they were living in an unsafe home which have been described. The poor developmental progress of two siblings in particular were not explored robustly in any assessment.   253. Not enough attention was given to collating systematically the evidence about risk, vulnerability and resilience. Without having any reference points key professionals lacked vital compass reference points against which to judge the children’s circumstances.   254. In order to judge the degree of risk to an individual child requires assessments to be informed by people who know the child well. It is clear from the information collated by the review that Sibling 2 did not share some of the learning and developmental concerns of the siblings. This had consequences for Sibling 2 that was not explored in any of the assessments for example.  4.2 Family and professional contact and interaction  Recognising and having good enough strategies to respond to parental resistance; clarity about the respective roles of police and social workers in the conduct of enquiries; identifying who is living in households and the dangers of inappropriate adults hiding in plain view;   255. The extent to which father was demonstrating disguised resistance (in contrast to the more often referenced ‘disguised compliance’) was not recognised until April 2015 when the social worker noted a change in father’s attitude. It was apparent that as the contact and enquiries by children’s social care were escalating (albeit not quickly enough) father was increasingly showing a determination to not cooperate with enquiries.   256. Superficial engagement by parents with concerns and doing just enough to reduce the level of concern by professionals who then close their involvement that leads to a pattern of opening and closing intervention in long-term neglect cases has been a recurring theme in serious case reviews examining injury (or death) of children subject of long- term neglect.   257. Relying on voluntary and partnership based agreements to work with parents or care givers who are resistant to concerns about children (as father was on a consistent basis) creates the latent conditions for collusion between professionals and the resistant parent.    258. Relying only on a voluntary arrangement for removing the children from their unsafe home in April 2015 was inappropriate and delayed arrangements. This does not mean that children’s social care had sufficient evidence to have persuaded a court to grant an emergency protection order but it merited discussion with a lawyer as to whether there were grounds for proceedings through notice given the social worker’s clear instinct that alternative care was becoming necessary. Contemplating court FOR PUBLICATION Page 47 of 56 proceedings also has additional workload implications for any professional who is already trying to respond to a busy and complex workload.  259. Given the evidence presented in this report about neglect in the children’s early childhood and the extent of it whilst in Nottinghamshire and the implications for their longer term development, relying on mother just exercising her parental responsibility without clearer inquiries is questionable. It suggests that there may be factors associated with an apparent lack of confidence in using legal frameworks. Is it confidence and court related skills or is it the values and attitudes towards working with parents?  260. Being aware of the potential parental resistance has implications for how enquiries and assessments are conducted. Social workers and supervisors need to understand the distinct role that police have in child welfare enquiries and the powers that they have to support the conduct of enquiries and if necessary assisting in the removal of children.   261. The dangers of hidden men in households where vulnerable children live is a recurring theme in reviews such as this. The importance of identifying who is spending time in the household of a vulnerable child, not just relying on a parent for essential information where there are concerns, not overlooking the parent who is estranged from the household and listening to children who are stating that they are unhappy or afraid.   262. The absence of curiosity about the young males who were allowed to live in the house is a concern. There was evidence of sexual activity which was not welcomed by Perry who made clear that they were afraid at home. The evidence of unsupervised use of the internet and its use in transmitting inappropriate images and facilitating contact with males in different parts of the country were not investigated and most were not reported to the police.   263. All of the siblings were vulnerable to exploitation by virtue of their age or specific cognitive and learning difficulties, their isolation and the absence of supervision by their father. Issues such as consent need more meaningful exploration than was achieved in this case. Father was highly influential in those decisions.   4.3 Responses to information and incidents Purpose of assessment in revealing information about the child and accessing to resources; euphemistic language obscuring professional communication and understanding; prompt and rigorous enquiries and investigation of neglect; establishing the views, wishes and feelings of children and assessing their individual level of understanding;   264.  Workload influenced how busy social workers in particular approached tasks such as assessment. The principles of an assessment framework should be to discover and reveal information about a child that goes beyond proving or disproving an allegation or specific concern. It has to be multi-dimensional as described in the appraisal of practice.   FOR PUBLICATION Page 48 of 56  265. The use of ‘copy and paste’ to populate the assessments has the effect of reinforcing previous mind-sets and deficits and is evidence of people taking short cuts. Is this just the behaviour of people feeling too busy or does it indicate a need for more fundamental development of assessment capacity in regard to practitioner understanding about what assessment should be.   266. The euphemistic use of language is common. Examples have been provided in the previous chapter. This combined with the deficits in the quality of assessment.   267. Understanding the significance of neglect requires the focus of professional enquiry and assessment to be on the child and not to be distracted by optimistic promises to change behaviour. The cleanliness of children, their weight, their language and social development represent opportunities to record factual information about a child against which to map where they are in regard to expected milestones and are ongoing reference points to help inform whether the circumstances of a child are improving or not.  268. It remains unclear if at any stage a professional had a frank discussion with father about issues such as body odour, the appalling conditions in the home and the extent to which the children’s physical presentation was isolating them. Professionals need to feel confident about tackling sensitive and personal issues. The only person on record as having explicitly raised the issue in a direct manner was the teaching assistant. Some professionals may feel more inhibited about direct speaking on personal issues.  4.4 Tools to support professional judgment and decision making  Use of tools and frameworks in the assessment of neglect; dangers of support strategies minimising or disguising entrenched neglect; robustness of assessment frameworks that provide sufficient historical context, triangulation of evidence and information and explore risk and resilience; exploring what the child means to a parent and what a parent (absent or otherwise) means to a child;   269. Practitioners need to be sensitively attuned to the relationship between parents and children, even where parents present as loving but may be failing to cope such as in this case. Nobody has explained adequately what the obstacles were in regard to father being able to parent more effectively.  It is known that as the siblings became older he was facing difficulties in dealing with issues such as sexuality and made such a risky combination with the presence of males in the household and over the internet.   270. Parent–child relationships are often highly complex and practitioners need to be sensitively attuned to this relationship, even where parents present as loving but may be failing to cope. Neglect of medical care as demonstrated in this case can become fatal or cause life-long damage.  271. The fact that so many areas of information are unknown despite involvement over several years and the fact that assessments were completed in 2013, 2014 and again FOR PUBLICATION Page 49 of 56 in 2015 invites reflection about the systemic arrangements for enquiry and child assessment. Do the systems encourage the type of reflective and ecological enquiry that is required in complex child safeguarding work described in the appraisal of practice?19  272. None of the services have made reference to local toolkits and frameworks designed to assist professionals in assessing and responding to neglect. This seems paradoxical given that Nottinghamshire have developed and published a detailed and well referenced assessment framework that includes links to a wide range of toolkits and other resources to assist social workers in particular when conducting an assessment of a child.   273. Similarly, there has been significant work undertaken in regard to the neglect of children specifically and in June 2014 the local authority published a social work practice briefing entitled Working with Children at Risk from Neglect. It is less apparent how the framework applies to or includes other relevant services or professionals. Are these seen as relevant to the work of other relevant professionals such as designated lead professionals in other workplaces across the county and are social workers using them appropriately and consistently?  274. The formats for collating and presenting assessments need to encourage practitioners to develop both a sufficiently comprehensive narrative and to also provide a structure for analysing the information. The point being made here is whether practitioners regard the type of assessment that was completed for Perry as the type that is expected by the revised local arrangements and if so does it assist them in carrying out complex judgments and actions and help them make enough sense of how to most effectively help a child?   4.5 Management and agency to agency systems Ensuring that the police are involved and take the lead in investigations that relate to allegations of crime; encouraging and increasing the use of resources to support professional judgment; ensuring all professionals have knowledge and confidence to use escalation procedures; common understanding about what is contact, enquiry or a referral; having a common record of critical discussion such as strategy discussions; ensuring final child protection conferences are quorate.  275. Although the police were not made aware of all information relating to the neglect or other concerns they did have information about the allegation of rape and participated in the strategy discussion.  That resulted in the decision to investigate without direct police involvement. Recent audits indicate that the majority of strategy discussions are resulting in single agency investigations by children’s social care services.                                          19 Ecological enquiry refers to the informed understanding about how a child’s development is effected by its family and wider community environment.  FOR PUBLICATION Page 50 of 56 276. Reference has been made to the considerable investment in providing access to materials and resources that support assessment work with vulnerable children. This is most evident in children’s social care services where social workers have access via the local authority intranet to a wealth of material. There is also practice guidance provided in regard to recognising and responding to neglect published by the NSCB. This range of resource may appear somewhat overwhelming for professionals unfamiliar with using the material. This is an example of where line managers have a role in encouraging and directing attention to particular resources and ensuring, to paraphrase Professor Eileen Munroe that intelligent use is made of smart resources rather than random and uninformed application of forms by practitioners uncertain about their purpose or their application.   277. Not all of the material is exclusively the domain of a qualified social worker and there is merit in developing the knowledge and skills across the workforce of relevant professionals working with vulnerable children. Universal services are critical in identifying children who are being abused through neglect and have a role in ensuring effective advice and help is provided and securing the safeguarding of children at risk of harm. There have been pilot projects in the county to improve the identification and response to children at risk from neglect.   278. Contact from other services with children’s social care was described as being enquiry, contact or referral. Some professionals followed up their initial contact with children’s social care whilst others did not. Professionals need to know with certainty how their information is to be processed by children’s social care services; whether it is being managed as a simple enquiry or contact or whether it will be managed as a referral.   279. A further complicating factor in the case was that Perry was already known to social care services and had a social worker allocated. This in itself should not deter a professional making a referral when they have concerns. The Nottinghamshire procedures are explicit that any referral regarding an open case should be made to the social worker allocated for the case (or in their absence to their manager or a duty social worker.    280. Professionals need to know and understand the purpose of escalation procedures if and when they feel their information is not being processed correctly either in regard to being defined as a referral or there is a delay in allocating and processing enquiries or assessment. Escalation applies when for example CAF or child in need are being considered in circumstances where a multi-agency child protection conference should be meeting to make decisions. It also applies when final child protection conferences are deciding to end a child protection plan and ensuring that the conference is quorate and been seen to consider all the relevant professional information and judgment.   281. It should be an expectation that all professionals who have a designated safeguarding role in their agency or workplace are familiarised and updated in regard to safeguarding policies, protocols and practice learning.   FOR PUBLICATION Page 51 of 56 282. Professionals who are not sufficiently versed in the processes may resort to personal initiative when concerned about a child as occurred in this case. Such action, although well intentioned, can contribute to systems not working effectively enough. An example in this case was a teacher taking Perry to hospital but having no legal role in pursuing enquiries.   283. Reliance on individual practitioners and agencies to record critical discussion and decisions such as strategy meetings is unreliable and susceptible to misinterpretation and assumptions being made.   4.6 Issues for the Nottinghamshire Safeguarding Children Board to consider in regard to learning and improvement 284. Individual services will use the review as an opportunity to examine other aspects of policy, practice or processes in responding to vulnerable children at risk from neglect and other abuse.    1. Does the Nottinghamshire Safeguarding Children Board have sufficient information about the use and effectiveness of local assessment resources, including the guidance on neglect in identifying and responding to children at risk of significant harm from neglect?   2. Is the Nottinghamshire Safeguarding Children Board sufficiently informed about the circumstances and reasons for the low proportion of s47 investigations that involve the police?  3. Is the Nottinghamshire Safeguarding Children Board sufficiently informed about the conduct and quality of assessments of neglect?  4. How can the Nottinghamshire Safeguarding Children Board ensure that the arrangements for escalating issues and concerns about individual children are known and used by professionals?  5. Has the review identified any additional training requirement in regard to parents who are absent from households where children are subject to child in need, child protection or looked after arrangements?  6. Has the review identified any additional areas for quality audits or evaluation?  7. Has the review identified any additional training or development needs in regard to recognising and responding to resistant parents?   4.7 Recommendations   1. The Nottinghamshire Safeguarding Children Board should ensure that appropriate professional briefings and practitioner learning events on the findings from this review are completed. FOR PUBLICATION Page 52 of 56  2. The Nottinghamshire Safeguarding Children Board should ensure that the use of local escalation procedures are monitored as part of the quality assurance arrangements and commented upon in the annual report.   4.8 Issues for national policy  285. The serious case review has noted that the use of the ‘Red Card’ family liaison meetings are not a national framework or requirement for GP practices.        FOR PUBLICATION Page 53 of 56 Appendix 1 Terms of reference identified by the serious case review team for further investigation by the key lines of enquiry:   1. In response to observations and concerns around home conditions, care of the children, their health and welfare did agencies: -  a) Follow relevant law, procedures or professional standards that were in place at the time? b) Complete appropriate assessments? c) Recognise risks and respond appropriately to them?  d) Apply thresholds for services appropriately and in line with the Pathway to Provision. When decisions were taken to step down or step up, was the transition managed effectively and what was the impact on the children? e) Provide services and support appropriate to meet the needs of the children and any risks identified? f) Communicate effectively within and between agencies and where appropriate escalate any professional disagreements? g) Is there evidence of effective working together to safeguard and promote the welfare of the children? h) Use effective strategies to deal with resistance shown at times by the father? If not, why was this the case? 1. Plans:  a) Were appropriate plans developed in response to information and observation of the children? b) Did professionals work effectively to implement and monitor the plans? c) Was appropriate advice and action taken? d) Was consideration given to legal planning processes? If not, why?  2. Did agencies hear the voice of the child and was it acted upon by staff working with the family? If not, what were the barriers to them doing so?  FOR PUBLICATION Page 54 of 56 3. Were there any racial, cultural, linguistic, faith or disability issues that needed to be taken into account in the assessment and provision of services?  How were these issues managed by agencies?  4. Did professionals working with the family receive appropriate supervision and support?  Was there adequate management oversight in this case?  5. Were there issues in relation to capacity or resources in agencies that impacted on the provision of services?  FOR PUBLICATION Page 55 of 56 Appendix 2 Membership of the case review team    Service Director Children’s Social Care Nottinghamshire County Council Inspector Nottinghamshire Police  Service Director Education, Standards and Inclusion Nottinghamshire County Council Associate Director for Safeguarding and Social Care Nottinghamshire Healthcare NHS Trust Director of Quality and Performance Mansfield and Ashfield Clinical Commissioning Group (CCG) Associate Designated Nurse for Safeguarding Children NHS Newark and Sherwood CCG (working on behalf of NHS Newark and Sherwood CCG, NHS Mansfield and Ashfield CCG, NHS Nottingham West CCG, NHS Nottingham North and East CCG and NHS Rushcliffe CCG) Medical Director Nottinghamshire University Hospital Named nurse Nottinghamshire University Hospital Safeguarding Group Manager Nottinghamshire County Council Board Manager Nottinghamshire Safeguarding Children Board Development Manager (child deaths) Nottinghamshire Safeguarding Children Board Independent reviewer (author of this report) Professional support Child Death Administrator  Nottinghamshire County Council   FOR PUBLICATION Page 56 of 56 Appendix 3 Biographical summary of the independent reviewer  The safeguarding children board commissioned Peter Maddocks as the independent reviewer who has written this overview report.   He has over thirty-five years’ experience of social care services the majority of which has been concerned with statutory services for children and families. He has experience of working as a practitioner and senior manager in local authority services and of working in national inspection services and with the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and statutory inspections in relation to the safeguarding children. He has undertaken independent agency reviews and has provided independent overview reports to several local safeguarding children boards in England and Wales as well as regularly working on domestic homicide reviews for several community safety partnerships. He has not been employed by any of the services contributing to this serious case review. He has completed training for overview authors and independent reviewers including the application of systems learning and participation in masterclass professional development 