Death of a 14-year-old young person from an aggressive malignant tumour. Child F suffered chronic neglect and abuse before entering foster care at age 7. At age 8, Child F was diagnosed with a Growth Hormone Deficiency and was started on therapy. From age 13 and 9 months, Child F presented at the GP twice and at A&E on five occasions, once for a leg injury and four for feeling unwell. Foster carers thought the illness was fabricated and a result of previous trauma. At age 14, Child F was moved to a respite foster carer. Attendance at the GP led to transfer to a specialist children's hospital and Child F subsequently received palliative care in a hospice. Child F was White British. Learning: Child F's voice was heard but was not understood and acted on; evidence of poor interagency communication and information sharing; the need to manage conflict and work with challenging carers whilst not losing focus on the child; quality of care issues raised by Child F received an inadequate response by Children's Social Care. Uses a systems approach with the practitioners' event based on the Child Practice Review Model. Recommendations include: children cared for by the Local Authority should be provided with advice either from an independent legal advisor or advocate when they are in disagreement with professionals or carers; raise awareness regarding prevalence and symptoms of brain tumours in children and young adolescents; foster carer recruitment, training and supervision should encompass lessons from this review.
      
    Serious Case Review No:  2019/C7931  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.      MANAGED REVIEW CHILD F       Independent Reviewer Sharon Hawkins February 2019       1 Contents  1. INTRODUCTION-The Child’s Journey ................................................................................ 3 2. PUBLICATION ........................................................................................................................... 4 3.  REASON FOR THE MANAGED REVIEW ............................................................................ 4 4. SPECIFIC TERMS OF REFERENCE .................................................................................... 5 5. TIMESCALE ............................................................................................................................... 6 6. FAMILY INVOLVEMENT ......................................................................................................... 6 7. PARALLEL PROCESSES ....................................................................................................... 7 8. INDEPENDENT REVIEWER AND PANEL ........................................................................... 7 9. PROCESS AND METHODOLOGY ........................................................................................ 8 10. ETHNICITY, DIVERSITY AND CULTURAL ISSUES ........................................................ 8 11. BACKGROUND NARRATIVE AS KNOWN TO AGENCIES ........................................... 9 12. CHRONOLOGY OF SIGNIFICANT EVENTS IDENTIFIED IN THE IMR’S .................. 10 The Year of Diagnosis ............................................................................................................. 13 1st A&E Attendance- 13th Year ............................................................................................ 13 2nd A&E Attendance- 13th Year .............................................................................................. 14 3rd A&E Attendance- 14th Year ............................................................................................... 14 4th A&E Attendance- 14th Year – July .................................................................................. 17 5TH A&E Attendance- 14th Year – July ................................................................................. 20 13.   HEALTH OVERVIEW REPORT ........................................................................................ 20 Care and Delivery Problems .................................................................................................. 21 14. RESPONSES FROM THE KEY LINES OF ENQUIRY .................................................... 22 Did being a looked after child impact on the actions of practitioners? .................... 22 Was the voice of the child heard in this case?................................................................. 23 Did the history of earlier abuse cloud medical judgement? ......................................... 25 Was Child F seen as troubled or troublesome by practitioners?................................ 25 Could and should something different have been done given their presentation at different health settings? ....................................................................................................... 26 2 15.  Key Practice Issues / Learning ........................................................................................ 27 Theme: Voice of the Child ...................................................................................................... 27 Theme: Poor Communication and Information Sharing ................................................ 28 Theme: Lack of Professional Curiosity and Professional Challenge ......................... 29 Lack of adherence to Safeguarding Procedures ............................................................. 29 16.  PRACTITIONERS EVENT ................................................................................................... 29 17.   CONCLUSION AND RECOMMENDATIONS ................................................................. 30 Recommendation 1 .................................................................................................................. 31 Recommendation 2 .................................................................................................................. 32 Recommendation 3 .................................................................................................................. 32 Recommendation 4 .................................................................................................................. 32 Recommendation 5 .................................................................................................................. 32 Recommendation 6 .................................................................................................................. 32 Notable Practice identified in this review .......................................................................... 32 Single Agency Recommendations ...................................................................................... 33 Community Foundation Trust ............................................................................................... 33 Acute Hospital ........................................................................................................................... 33 School 1 ...................................................................................................................................... 34 Clinical Commissioning Group ............................................................................................ 34 Children’s Social Care ............................................................................................................ 35 Educational Psychology Service ......................................................................................... 35 GLOSSARY ................................................................................................................................... 37  3 1. INTRODUCTION-The Child’s Journey 1.1 In her second interim report titled ‘The Child’s Journey1, Professor Munro identified the importance of understanding the ‘child’s journey’ through services and for families to receive effective help at the earliest point from the most appropriate professional and agency for problems arising from family and social circumstances.   1.2 For Child F that journey started from birth until the date of their death in the spring of the year of their 15th Birthday.   1.3 Child F, a fourteen-year-old young person, who loved sport and street dancing, was admitted to hospital in the summer time of their 14th Year, Child F had been feeling unwell; it later transpired Child F had been feeling unwell from the autumn of the previous year.  1.4 Child F was a Child in Care (CIC) and was one of five siblings. Child F suffered chronic neglect and abuse before entering care when seven years of age. Child F was placed in Foster Care along with their youngest two siblings.  1.5 When eight years of age Child F was diagnosed with a Growth Hormone Deficiency2. This is a medical problem caused by problems occurring in the pituitary gland. Following diagnosis Child F was started on Growth Hormone Therapy.  1.6 Child F had presented at the General Practitioners (GPs) twice and A&E on five occasions, one for a leg injury and four occasions accompanied by the Foster Carers due to feeling unwell.  Subsequent tests did not indicate any organic reasons for Child F’s presentation and Child F was referred to the local CAMHS for support due to concerns raised by the Foster Carers as they were concerned that Child F was becoming depressed.  1.7 Child F was convinced that they were seriously ill and reported to the Foster Carers and various professionals on more than one occasion that there was something seriously wrong.                                                            1          The Child’s Journey- 2nd Interim report .https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/206993/DFE-00010-2011.pdf  2         https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/growth-hormone-deficiency  4  1.8 The Foster Carers felt unable to continue caring for Child F and just prior to the diagnosis they requested that Child F be moved to a Respite Foster Carer.  1.9 Prior to being admitted to hospital Child F had presented to the GP earlier in the day accompanied by the Respite Foster Carer and following assessment by the GP was referred for an urgent paediatric assessment and examination. The GP had noticed that Child F had an unsteady gate and was limping and had a facial drooping on one side of the face. An MRI scan later revealed the presence of a brain tumour on Child F’s brain stem.  1.10 Child F was subsequently transferred to a specialist children’s hospital and underwent surgery. Child F was found to have a particularly aggressive Grade 4 malignant tumour which was cancerous and life limiting.  1.11 Child F received palliative care in a hospice setting over the following months and in the spring following diagnosis, sadly passed away.  2. PUBLICATION   2.1 This report has been anonymised to protect the identity of the child involved; the subject child shall be known as Child F. Neither the date of birth, place of birth nor the Local Safeguarding Children Board (LSCB) or region the young person originates from, will be included in the report. Child F was an immensely private child and did not want other young people to know about their Looked after status. It is important that this desire for privacy is respected in their death. 3.  REASON FOR THE MANAGED REVIEW 3.1 In England, Regulation 5 of the LSCB Regulations 2006 sets out the functions for LSCB’s. This includes the requirement for LSCB’s to undertake reviews of serious cases in specified circumstances. How LSCB’s actually undertake the review is not set out in statutory guidance however  “Working Together to Safeguard Children 2015”3 identifies that  “Reviews are not the  ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which                                                            3 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 5 lead to sustainable improvements and the prevention of death, serious injury or harm to children.” 3.2 Working Together 2015 requires Serious Case Reviews (SCRs) to be conducted in such a way that:   recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings 3.3 Some cases may not meet the definition of a ‘Serious Case Review (SCR),’ but nevertheless raise issues of importance to the local area.  Safeguarding partners may choose to undertake a local review in these or other circumstances. 3.4 The SCR Sub Group met to consider the case and made a recommendation to the Independent Chair of the Board, that the case did not meet the criteria for a SCR. This view was also held by the National Panel, however, because of the local learning arising from this case, agreed that a local Managed Review would be undertaken into the involvement that organisations and professionals have had with Child F and their siblings. 4. SPECIFIC TERMS OF REFERENCE 4.1 The Review will:  Examine all relevant information provided by individual agency reports.  Establish if there was clear evidence of a risk of significant harm which was not recognised by agencies or professionals in contact with the child or family, or not shared with others, or not acted upon appropriately.  Establish from the case if there are any points of learning from which local Child Protection (CP) procedures may be improved for the future.  Did all agencies work together effectively to safeguard this young person?  Was the outcome preventable? 6  Were the Safeguarding Procedures followed appropriately?  Was the young person’s voice heard throughout agencies involvement?  The time period for the review will cover the period from 1st January 2015 to the 20th July 2017.  The Managed Review Panel will examine all information provided by individual agency and professional reports.  The Family and Foster Carers to be informed that a Managed Review is to be undertaken.  The scope of the review will be limited to Child F and their two Siblings that are Looked after Children (LAC). The issues that should be covered within the scope of this Managed Review are:  Did being a LAC impact on the actions of practitioners?  Was the voice of the child heard in this case?  Did the history of earlier abuse cloud medical judgement?  Was Child F seen as troubled or troublesome by practitioners?  Could and should something different have been done given their presentation at different health settings?  The publication date of the final overview report will take into account the statutory responsibilities of any other statutory body or criminal proceedings.  5. TIMESCALE 5.1 The timescale for the active period of the review is from 1st January 2015 to 20th July 2017.  6. FAMILY INVOLVEMENT  6. 1 It is important that family members are involved in the review process and that they have the opportunity to understand why a local Managed Review was being conducted. Family members should be consulted and given the opportunity to provide information about their contact with professionals and the quality of services that have been provided. The family and the Foster Carers were notified that a Managed Review would be taking place.  6. 2 The Independent Reviewer had requested to meet with Child F’s Parents and Foster Carers however this was declined. The Foster Carers have agreed to discuss the final report. They provided some feedback which has been considered and reviewed. 7  7. PARALLEL PROCESSES  7. 1 There are no current parallel processes involved in this review. The review was delayed until after Child F’s death.  8. INDEPENDENT REVIEWER AND PANEL  8.1 Independent Reviewer, Sharon Hawkins was commissioned to undertake this Managed Review. Sharon qualified as a Social Worker in 1994 and after 18 years of being employed in Local Authorities in the North West of England she became an Independent Safeguarding Consultant in 2012. Sharon has 23 years of experience of both social work and management at various levels including Head of Service and Assistant Director in frontline children’s services. She is experienced in completing Serious Case Reviews, Managed Reviews and reflective learning reviews and completed the national training programme for Managed Review authors in 2013. 8.2 Chronologies and Individual Management Reviews (IMRs) were requested from the following agencies: In addition a Health Overview Report was completed.  Children’s Social Care (CSC)  Police  Specialist Children’s Hospital  Local Clinical Commissioning Group (CCG) on behalf of NHSE for Primary Care  Community Foundation Trust  School 1  School 2  Acute Hospital  Youth Offending Service  CAFCASS  Virtual School  Educational Psychology 8.3 The members of the Managed Review Panel for Child F comprised of senior managers from the key statutory agencies who have had no direct involvement with the case. The Panel members identified authors within their own agencies to complete IMRs. The role of the Panel was to actively manage the review and to provide oversight and scrutiny through all aspects of the process. The Board Manager chaired this Panel. 8.4  The following agencies were represented on the Panel.   Acute Hospital    Legal Services 8   CSC   Police   Local Community Foundation Trust    Education   CCG   CAFCASS  9. PROCESS AND METHODOLOGY 9.1 The Managed Review Panel met to consider the timeframe and Terms of Reference for the review. This review was undertaken using a systems approach and is compliant with Working Together 20154 and Working Together 20185. Each agency with knowledge of the family has completed an IMR, Chronology and History document alongside a Practitioners Event.  9.2 The Practitioners Event was an integral part of the review, ensuring that the voice of practitioners was heard and that they had the opportunity to actively contribute to the process. Using a systems approach, the emphasis of the Practitioners Event was on understanding what happened, why some decisions were made and what learning could be captured. The Practitioners Event was based on the Child Practice Review Model6. 10. ETHNICITY, DIVERSITY AND CULTURAL ISSUES 10.1 Child F, siblings and parents are of White British heritage. Child F and two of the siblings all suffered from Growth Hormone Deficiency, this was diagnosed when Child F entered care. The children were under the care of two Endocrinologists at a local hospital and also a tertiary hospital. The children were seen by Endocrinologists on a six monthly basis.                                                            4 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 5 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/729914/Working_Together_to_Safeguard_Children-2018.pdf 6      Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012   9 11. BACKGROUND NARRATIVE AS KNOWN TO AGENCIES          11.1 Child F first came to the attention of agencies during infanthood. The family initially received a universal health service however due to vulnerabilities within the family this was increased to Universal Plus. Universal Plus promotes health and wellbeing as well as a rapid response from the local health visiting team when specific expert help was needed for example with postnatal depression, a sleepless baby, weaning or answering any concerns about parenting. 11.2 During their six week developmental check, Child F was referred to a Paediatrician due to poor weight gain, faltering growth, feeding problems and vomiting. Child F had been brought to the clinic by their mother. By the age of nine months Child F’s growth was in line with expectation.  11.3 There is a long history of involvement with Child F and the siblings in respect of poor home conditions and neglectful parenting. Concerns escalated when Child F was aged three culminating in Child F and the siblings being temporarily accommodated in Foster Care by CSC due to the poor and cluttered home environment.  11.4 Following this brief period in Foster Care, Child F and the siblings returned home to their parents subject to CP Plans under the category of neglect. The CP plans were in place for a two year period from Child F’s fourth year until the sixth year. 11.5 Nine months after the first CP Plan ended concerns again escalated and the children became subject of a second period of CP planning which ceased following Child F and the siblings becoming Looked After. Care proceedings were initiated and the children became subject to Full Care Orders. Historical information identifies that Child F grew up in a household where there was severe neglect and concerns regarding compromised parenting.  11.6 When they were aged eight Child F was referred to the Local Acute Hospital and seen by a specialist Endocrinology Paediatrician and subsequently diagnosed with a Growth Hormone Deficiency. The mother had also suffered from this condition. Growth Hormone Deficiency is a medical condition which required medical intervention and monitoring.  It is caused by a problem in the pituitary gland and results in the body not making enough growth hormone. Following diagnosis Child F was started on Growth Hormone treatment. Follow up six monthly appointments were in place.  11.7 During their time in care Child F lived with two sets of Foster Carers and a Respite Foster Carer. Initially Child F and two of the siblings were placed together with Foster Carer 1. Whilst living in this placement Child F presented with quite 10 challenging behaviour at times. It was during this time that care proceedings were ongoing and stability and permanence had not been achieved.  12. CHRONOLOGY OF SIGNIFICANT EVENTS IDENTIFIED IN THE IMR’S  12.1 In their eleventh year Child F was being seen by the therapist from the CAMHS. It was noted that Child F had been showing confrontational behaviour which had been getting worse since starting Secondary School. Child F was observed to be more comfortable in 1:1 situations and struggled with unstructured times throughout the day. Of particular concern was that the challenging behaviour observed in School was also developing in the placement. The therapist noted that the Foster Carers could at times view Child F in a negative context, but they were struggling with Child F’s behaviours which were described as impulsive with Child F’s mood changing quickly. Child F was also struggling with managing their emotions.  12.2 In January 2015 Child F was excluded by School 1 for three days due to persistent disruptive behaviour and defiance in lessons. School 1 had emailed the Social Worker with details of the incident which caused the exclusion and indicated that a drama/dance route for education would be sought when Child F returned to School. 12.3 The following week a meeting was held at the school regarding the exclusion. The Virtual School Head Teacher, Social Worker and the Head of Year met to discuss recent events. Child F's behaviour was not improving and the recent incidences in lessons were escalating. The Virtual School agreed to provide a behaviour support worker who could observe and support Child F and give staff strategies to help with classroom behaviour. 12.4 Two months later, aged 11 years and ten months, Child F and the two siblings were placed in a new foster placement with Foster Carers 2. This was to be a long term foster placement. Initially Child F presented with some behavioural difficulties but these were minor including telling lies and acting impulsively. 12.5 Two weeks after moving into the new placement Child F assaulted another pupil in school 1 by slapping and grabbing the pupil around the back of the neck and pulled the pupil towards a window and banged their head three times on the window causing bruising. Child F received an exclusion from School 1 for five days due to behaviour.   12.6 Following the assault at School 1, Child F was interviewed under caution by the Police and charged with assaulting a pupil. 11 12.7 Child F received support from the Youth Offending Team during this time and engaged well in their sessions although it was noted that they did struggle with some of the concepts covered. Child F also had anger management 1-1 work. 12.8 The Virtual School also had regular involvement with Child F during this period and weekly sessions were undertaken with them in School 1 to develop strategies for developing positive behaviour.  12.9 The Educational Psychology Service was involved with Child F via the Virtual School. At this time Child F had been living out of area however due to concerns regarding Child F’s level of vulnerability, a decision was made to provide additional support.  12.10 By the autumn of Child F’s 12th year they had moved to  School 2 near to the Foster placement, Child F had settled well and was making good progress  12.11 Also in autumn of the 12th year, Child F disclosed to the Foster Carers that an older sibling had tried to sexually assault them on numerous occasions and that the Mother had made Child F watch pornography and would hit Child F with a rolling pin. A Section 47 investigation was undertaken; and the younger siblings were also spoken to but made no disclosures.  12.12 Child F underwent two ABE7 interviews and Mother was voluntarily interviewed by the Police but was released without charge. Child F’s older sibling was arrested and interviewed during the investigation process. After consideration the decision was made by the Police that there was not a realistic chance of a prosecution. This was because Child F had significantly changed the story from the first interview and it was also of concern that Child F’s medical notes, when reviewed, had noted the history of behavioural concerns and more notably “concerns regarding compulsive lying.”8 This led the Police to believe that there would be no realistic chance of a prosecution as Child F would not have been a credible witness.  12.13 During their 12th year Child F attended two health appointments. These appointments were at the specialist Endocrine Clinic where Child F was monitored on a six monthly basis.   12.14 In their 12th year Child F and the siblings were also referred to a Specialist Consultant Endocrinologist. Child F was noted to be self-administering the injections                                                            7 https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/best_evidence_in_criminal_proceedings.pdf 8 Police Chronology 12 and advised doctors that they did not miss these. The referral letter mentions that Child F had a particularly small pituitary which was measuring at 2.33mm.  12.15 Child F’s Foster Carer was present during both Endocrine Clinic appointments. During the first appointment, shortly after Child F moved in, the Foster Carer described behaviour which included Child F lying and having difficult behaviours which included not listening or following rules. By the latter appointment the Foster Carer was much more positive although did advise the Consultant that Child F had behavioural difficulties. It was observed during the appointment that Child F had grown in stature and was starting to show signs of entering into puberty. Child F was described as sporty, learning a foreign language and learning to cook.  12.16  During the months following their 13th birthday and following Child F being informed that the Police were to take no further action in respect of the allegations regarding the older sibling, there were some minor changes noted in Child F’s behaviour in School 1. Child F was observed to be argumentative and at times defiant. In a five week period Child F had five behaviour logs completed for disruptive behaviour in school. Around this same time period Child F and the younger siblings were discharged from CAMHS.  12.17  Child F’s health needs appear to have been met during the first six months of the 13th year. In the early part of the year Child F completed a Strengths and Difficulties Questionnaire9. This questionnaire is used within research, evaluating treatment outcomes and also as part of an assessment to examine a young person’s mental wellbeing. One of the questions asked is if the young person often complains of headaches, stomach aches or sickness. In the 13th year Child F answered that this was not true.   12.18  Other health appointments included two routine Endocrine Clinic appointments at six monthly periods and also a review health assessment as part of Child Fs looked after status. During the CIC Health Assessment which was towards the Christmas of Child F’s 13th year; Child F is reported to have been feeling well and was self-administering the hormone injection. At the Endocrine Clinic Child F’s dosage of growth hormone was increased due to continued growth and emerging adolescence.   12.19  The other health related issue of note in the 13th year was that the School Nurse was not invited to the Children’s Statutory CIC reviews but did receive the minutes.  12.20  By the time that Child F was approaching the end of their 13th year it was observed that Child F was much more settled in the Foster Placement and School 2.                                                             9 http://www.leicspart.nhs.uk/Library/poilkj690.pdf 13 Discussions had taken place with the Foster Carers in the autumn for them to become special guardians10 which would provide all of the children with permanency. Child F and the siblings were very happy with this plan.  12.21  At the end of the year Child F’s Pupil Education Plan (PEP) meeting took place. Feedback from teachers was positive describing a well behaved student who was eager to do well and was making good progress in all areas. Child F was proud of how well they were doing.  The Year of Diagnosis 12.22 When aged 13 years and nine months Child F and the siblings attended the Endocrine Clinic for the routine six monthly reviews. The Consultant Paediatrician in attendance noted that Child F was compliant with the Growth Hormone treatment. The Growth Hormone dose was increased by 1.2mg and the endocrine plan was updated to reflect annual blood tests to measure hormones and a repeat bone density scan was to take place in their 15th year.  12.23  The next week following the clinic appointment Child F attended at the medical bay in school 2; Child F had fallen over on the school field after feeling dizzy and landed on the side of their face. Child F felt okay and wanted to go to their street dance lesson. The school nurse ensured that the dance teacher was informed of the incident and also informed the Foster Carers.  1st A&E Attendance- 13th Year 12.24  Seventeen days following the dizzy spell in school 2, Child F presented at A&E following a fainting episode in church, Child F also had abdominal pain and had fainted for a few seconds after feeling clammy. History which was given at A&E included loss of consciousness for a few minutes, pale in colour and complaining of right sided abdominal pain. Child F also had reduced eating and drinking for a few days. Medical investigations were undertaken, which included clinical observations, blood pressure, abdominal scan and urine tests; results of which all came back as within normal range. Child F was discharged home after being given pain relief and the episode was recorded as a vasovagal episode11 which is also known as a fainting episode. The results of the abdominal scan were received and there was no abdominal or pelvic abnormalities detected.                                                            10 https://www.familylives.org.uk/advice/your-family/fostering-adoption-kinshipcare/special-guardianship-orders/ 11 https://www.medicinenet.com/script/main/art.asp?articlekey=7713 14  12.25  During this time feedback from Child F’s school (2) during the PEP meeting continued to be very positive. Child F was engaged and working well. Their behaviour and effort in lessons was described as excellent. Child F was keen to do well and was working towards becoming a prefect.   12.26  In contrast, the Foster Carers had started to report some changes in Child F’s behaviour which they were attributing to puberty and the impact of recent contact with the Mother. This contact had included the sibling and both children had struggled since this had taken place. In their Foster Carer Supervision, the Foster Carers advised their Supervising Social Worker (SSW) that they felt that Child F was pulling away from them. It was recorded by the SSW that the Foster Carers had stated that Child F had experienced a lot of stomach pains and had been dizzy on one occasion. This was also relayed to Child F’s Social Worker during a statutory looked after visit.  12.27  Also during this same month Child F had their Statutory CIC Review. The school (2) nurse did not attend this meeting, having not been invited.  2nd A&E Attendance- 13th Year  12.28  A week prior to their 14th Birthday Child F had a second attendance at A&E. Presenting symptoms where similar to the previous attendance three weeks earlier. Child F was complaining of symptoms of dizziness, abdominal pain, feeling clammy, had nausea and had vomited. Child F was accompanied by the Foster Carer. Blood and urine tests were undertaken and these returned within normal range, it was noted that Child F had elevated blood pressure of BP145/97; this was repeated and had reduced to 136/87. The Children’s Early Warning Tool12 was used and scored as Amber. During this attendance no detailed neurological history was taken and following review by the A&E doctor and after receiving pain relief, Child F was discharged home with the Foster Carer.  3rd A&E Attendance- 14th Year 12.29   Two weeks later following the attendance at A&E, Child F again presented at hospital, this time with a left ankle fracture which had occurred whilst participating in a sports activity at school 2. Child F received treatment, a below knee plaster back slab was applied and pain relief given, following review Child F was discharged                                                            12       The Early Warning Score is a guide used by medical services to quickly determine the degree of illness of a patient. CEWT 1 Amber -Trigger Nurse in Charge and Senior Doctor to review within 20 minutes. 15 home with the Foster Carer. 11 days later Child F was admitted to hospital as a day patient for a Left Ankle Reduction and Internal Fixation.  12.30   Also in this same month the Foster Carer advised Children Services that Child F was stealing money from them. The Foster Carers view was that Child F was stealing the money to buy junk food, this was on the basis that Child F was not eating with the family.  12.31   In June Child F’s Social Worker visited the placement to carry out a statutory visit. Child F was spoken to regarding the concerns raised by the Foster Carers in respect of stealing money. Child F denied this.  Child F advised the Social Worker that they had not been as happy lately and linked this to the abdominal pain that they were experiencing. The Foster Carers advised the Social Worker that they thought that Child F was using physical health as a reason not to have difficult conversations and that there was no medical reason identified for experiencing dizzy spells.  12.32   The Foster Carer contacted the GP at the beginning of the 2nd week of June for a telephone consultation. The Foster Carer advised the GP that Child F was complaining of 'not feeling well’ and was experiencing cramps in their stomach. The Foster Carer stated that Child F was complaining of being dizzy, nauseous and generally unwell. The Foster Carer advised GP that Child F was ‘faking’ their symptoms and that Child F had started being sick when told to get ready for school. Child F was said to be screaming and crying when asked to get into the car. The Foster Carer believed that the current issues all began after the younger siblings had contact with their mother; Child F had also disclosed abuse by their older sibling. The Foster Carer continued to identify a range of problems that they were experiencing with Child F including stealing money, getting up at night to eat food and having controlling behaviours. The GP was advised that the Social Worker was aware of these concerns. The GP concluded the telephone consultation and arranged for Child F to be brought to the surgery.  12.33 In mid-June Child F was brought into the doctor’s surgery accompanied by the Foster Carer. Child F was seen by the GP who had undertaken the telephone consultation with the Foster Carer. Initial problem was diagnosed as hyperventilation. Child F was on crutches and their leg was still in a plaster cast from the recent fracture. Child F was complaining of episodes of pain which spread across the lower ribs and into their chest. Child F also had experienced dizziness and tingly fingers and tingling around the mouth. Child F was observed to be breathing fast. The GP observed a quiet and meek looking child who appeared to be downcast and only smiled occasionally.   12.34   The GP attributed the tingling and dizzy sensations down to the fact that Child F was hyperventilating and that the symptoms were likely to be psychological in origin. Child F was offered mental health support but was not keen to access this; contact 16 details for mental health support were given to Child F and the Foster Carer advised that this would be discussed with Child F’s Social Worker. The GP noted that now Child F was growing up they were more aware of being a CIC. The GP noted that the Foster Carer lacked an empathetic approach. This is noted in the records but not acted upon by GP.   12.35 Three days later, Child F attended the medical bay in School 2 first thing feeling unwell. The Foster Carer was contacted and Child F was sent home. Child F also presented at the sick bay on the 22nd day and 23rd day again feeling unwell. On the first occasion it was suggested that Child F try their lesson and come back if they still felt unwell.  Child F was given an ice pack to cool their neck. On the second occasion the Foster Father was contacted and suggested that Child F should be encouraged to stay in class.  12.36   By the end of June a new referral was received by CAMHS. The referral stated that the Foster Carer was concerned for Child F’s wellbeing. Information contained in the referral indicated that Child F was faking being ill. The referral was accepted by CAMHS.  12.37   Also at the end of June the Foster Carer again contacted the GP for a telephone consultation. The Foster Carer was concerned about Child F; the Foster Carer stated that Child F had not contacted the CAMHS. Child F was refusing to go to school and would sit naked refusing to dress. When in school 2 the Foster Carer stated she was being contacted as Child F had vomited and needed to be brought home. Child F had attended contact with Mother the previous day and the Foster Carer advised the GP that Child F had asked for the contact to finish early; this was something Child F had never done before. The Foster Carer was concerned that Child F was becoming depressed. GP gave the Foster Carer the number for the CAMHS and advised the Foster Carer to ring that day, in addition GP referred Child F for a fast-track assessment and intervention.  12.38  There was telephone contact between the Social Worker and the CAMHS practitioner that week. The records indicated that the Social Worker was concerned as Child F had emotionally withdrawn from the Foster Carers. Child F was still being physically sick and stating they were unwell. There was also telephone contact between the Foster Carer and CAMHS on the same day, it was noted that the Foster Carer was indicating that there was a correlation between the symptoms Child F was experiencing and the trauma experienced in their childhood. Following the consultation an appointment letter was sent for the second week of month six.  12.39  At the end of June, the Social Worker carried out a statutory visit to the placement. During the visit Child F talked to their Social Worker about how they were feeling. During the discussion Child F also advised the Social Worker that they had concerns regarding the quality of care being given by the Foster Carer. Child F informed the 17 Social Worker that they had fallen over and that the Foster Carer had refused to help them to get back up again. The Social Worker discussed the issue raised by Child F with the Foster Carers and also raised concerns with the SSW. Following the visit a professionals meeting was arranged.   12.40 The following day the SSW visited the foster placement. The SSW spoke to Child F during this visit about their illness. The IMR author for CSC notes that the recording gives the impression that the SSW is reinforcing the idea that this is a psychological issue rather than a medical issue. Child F again disclosed concerns about the standard of care they were receiving. The SSW did discuss the concerns with the Foster Carers. The IMR author notes that the recording gives the impression that professionals are of the understanding that Child F’s concerns are psychological and therefore they interpret the evidence via that lens.  4th A&E Attendance- 14th Year – July 12.41 On the 3rd day of July13, Child F presented at A&E with their Foster Carer, complaining of feeling unwell and was experiencing dizziness and vomiting. The Foster Carer’s voice was heard during the consultation; informing the Doctors that Child F was fabricating their illness. Child F had not been attending school and was reported to be vomiting every morning and refusing to eat breakfast. The history taken by the Doctor identified that Child F had a history of depression and had made allegations of sexual abuse by Mother and older sibling. The Foster Carer reported that Child F had been staying in their room for three days refusing to leave. Child F had experienced mood changes and was awaiting an appointment with ‘a counsellor’. This reference was likely in respect of the new referral that GP had made to CAMHS.  12.42  Child F was spoken to and denied making themselves sick; advising that they were unhappy but could not elaborate why. Clinical observations were carried out and Child F’s blood pressure was noted to be elevated during three reviews 144/99, 152/103, 150/109. The Children’s Early Warning Tool (CEWT) assessed Child F as Amber. The Early Warning Score is a guide used by medical services to quickly determine the degree of illness of a patient. The assessment at Amber required Child F to be reviewed within twenty minutes by a Senior Doctor. The review took place and Child F was diagnosed with regular vomiting and following pain relief and assessment by the crisis team was discharged home. Child F was clear with the practitioner that they felt physically unwell but that everything else was fine.                                                             13        The style of the report in respect of dates has changed from July onwards to reflect the increase in concerns within a short timescale. 18 12.43  At the beginning of July Child F’s School 2 contacted the Social Worker expressing concern about the quality of care Child F was receiving in the placement. During the conversation the Social Worker informed the school that their understanding of the view of medical professionals was that the difficulties faced by Child F were psychological rather than a physical illness. On the same day the Social Worker spoke to the Foster Carer and the CAMHS Practitioner, there was no challenge in respect of the view that Child F’s problems were psychological.  12.44   Also in the first week of July a Professionals Meeting took place. It was noted that the Foster Carers were really struggling with Child F and did not have the resilience to be able to cope with the situation. It is clear that professionals were still not fully hearing and acting upon Child F’s voice. The information shared indicated that there was no medical reason for Child F’s difficulties and therefore the work with Child F would focus on emotional causes for their presentation. The ability of the professionals to “hear” Child F’s voice was undermined as Child F was very clear that there was a problem with their physical health.  The Social Worker was clear that all possible explanations need to be fully explored including both physical and emotional issues.  12.45  The practitioner from CAMHS did a follow up telephone call with the Foster Carer the following day. The Foster Carer confirmed that Child F was still unwell and being physically sick however the Foster Carer advised the practitioner that Child F was fabricating their illness and was lying and stealing. This view was not challenged by the practitioner.  12.46  On the 10th day of July, Child F was seen by CAMHS and a full assessment was undertaken. The assessment indicated that there was a complex picture of physical health issues which sat alongside other emotional and relational issues. During the consultation it was observed that the relationship between Child F and the Foster Carer appeared to be deteriorating further. This same day Child F was given a diagnosis of psychosomatic disorder14.  12.47  The following day Child F’s Foster Carers gave notice on the placement and Child F was moved to Respite Foster Carers. The Foster Carers stated that they were concerned about Child F’s behaviour impacting on the younger siblings.  12.48  On the 17th day of July the Respite Foster Carer contacted the GP. The Respite Foster Carer expressed concern that Child F was still being sick and advised that this was not self-induced. Child F was observed to vomit approximately an hour after food, they were also noted to hiccup and when sick observed to be bringing up bile                                                            14 https://adc.bmj.com/content/archdischild/99/Suppl_2/A558.2.full.pdf 19 and this was noted to be worse in the morning. The Respite Foster Carer advised the GP that she had been told that Child F’s problems stemmed from trauma and that Child F was receiving psychological support from CAMHS but the Respite Foster Carer wondered if there was an acid reflux issue as she had given Child F antacids and these had helped marginally. The GP arranged to see Child F three days later for review.  12.49   The Social Worker visited the respite placement two days later. Concerns were raised by Child F and the Respite Foster Carer in respect of the quality of care Child F had received in the previous placement. Child F made allegations regarding inappropriate handling by the Foster Carer during an incident when they were dizzy and unable to stand independently, Child F voiced the Foster Carer ‘kneeing them in the back on purpose and pushing them forward every time they tried to stand up’. The Social Worker discussed the concerns with the Respite Foster Carer and it was agreed that the Respite Foster Carer and the SW would continue to explore an explanation regarding what was happening to Child F. The quality of care issues were discussed by the Social Worker with their manager and Section 4715 enquiries were ruled out and the Fostering Service were tasked with raising the issues with the Foster Carer. The issue was not discussed with the Local Authority Designated Officer (LADO16). This is a key practice area.  12.50  This same day a multi-disciplinary team discussion took place at CAMHS to discuss Child F. The information regarding the foster placement breaking down was not known by the person presenting the case although the service had been informed of this information some two days previously. The outcome was for work to be undertaken with the carers and art therapy for Child F.   12.51   On the 20th day of July the Respite Foster Carer and Child F presented at the GP surgery and were seen by the same Doctor whom had seen Child F during their previous presentation. The Respite Foster Carer allowed Child F’s voice to be heard. Child F advised the GP that “I feel sick, my eyes go blurry and I see two things, I go dizzy. Child F disclosed that they had been having headaches since month nine of their 13th year”.17                                                              15 Where there are child protection concerns, the local authority must make enquiries and decide if any action must be taken under section 47 of the Children Act 1989            16https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/729914/Working_Together_to_Safeguard_Children-2018.pdf    Chapter 2 Para 4 17        Voice of Child F as detailed in GP notes 20 12.52  The Respite Foster Carer advised the GP that Child F was having episodes of vomiting and preferred to lie down. Their sleep at night was observed to be poor. The Respite Foster Carer stated that Child F was taking what was happening in their stride. Child F was not currently in School 2. On examination the GP noted that Child F was limping and that their right foot appeared to have a loss of proprioception18 and Child F had an unsteady wide gait using their arms to balance and preferred to hold onto someone. A full assessment was undertaken. Child F’s pupils were equal and reactive, nystagmus19 to right and diplopia (double vision) looking left.  Neurological symptoms at that time were obvious and the GP made an urgent referral to the Acute Hospital for an urgent paediatric assessment that same day.   5TH A&E Attendance- 14th Year – July 12.53  Child F and the Respite Foster Carer attended A&E. Clinical tests were undertaken Child F’s blood pressure was elevated 135/92 and pulse rate was 102. An MRI brain scan was undertaken and a mass was seen on the MRI indicating a Brain Tumour. Paediatric Consultant and Paediatric Registrar discussed the results with the Respite Foster Carer and Child F. Child F was informed that they were going to be transferred to a Paediatric Specialist Hospital for further treatment and Child F requested for their biological Mother to be present if they had to go to another hospital; this was agreed. Child F’s previous Foster Carer was also informed about the diagnosis and attended the hospital.  12.54   On the 21st day of July Child F underwent surgery to remove part of the tumour: Following the surgery Child F required intensive care treatment and was transferred to a ward after two days. Child F subsequently received both radiotherapy and chemotherapy but sadly died some months later in a children’s hospice.     13.   HEALTH OVERVIEW REPORT 13.1 A Health Overview Report was completed by the Designated Nurse for Children in Care. The significant events in relation to health have already been identified and are contained in Section 12. The key practice areas are identified below:                                                            18         Proprioception is the unconscious awareness of sensations from our joints, muscles and ligaments. It provides us with an internal awareness about where our body parts are moving in space. http://www.wales.nhs.uk/sitesplus/documents/863/Strategies%20to%20help%20manage%20reduced%20proprioceptive%20awareness%20%20%2008%2001%202015.pdf 19 https://www.rnib.org.uk/eye-health/eye-conditions/nystagmus 21         Care and Delivery Problems 13.2 The first key area of practice identified in the Health Overview Report was in respect of Care and Delivery Problems. The Overview Author identified that this was an issue in a number of settings. The GP recorded early in June when Child F was seen in the surgery with the Foster Carer that the Foster Carer lacked an emphatic approach. This observation did not prompt the GP to take a different approach or take a precise neurological history, the primary focus of this consultation was Child F’s mental health. The concerns were not shared with CSC.  13.3 Lack of professional challenge or escalation in respect of the comments made by the Foster Carers about Child F on the 26th June 2017 and the 8th July 2017. The voice of the Foster Carers overpowers Child F. The deterioration in the relationship between the Foster Carer and Child F during the mental health appointment on the 10th July 2017 did not prompt a discussion with CSC.   13.4 There are issues identified in respect of the CIC Nurse Team Records with both presentations at A&E by Child F on the 3rd July 2017 and the 20th July 2017 not being recorded. Previous attendances earlier in the year in March and April 2017 were recorded but the overview author notes that there is no investigation regarding the attendances or evidence of professional curiosity.   13.5 The CIC Nurse also did not attend the Statutory Review in April 2017, there was no evidence that apologies were sent to the meeting or a report provided. The Health Overview Author notes that the symptoms of a neurological issue were present at the March A&E attendance and the information was readily available for the CIC review. This was a missed opportunity.  13.6 The penultimate A&E attendance evidences a lack of monitoring and assessment of Child F’s high blood pressure. This combined with the other presenting symptoms such as vomiting, dizziness, pins and needles and generally feeling unwell should have resulted in more medical investigations. Instead there was an emphasis on Child F’s Mental Health and this was a missed opportunity to thoroughly assess Child F’s presentation. Child F had presented on four occasions to A&E with physical and neurological symptoms which should have warranted a Paediatric Review. When Child F was reviewed by CAMHS during this attendance Child F clearly voiced that they were not making themselves sick yet this did not elicit any curiosity or challenge by the CAMHS practitioner nor was this information shared with the medical staff.  22 14. RESPONSES FROM THE KEY LINES OF ENQUIRY  Did being a looked after child impact on the actions of practitioners? 14.1 Child F was a CIC and subject to a Full Care Order; as a result of this status the Local Authority was their legal parent and shared parental responsibility20 with Child F’s birth parents. As legal parent, the roles, responsibilities and rights of the parent thus fell upon the LA. One question this review has to answer is whether Child F’s status as a CIC impacted on the decisions which were made and sadly this does seem to have been a contributory factor in this case.   14.2 Child F did not have anyone in their corner who was challenging the picture presented by the Foster Carers. To truly understand this we have to ask what in similar circumstances would any reasonable parent have done if their child was presenting with the same symptoms as Child F. It is likely that the majority of parents would advocate on their child’s behalf and ensure that there was a challenge to health professionals. They would not accept an explanation which did not fit with their perception of what was happening; parents would shoulder the burden so the child did not have to. There were a number of professionals who had contact who could have advocated for Child F and escalated concerns but failed to do so. There was a lack of professional curiosity and challenge by all professionals.  14.3 The IMR author for CSC noted that Child F, like many children in care, had survived difficult and traumatic life experiences, such experiences as may leave one depressed, anxious and in trauma. Once the hypothesis was established that Child F was suffering emotional turmoil there would have been many experiences of trauma in life to identify from.   14.4 We now know that Child F had been experiencing problems symptomatic with a neurological condition for approximately ten months preceding diagnosis. These symptoms were not always present initially but in the latter months prior to diagnosis Child F advised a number of professionals that they were unwell, commenting that they thought they were seriously ill. Yet despite stating this it did not galvanise the sort of response that most parents would take in these circumstances. The majority of parents would be escalating their concerns and demanding an explanation or a second opinion. Being a CIC seemed to exacerbate the lack of response, there was a reason for Child F’s symptoms which was widely accepted. Apart from School 2 challenging the standard of care there was no other professional willing to challenge the picture presented.                                                             20 https://www.gov.uk/parental-rights-responsibilities 23  14.5   Polarised views had been noted by the CAMHS practitioner who saw both Child F and the Foster Carer, following the referral to that service, with Child F being very clear that they were physically unwell and the Foster Carer viewing the symptoms as psychological and being caused by a trigger event of life story work which was being undertaken at that time. Following this triage an initial assessment was arranged for Child F but this was for 14 days following the triage appointment rather than the recommended seven days. Child F’s care history and being a CIC, plus the Foster Carers entrenched view that the issues were psychological and triggered by their early experiences, is likely to have influenced the CAMHS practitioner to not hear truly what was being said by Child F or to challenge the view of the Foster Carer.  14.6   Lord Laming (2009) stressed the importance of ‘respectful challenge’ of parents, colleagues and professionals in other agencies and remarked that this needs to be an integral part of professional practice. In this review, challenge which should have taken place between CSC and the Health Practitioners did not take place. The use of escalation would have been appropriate on a number of occasions.  Was the voice of the child heard in this case? 14.7  This Managed Review explores the circumstances of Child F a fourteen year old young person who was on the cusp of emerging adulthood.  Child F was not a child without a voice; Child F was clearly and for a considerable period of time voicing concerns about their health. Child F knew something was wrong. Multiple professionals spoke to Child F however with hindsight no professional prior to the day of diagnosis truly listened, heard and acted, on what was being articulated by Child F. Professionals from both Health and Children’s Services failed to act upon the concerns Child F was voicing and the views and opinions of the Foster Carer held much more weight.   14.8   During their placement with the first Foster Carer, the Foster Carer’s voice was significant in reporting concerns around behavioural issues, compulsive lying and physical lashing out. This was during a time when both Child F and the siblings future was uncertain and Care Proceedings were ongoing Child F’s voice at this time spoke of the emotional challenges they were going through.  14.9  Child F was not spoken to alone by medical professionals and saw many of these over the months including four occasions in A&E and two occasions with the same GP, in addition Child F was a CIC and as such their medical and health needs would have been regularly reviewed by the CIC Nurse Team and overseen by their Independent Reviewing Officer (IRO) at their Statutory CIC Reviews  24 14.10  During the Practitioners Event the GP identified that in their initial consultation with Child F and the long term Foster Carers, Child F’s voice was ‘drowned’ out by the Foster Carer. The voice of the Foster Carers without doubt carried influence and their voice was truly heard and acted upon. This was not only evident in relation to health but also in respect of the Police investigation into the allegations made of sexual abuse by their older sibling. Whilst Child F’s recollection changed between the two interviews it was the information recorded in Child F’s medical notes, indicating that they had behavioural difficulties and lied, which appears to have influenced the Police decision not to proceed. Child F was not perceived as a credible witness.   14.11 The Foster Carer did not act in malice but from a belief that Child F had longstanding psychological issues related to trauma. The system around them failed by not using an escalating process in place to be able to challenge and advocate for Child F.   14.12 The IMR Author for CSC identified that the scripts that professionals identify with when working with “damaged children”, coupled with the medical response created a “perfect storm” which literally drowned out Child F’s voice despite Child F continuing to rightly express that something was seriously wrong.  14.13 Child F’s voice was heard on a number of occasions but it was the Foster Carer’s voice that carried the most power as identified in 12.11, 12.28, 12.31, when the Foster Carers advised the Social Worker that they thought that Child F was using physical health as a reason not to have difficult conversations and that there was no medical reason identified for experiencing dizzy spells. 12.32 - when the Foster Carer stated Child F was faking their symptoms, 12.34 to 12.36 - during a telephone consultation with the GP the Foster Carer again stated that Child F was faking their symptoms. The Social Worker during a telephone call with CAMHS in 12.38 expressed the Foster Carer’s version and not Child F’s voice.    14.14 Child F raised concerns about the standard of care they were receiving from the Foster Carer as evidenced in section 12.39. In 12.40 during the A&E appointment it was again the Foster Carer’s voice that practitioners listened to. The Social Worker again failed to evidence Child F’s voice during a consultation with school 2 in 12.42, despite the school clearly raising concerns regarding the care Child F was receiving. In 12.48, after Child F moved to the Respite Foster Carer their voice was again not acted upon. A Section 47 investigation did not take place despite the serious nature of the allegations that Child F had raised regarding their Foster Carer.  There was not a referral to the LADO and it was not until Child F moved to the Respite Foster Carer and attended the GP at 12.49 that their voice was truly heard and action taken.  25 14.15 After the Practitioners Event concerns were raised by an attending Health Practitioner that Child F’s voice was still not heard even after the terminal prognosis. There was a clear disagreement between agencies about how and when to answer questions around how this situation was to be managed. There was not an Independent Advocate identified to mediate and reach a decision that was in Child F’s best interest. This matter was eventually resolved and an Advocate put in place but this was at a very late stage and this situation should never have occurred given how ill Child F had become. This incident has fallen outside of the parameters of the review but is particularly relevant given how Child F’s voice was silenced in the many months leading up to diagnosis.  Did the history of earlier abuse cloud medical judgement? 14.16 Many Children in Care have experienced adverse childhoods and often trauma can manifest in their behaviours. Maltreatment can take many forms, it can be physical, emotional, neglect, sexual and physical abuse. The child experiences the kind of parenting in which key nurturing experiences are missing, leading to developmental impairments (Howe, 2009).21 Knowledge about early childhood trauma is becoming well embedded in current social work practice and Foster Carers undergo training about the impact of trauma on a child or young person development and also training in respect of attachment.  14.17  In this context it can be understood how the Foster Carer moved towards a trauma based explanation for the difficulties being experienced by Child F, the medics had not found an organic reason for the symptoms. Therefore the professionals involved with Child F at this time, lacked curiosity or healthy scepticism regarding the lack of a medical explanation. The psychological explanation which fitted with the “scripts” of what they thought was occurring and also fitted with their knowledge and learning in respect of trauma. This was done to the exclusion of all other explanations. Systems in place to guide the Foster Carer’s views such as robust and challenging supervision did not take place and there was no process in place to challenge the emerging picture.    Was Child F seen as troubled or troublesome by practitioners?  14.18  The IMR from School 1 identified the difficulties that they experienced in understanding and dealing with Child F’s complex behavioural and attachment needs. As a result they were unable at times to meet needs and felt that there was                                                            21 Howe D (2009) ‘The impact of histories of abuse and neglect on children in placement’ in Schofield G and Simmonds J (eds) The Child Placement Handbook. London: BAAF 26 limited therapeutic support available for them to access. Some of the complex behaviours identified included violence towards other pupils including kicking, verbally aggressive behaviour and barking like a dog.  School 1 felt that the behaviours exhibited were beyond the expertise offered in a school setting and that specialist help for Child F was needed. The transition to Foster Carer 2 was also cited as an area where better planning would have assisted as they had little time to prepare for the transition and it was at a time whereby consideration regarding permanent exclusion was being considered with the school advocating a move to a Pupil Referral Unit (PRU). This was not agreed by the Social Worker who identified that Child F would struggle with this on top of a placement move. The IMR Author identified that training for educational staff in respect of attachment would have been of benefit.  14.19 The CSC Author noted that the idea of Child F as a troubled child was a widely held view amongst professionals and this was ‘driven by an assumption that their behaviour was as a result of psychological issues’. A knowledge of Child F’s early experiences and difficulties they faced regarding familial contact was well known amongst the professional network and powered these assumptions. This view however was not held by all agencies and the Community Foundation Trust Author noted that there was no evidence of Child F being viewed as troubled or troublesome by either the Psychologist who carried out the assessment at CAMHS or by the School Nurse, however what is not considered in this analysis is the subliminal messages absorbed by professionals in respect of Child F’s history along with the Foster Carers view and how this impacted on professional opinions and assessments.  14.20 School 1 identified that in the month of their 12th Birthday Child F was seen as troubled and troublesome, however within a couple of months their behaviour had changed, and they presented as much more settled at home and the incidents had reduced. Child F was looking forward to starting Year 8.   Could and should something different have been done given their presentation at different health settings? 14.21 The attendance of Child F on five occasions at A&E in as many months should have triggered a more robust response from Health Partners and CSC. The Community Foundation Trust in their response identified that the fracture in the middle of a group of attendances for vomiting and dizziness may have detracted from what was clearly an ongoing problem. However four attendances at A&E with the same symptoms should have triggered a response from Universal Services, Child F’s Social Worker and the CIC nurse, to review Child F’s health needs, yet this was missed.  27 14.22 It was only during the last presentation at A&E on the day of diagnosis that a full clinical history was taken from Child F, during this Child F disclosed having suffered from headaches and nausea since the October of the previous year. This information had not been shared at the previous attendances and it is likely that the Foster Carer’s voice, identifying that Child F was fabricating their symptoms, was given precedence over Child F’s, thus ensuring that this full history taking did not take place. Child F attended at hospital on three previous occasions with a clinical presentation of dizzy spells, fainting, feeling clammy and abdominal pain.   14.23 The IMR author from the Acute Hospital has noted that during Child F’s first attendance they did not present with any blood pressure issues however during their second attendance with the same clinical symptoms their blood pressure was high, triggering Amber on the CEWT score. The Author notes that a diagnosis of vasovagal episode was made. The Author notes that this diagnosis is associated with a drop in blood pressure thus bringing on a fainting episode. This second presentation with repeat clinical symptoms of a neurological nature coupled with high blood pressure should have brought about a different response and may have resulted in an earlier diagnosis.  14.24 One would have expected there to have been some professional challenge from either CSC via the IRO or the Social Worker to Health with a request for more thorough examinations and testing of Child F, but this did not happen and professionals were not sighted on the potential for Child F to be seriously ill.   14.25 However what is striking is that Child F was spoken to alone by their SW, IRO and also the Foster Carers SSW and did not disclose their full range of symptoms and how long they had been ill.  15.  Key Practice Issues / Learning  Theme: Voice of the Child 15.1 This review has clearly evidenced how marginalised Child F became in the last year of their life and how they were not listened to in any meaningful way. In the circumstances where there is such clear disagreement it would have been appropriate for an Independent Advocate to have been made available to them.  15.2 In the analysis of SCRs evaluated by Ofsted between 2009 and 2010 it was identified that too often the focus on the child was lost; adequate steps were not 28 taken to establish the wishes and feelings of children and young people, and their voice was not sufficiently heard22. 15.3 It would be difficult to argue that Child F’s voice was not heard as this review has clearly demonstrated. Their voice was heard loudly and clearly but no professional truly listened and then took action. Hearing Child F’s voice without acting on what they are saying is a theme in this case that continued to resonate past diagnosis.  Theme: Poor Communication and Information Sharing 15.4 There is evidence of inter-agency communication and information sharing not being as good as it should be. At the Practitioners Event it became clear that CSC as Child F’s corporate parent had not been liaising with the Consultant Endocrinologist and information which may have shone a different light on what was happening for Child F. This was also evidenced in placement changes when a different Foster Carer would attend clinic and in the latter year when the concerns regarding Child F’s health were not shared.  15.5 The Foster Carer had delegated authority and attended all Child F’s health appointments. Delegated Authority’ refers to the arrangements for all or some of the responsibilities held by those with parental responsibility,23 being met, in certain circumstances, by someone else, the someone else can be the Foster Carer. This is in place primarily to ensure that Foster Carers can make day to day decisions about the children they are caring for. Some of these decisions may be in respect of a child or young person getting their hair cut, consent to medical treatment and who they may have contact with. The Foster Carer does not acquire parental responsibility, this remains with the Local Authority and the child’s parents. The Social Worker should have been sighted on and had a role in coordinating the appointments by speaking to health professionals however this did not happen.  15.6 Good multi agency working between professionals involved with Children in Care is absolutely crucial to improving children and young people’s outcomes and to resolving issues. Effective care planning and opportunities to share information in a meaningful way were not present.  In the analysis of SCRs evaluated by Ofsted between 2009 and 2010 it was identified that in most of the SCRs analysed there were sources of information that could have contributed to a better understanding of                                                            22 https://www.gov.uk/government/publications/ofsted-learning-lessons-from-serious-case-reviews-2009-2010 23 https://www.gov.uk/parental-rights-responsibilities 29 the children and their families. They also highlighted concerns about the effectiveness of assessments and shortcomings in multi-agency working.         Theme: Lack of Professional Curiosity and Professional Challenge 15.7 The need for professional curiosity about repeated symptoms and signs which may indicate that something more concerning is happening was a key learning point in this review. Neither Health nor CSC staff seemed to wonder what else could be at play given the number of presentations made at A&E with the same or similar symptoms. CSC deferred to the medical view. This listening to the expert opinion of Doctors was undertaken without heed to what Child F was reporting. 15.8 There was not appropriate challenge to the views and opinions of Foster Carers. There was an assumption that the Foster Carers knew and understood what was happening to Child F. Supervision of the Foster Carers was not sufficiently challenging and neither the Social Worker nor SSW challenged the picture being presented.           Lack of adherence to Safeguarding Procedures 15.9 The quality of care issues that were raised by Child F received a wholly inadequate response by CSC. There should have been a Strategy Meeting and enquiries under Section 47 of the Children Act in respect of the second set of allegations that Child F made. The LADO should also have been consulted and a referral made. There was no investigation as to whether it was a safe placement for the children to live in. The school also raised the concerns on Child F’s behalf with CSC. 16.  PRACTITIONERS EVENT 16.1 A Practitioners Event took place and was attended by practitioners and managers from the main agencies. Some key information was shared during the Practitioners Event which clarified information already provided by agencies via IMR’s and contextual information regarding the family was shared. Attendance at the Practitioners Event was good and those attending participated actively in assisting with analysis of events and identifying learning from the case. Some key personnel such as the IRO did not attend.  16.2 During the Practitioners Event a key issue identified was in respect of information sharing across the many different health economies. In particular the Specialist Consultant Endocrinologist was not aware of Child F’s many presentations at A&E and this presented a key missed opportunity for information sharing. Some of these 30 issues have now been resolved by the introduction of a new system for sharing information within Health.  16.3 The Consultant Endocrinologist who knew Child F and siblings, well and had seen them as part of their treatment for their Growth Deficiency also had a period of absence in periods during 2015 and in 2016/17 and felt this impacted on the continuity of care the siblings received.  16.4 It was identified that there was a lack of knowledge amongst many professionals about the early symptoms of brain tumours in children, this could lead to late diagnosis as in Child F’s case.   16.5 Lack of challenge and escalation from CSC. CSC were Child F’s Corporate Parent however there was no-one who advocated or escalated concerns on their behalf.  16.6 Child F’s voice was heard by professionals but not acted upon. The Foster Carer wielded a lot of control and their voice overrode Child F’s on occasion, this in turn influenced the services and care received. The GP reflected on the two consultations that had taken place at the surgery and how at the first consultation the Foster Carer’s views regarding Child F influenced the decisions made.   16.7 The GP reflected on a very different approach taken by the Respite Foster Carer and how Child F’s voice was clearly heard and acted on however this was also influenced with the obvious visual signs of a potential neurological issue. The GP has, since this time, ensured that she hears and acts upon children’s voices.  17.   CONCLUSION AND RECOMMENDATIONS 17.1 In 1989 the United Nations Convention on the Rights of the Child (UNCRC) set out in detail what every child needs to have for a safe, happy and fulfilled childhood24. Article 12 includes the assurance that every child who is capable of forming a view shall have the right to express those views on all matters affecting the child, and these should be given due weight in accordance with the child’s age and maturity. Moreover, the child shall be provided with the opportunity to be heard in any judicial and administrative proceedings affecting the child. Complementary rights are enshrined in Articles 6 and 8 of the European Convention on Human Rights (ECHR).  17.2 When diagnosed, Child F had an aggressive Grade 4 tumour which was cancerous and at that stage life limiting. It is not possible for this review to identify if an earlier diagnosis would have led to a more positive outcome. However earlier detection may                                                            24 https://www.unicef.org/french/adolescence/files/Every_Childs_Right_to_be_Heard.pdf 31 have enabled Child F to have undergone earlier treatment and to have fulfilled some of their wishes which sadly they were unable to do at the end of their life.  17.3 This case has identified that there were lessons to be learnt across many of the agencies in respect of practice which truly enabled Child F’s voice to be heard, understood and acted upon.  17.4 Child F was a bright young person who was approaching their fifteenth birthday. Child F had the competence and understanding to know what would have been involved in their treatment. They had the right to be informed they were going to die when they asked the question.   17.5 Knowledge of the prevalence and symptomology regarding brain tumours in children is variable across the partnership. Children and young adults in the UK experience, on average, a longer time between the onset of symptoms and diagnosis (symptom interval) of a brain tumour than their counterparts in many other countries.25 Headsmart.org.uk have a range of free downloadable materials that boards and agencies can make use of to raise awareness. The materials include posters, symptoms cards and symptom diaries.   17.6 Managing conflict and working with challenging carers whilst not losing the focus on the child was a feature of this review.  17.7 There was evidence of ineffective management oversight; there was a lack of reflection as to whether the plan was correct and even when new information became evident this did not change the course of action or harness any challenge. When information was presented regarding the quality of care issues there was a lack of adherence to basic safeguarding procedures. This has identified gaps in the knowledge and skills in the Children in Care teams.  Recommendation 1 A mechanism should be identified as a priority to ensure that children who are cared for by the Local Authority are provided with advice either from an independent legal advisor or advocate when they are in disagreement with professionals or carers.  This should be undertaken in a timely manner.                                                             25 https://www.headsmart.org.uk/clinical/information-researchers/ 32 Recommendation 2 The LSCB and partner agencies should ensure that practitioners and line managers are able to evidence that children and young people have been listened to and their wishes and feelings heard, understood, regarded and taken into account in decision making and planning.  Recommendation 3 Awareness raising regarding the prevalence and symptoms of brain tumours in children and young teens should take place as a priority across the partnership.  Recommendation 4 Training should be delivered across the partnership to ensure that practitioners have the skills to manage similar situations in the future.  Recommendation 5 Lessons from this review should be incorporated into Foster Carer recruitment, training and supervision, by CSC. This should be audited by the LSCB to ensure compliance.  Recommendation 6 Social workers in the Children in Care Teams will undertake LADO training with their staff   Notable Practice identified in this review 17.8 The Health Overview Author identified two areas of practice which warranted mention. The first is in respect of the referral to CAMHS which was sent on the 26th June 2017. Child F was seen for a face to face appointment with the Foster Carer on the 10th July. They were seen within eleven working days of the initial contact.  17.9 The GP was responsive and proactive when dealing with the issues raised via the telephone consultations with the Foster Carer. The same GP then saw Child F in the surgery with the Foster Carer thus ensuring continuity of care.  33 17.10  School 2 also supported Child F throughout their time there which appeared to be positive and a place of stability for Child F. The school also appropriately raised concerns on Child F’s behalf in respect of the quality of care issues.  Single Agency Recommendations  Community Foundation Trust 17.11  Community Foundation Trust to review communication and pathways relating to Statutory CIC Health Assessments and ensure there is robust guidance in place that clearly defines roles and responsibilities.  17.12  Community Foundation Trust to review policies/SOP relating to the follow up of A&E attendance and the management of repeat attendances by CIC Child and Young People.  17.13  Community Foundation Trust to review how the voice of the child is captured and recorded in all contacts.  Acute Hospital 17.14   Voice of the Child: The Acute Hospital to uphold the voice of the child and demonstrate appropriate responses to that voice ensuring that a child’s wishes and feelings are considered and addressed.  17.15   Observations: Acute Hospital to review staff responses and practice to the use of the CEWT Scoring system ensuring that appropriate reviews are carried out in view of the RAG ratings.  17.16   Curiosity: Acute Hospital staff to apply some degree of professional curiosity and be inquisitive when a child continues to present with the same symptoms, ensuring all risk is averted.  17.17   Pathways: Acute Hospital A&E and Paediatric Assessment Unit to work jointly to develop a pathway that will trigger notification for repeat attendances and reconsider their management plan.  17.18   Advocacy: Acute Hospital Staff to act as advocates for Children in Care at all times ensuring that their needs are prioritised and all concerns communicated to the local authority that looks after them.  34 School 1  17.19 School 1 have identified some learning on the fringes which will be followed up through the Managed Review Panel Education representative.  17.20  Train staff in attachment issues  17.21  Ensure that all teachers of children with complex emotional needs understand the behavioural support plan in place.  17.22  Looked after children who exhibit troubled behaviour should have regular multi agency review meetings. These are to be in addition to PEP meetings.  17.23 To continue to push external agencies to provide specialist interventions.  17.24 To report to senior practitioners earlier on if no support is given (as time delay is an issue)  17.25  To request that the Social Worker/Foster Carer apply for needs assessment for an Educational Health Care Plan (EHCP) when attachment issues are raised.  17.26 Request Educational Psychologists support via Social Services and Virtual School (school access is limited and has been reduced - hence support needed via CSC system)  17.27 Request for specialist counselling via Social Services (school provision is only tier 1 and Looked After and in care for child requires specialist support)  17.28 Continue to invite Children in Care for extra transition days which we can run.  Clinical Commissioning Group 17.29  Childs Voice: All health staff seek, hear and act on the voice of the child (including children who do not necessarily have a voice, including those with complex and severe developmental, physical, emotional and mental health). They should involve children at each stage of their health history taking and care planning, and listen and respond to their views about their concerns and what is important to them.  17.30  Precise Neurological History Taking/ Errors in clinical reasoning: Any child or young person who presents with history/complains of early signs and symptoms of intracranial pressure, should be clinically examined, assessed, analysed and if necessary to seek a second opinion and refer urgently. 35  17.31 Sharing concerns about Foster Carers/Parents- Information Sharing: All health staff- primary care to ensure that any parenting capacity concerns noted/felt/observed about a Foster Carer/Parent that may impact and or affect the parenting of a child must be shared with CSC / Fostering Team and or CCG Safeguarding Team.  17.32 Professional Curiosity/ Challenge/ Respectful Questioning: All health care/ primary care practitioners should be able to challenge and be curious enough to have exploratory discussions with foster carers and parents where there are uncertainties to information provided. Health/ primary care staff should be confident to respectfully challenge their patients, parents and carers and this culture should be embedded in practice. Where there are concerns SET guidance should be followed.  17.33  Dissemination of Learning: CCG to embed findings and lessons to be learned into Primary Care Level 3 Safeguarding Training and GP Forums with an emphasis on the voice of the child, sharing information, professional challenge, professional curiosity, respectful questioning and neurological history taking.   Children’s Social Care 17.34  Clarification for all staff around the expectation for CIC to be supported by an independent advocate.  17.35  Clarification around how to address concerns raised by children in relation to their carers.  17.36 Clarity in the expectation and process around challenge between health and CSC agencies.  17.37 The Local Authority to ensure that all professionals involved in this case receive support to address the emotional impact upon them.  Educational Psychology Service 17.38 Consideration to be made of whether more systematic reviews of CIC children should be carried out by the Educational Psychology Service in liaison with the Virtual School.  17.39 Consideration to be made of developing a mechanism for social workers to discuss any changes in the health and wellbeing of children (significant enough to stop them attending school) with the Educational Psychology Service.  36 17.40 Educational Psychology Service to ensure that informal conversations about both initial case allocation and transfer between colleagues are recorded on the child/young person’s file.   37 GLOSSARY  A&E Accident and Emergency ABE Achieving Best Evidence CAFCASS Children and Family Court Advisory and Support Services CAMHS Child and Adolescent Mental Health Services CCG Clinical Commissioning Group CEWT Children’s Early Warning Tool CIC Child in Care CP Child Protection CSC Children’s Social Care ECHP Education and Health Care Plan ECHR European Convention on Human Rights GP General Practitioner IMR Individual Management Review IRO Independent Reviewing Officer LAC Looked After Child LADO Local Authority Designated Officer LSCB Local Safeguarding Children’s Board NHSE National Health Services England PEP Pupil Education Plan 38 PRU Pupil Referral Unit SCR Serious Case Review SSW Supervising Social Worker UNCRC United National Convention on the Rights of the Child  