Death of a 22-month-old boy on 20 February 2013. Child S was taken to hospital after his mother found him lifeless. A post mortem examination established that he had suffered severe abdominal injuries. Mother and father were both convicted of causing or allowing the death of a child in December 2014. Child S had been the subject of referrals prior to his birth and had been subject to a child protection plan for emotional abuse since August 2012. Mother had a history of substance misuse and mental health issues and father had a history of domestic abuse and drug dealing. Learning points identified include: difficulties in working with individuals who disguise their compliance resulting in an overly optimistic view of outcomes for the child; misunderstanding between agencies about what and how information about adults who may post a risk to children can be shared; poor attendance by some agencies at initial child protection conferences. Recommendations include: development of clear joint information protocols for the police and children's social work services and a review of the booking system for initial child protection conferences to ensure a minimum notice period is given to professionals across all agencies.
      
 Title:  Independent overview report of the serious case review following the death of Child S. LSCB: Solihull Local Safeguarding Children Board Author: Mike Harrison, Jim Stewart Date of publication: 2015  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.                                                                                            SOLIHULL LOCAL SAFEGUARDING CHILDREN BOARD  Independent Overview Report of the Serious Case Review  following the Death of Child S  Date of Serious Incident: 20.02.2013  This report has been commissioned and prepared on behalf of the Solihull Local Safeguarding Children Board. Until publication this report is confidential and must not be shared with non-relevant parties.  References relating to the subject child, family members, organisations, and professionals have been coded and anonymised. Independent Authors, Overview Report    Mr Mike Harrison:  March 2013-December 2014 Mr Jim Stewart: December 2014- September 2015  Independent Chair, Serious Case Review Panel;  Ms Jane Held: March 2013 – November 2013 Independent Chair, Solihull LSCB   Ms Marion Davis CBE:  May 2013 - September 2014 Ms Edwina Grant OBE:  September 2014 - present day   Agreed by Solihull Local Safeguarding Children Board: 15th September 2015  CONTENTS   Foreword by Independent Chair ............................................................................................................ 3 1 INCIDENT LEADING TO THIS SERIOUS CASE REVIEW ......................................................................... 4 2 THE SERIOUS CASE REVIEW PROCESS ............................................................................................... 4 3  PARALLEL INVESTIGATIONS ............................................................................................................... 9 4 FAMILY INVOLVEMENT IN THE SERIOUS CASE REVIEW .................................................................... 9 5.  KEY TO PERSONS LISTED .................................................................................................................... 9 6 GENERAL FAMILY BACKGROUND .................................................................................................... 10 7 CHRONOLOGY OF SIGNIFICANT EVENTS IN RELATION TO THE INVOLVEMENT OF THE AGENCIES 10 8 ANALYSIS OF AGENCIES’ INVOLVEMENT ......................................................................................... 16 9 CONCLUSIONS ................................................................................................................................. 38 10 LESSONS LEARNED ........................................................................................................................... 40 11 RECOMMENDATIONS ...................................................................................................................... 43 Appendix 1: LSCB Action plan; Position statement. ............................................................................. 47 Appendix 2: Individual Agency Recommendations .............................................................................. 54 Appendix 3:  Roles of Agencies ............................................................................................................. 57 Appendix 4: Glossary of Terms ............................................................................................................. 59 Appendix 5: Bibliography ...................................................................................................................... 61     2  Foreword by Independent Chair  The death of a child is a tragedy.  This little boy, “Child S” was born in April 2011 and died on February 20th 2013.  Investigations into his death revealed that he suffered traumatic abdominal injuries sustained in a way that the experts say cannot have been accidental.  The investigation also revealed that only two people could have been responsible for his death.  His parents were sentenced at Birmingham Crown Court on 22nd December 2014 for causing or allowing the death of a child under the Domestic Violence Crime and Victims Act 2004.    All those who knew him, or worked with him, want to know what happened and why he died. Solihull Local Safeguarding Children Board (LSCB) began this serious case review process in 2013 in order to help those who worked with this child and his family to establish if there is anything we can do to improve how we work together in Solihull to help protect and support children in this situation better in the future.  This serious case review took place over a period of 2 and a half years.  The process took so long as during that time it was suspended to allow criminal proceedings to complete.  Producing this report has involved staff and family members as well as leaders in the organisations involved working hard to convey their reflections and bring this learning together.  The delay in publication did not prevent everyone who worked on this report making changes as soon as they realised they were necessary to deliver better practice following lessons learned.  Actions plans were produced by the LSCB as well as by each of the agencies involved and all have been delivered.    A summary of the current position of the LSCB action plan is provided at the end of this report.  Each organisation involved continues to improve and the Local Safeguarding Children Board coordinates the way we act on lessons learned from this review and also from reviews carried out in other areas in the country.  In the time it took to write this report, organisations have changed, some have  re-structured, procedures and training have been reviewed and new quality assurance arrangements have been put in place.  All these changes are delivered with the single objective to strive for excellence in how we work together to safeguard children.     Edwina Grant OBE LSCB Independent Chairperson  3  1 INCIDENT LEADING TO THIS SERIOUS CASE REVIEW   1.1 Ms M, the mother of Child S, called an ambulance to her home address in the early hours of 20 February 2013 having found Child S lifeless.  Child S was 22 months old at the time. Ms M reported that Child S had been ill for the previous two days.  Child S was taken by ambulance to the local accident and emergency department and he was pronounced dead at 5.32 am that morning. 1.2 A post mortem examination was carried out and expert medical opinion was given at the subsequent criminal trial.  It has been established that Child S had suffered severe abdominal injuries likely to have been caused by a blow or blows of some kind, the injuries probably having been sustained up to approximately twelve hours before his death occurred.  It was also confirmed that there were older abdominal injuries which indicated that Child S had been the victim of a trauma about two or three weeks earlier. 1.3 Child S had been the subject of referrals prior to his birth and had been the subject of a child protection plan since August 2012 for emotional abuse.  His mother, Ms M, had had involvement with a number of statutory agencies over a period of some years in connection with her substance misuse, experience of domestic violence and fluctuating mental health and mood. 1.4 The partner of Ms M, Mr N, who is believed to be the father of Child S, was staying in the family home at the time of Child S’s death.  His presence in the home was in contravention of the child protection plan and a working agreement with the local authority.  The agreement was that he should not be staying at the home when Child S was there, whilst an assessment was being completed due to his history of suspected drug dealing and domestic abuse.  1.5 Both Ms M and Mr N were arrested and bailed by West Midlands Police and interviewed on suspicion of the murder of Child S.  They were subsequently charged and then remanded.  A criminal trial took place between November – December 2014 and Ms M and Mr N were both convicted of causing or allowing the death of a child.  2 THE SERIOUS CASE REVIEW PROCESS   2.1 The events surrounding the death of Child S were considered by an independently chaired serious case sub group of the Solihull Local Safeguarding Children Board (LSCB) on 11 March 2013.  2.2 The relevant guidance on the holding of Serious Case Reviews at that time is contained in Working Together to Safeguard Children. 2010 (Chapter 8) Paragraph 8.9 and states that: “When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family.  This is irrespective of whether local authority children’s social care is, or has been, involved with the child or family.  These SCRs should include situations where a child has been killed by a parent, carer or close relative with a mental illness, known to misuse substances or to perpetrate domestic abuse.” 2.3 The LSCB Chair agreed with the sub group’s recommendation that the appropriate threshold criteria for holding a Serious Case Review were met and the Department for Education (DfE) and Ofsted were notified of the decision on 22 March 2013 and agency files were secured. 4  2.4 Guidance on the conduct of Serious Case Reviews (SCR) was revised by the Department for Education in March 2013 and later in March 2015 in revised editions of ‘Working Together to Safeguard Children’.  This SCR has been conducted under the guidance in force at the time of the death of Child S (Working Together 2010), although the circumstances for holding such a review would also apply under the revised guidance.  The contents of the new guidance issued in March 2013 has also been taken into consideration in the preparation of this Serious Case Review and the guidance subsequently issued in March 2015 in its conclusion.  Purpose of the review 2.5 The purpose of the review was to:  Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children.   Identify clearly what these lessons are, how they will be acted upon, and what is expected as a result.  Improve inter-agency working, better safeguarding and promoting the welfare of children.  2.6 In accordance with the guidance contained within Working Together (2010) a SCR panel was formed and an Independent chair and Independent author appointed. 2.7 Ms Jane Held was appointed as the independent chair.  Ms Held has an extensive background in children’s services having formerly been a Director of Social Services and a senior manager within the Commission for Social Care Inspection.  At that time Ms Held was also currently the independent chair of both Leeds and Birmingham LSCBs and highly experienced in the conduct of Serious Case Reviews. 2.8 Mr Mike Harrison was appointed as the independent author.  He is an experienced SCR author with over thirty six years’ experience in children’s social care services.  He has held a number of senior management posts in local authorities including as an assistant director of children’s services.  He is a former National Inspector of Children’s Services and HMI with Ofsted and has received training in authoring Serious Case Reviews from the National Safeguarding Delivery Unit and the Social Care Institute for Excellence.  He is fully independent of all of the safeguarding agencies comprising the Solihull Local Safeguarding Children Board. 2.9 Mr Harrison retired before the criminal trial took place following Child S’s death.  A further independent author, Mr Jim Stewart, was commissioned to update the report in the light of any further information and learning identified during the criminal proceedings and subsequent interviews with family members who agreed to assist this Serious Case Review.  Serious Case Review Panel 2.10 A Serious Case Review panel was established with the following membership: • Independent Chair: Jane Held (From March 2013- November 2013) • The panel was chaired by the LSCB independent Chair, Edwina Grant from September 2014 until it was completed. • Solihull Local Authority Children’s Social Work Services 5  • Birmingham and Solihull Mental Health Foundation Trust  • Welcome • Solihull Integrated Addiction Services (SIAS) • Heart of England NHS Foundation Trust • West Midlands Police • Solihull Community Housing • Solihull Clinical Commissioning Group Please see Appendix 3, page 57 for a description of these agencies. 2.11 In addition the following post holders formed part of the SCR panel • The Domestic Violence Coordinator • Local Authority Legal Representative • Drug and Alcohol Action Manager • LSCB Safeguarding Officer/Manager • LSCB Lay members  The independent author attended panel meetings but was not a member of the panel.  Terms of Reference 2.12 The terms of reference for the review were initially drawn up by the SCR Sub Group and subsequently modified and agreed by the SCR Panel in respect of the compilation of Individual Management Reviews.  The terms of reference for the review drew on the guidance contained within Chapter 8 Working Together (2010). 2.13 Specific terms of reference were set for the compilation of this overview report.  The report should identify the key inter agency system learning, good practice and specifically address:  a)  The effectiveness of multi-agency identification, analysis and management of risk and information sharing arrangements including any identified barriers to achieving effective management of risk b)  The quality of risk assessments and validity of any tools or processes used to identify protective factors as well as risk factors c)  The quality and impact of multi-agency planning and review processes used to promote improved outcomes for children d) The impact and quality of professional supervision and its contribution to securing child centred practice including exploration of the ‘rule of optimism’ or any over reliance on protective factors e) The application of ‘thresholds’ and the degree of shared understanding and agreement across the partnership of those thresholds 6  f) Any ’cultural practice norms’ that could impact on the professional network’s capacity to deliver child centred practice including responses to domestic abuse or substance using parents g)  The degree to which the multi-agency system operates with the child at the heart of its intervention and any ‘system’ barriers to securing this 2.14 The scoping period for the review was set between August 2010 being the onset of Ms M’s pregnancy with Child S and 20 February 2013 being the date of Child S’s death.  Methodology 2.15 The following agencies were asked to produce Individual Management Reviews (IMRs) •   West Midlands Police  •   Birmingham and Solihull Mental Health Foundation Trust •   Heart of England NHS Foundation Trust •   Solihull Community Housing  • Solihull Clinical Commissioning Group (on behalf of and in collaboration with their member practice)  •   Solihull Metropolitan Borough Council •   Welcome 2.16 Information reports which did not constitute IMRs were received from the following agencies: •  HMP Eastwood Park •  Staffordshire and West Midlands Probation Trust  •  West Midlands Ambulance Service  2.17 Independent authors who had had no previous involvement with the case were identified by those agencies which had been asked to produce an IMR.  A briefing for those authors was held on 8 April 2013 led by the chair of the Serious Case Review Panel and involved the SCR panel members.  2.18 The terms of reference and scope of the review were provided to the IMR authors together with a standardised format for the production of the IMR reports.  The IMR authors were asked to compile a chronology of their individual agency’s involvement with the child or family using both electronic and paper records held by each agency and to comprehensively review that involvement.  2.19 In doing so the IMR authors conducted personal interviews with the key individuals who had involvement with Child S and Child S’s family.  The aim of the interviews was to look openly and critically at what happened in the case, to evaluate what actions were taken or not taken and why, to indicate any lessons to be learned for future practice and to make recommendations for action.  In completing the individual management reviews the authors were asked to take cognisance of the relevant guidance on such matters as contained in Working Together to Safeguard Children (2010) Paragraph 8.39. 7  2.20 The SCR Panel were provided with the completed IMRs and had the opportunity to question and challenge those reviews at panel meetings held on 10 June 2013 and 8 July 2013 where the IMR authors were present.  As a result of those challenges, the IMR authors completed further investigations and the IMRs were modified and enhanced, which improved their quality and analysis.  The SCR overview author was present for all of the case discussions, and was able to question the IMR authors and fully debate the issues in the case with the SCR Panel from an independent perspective.  2.21 The individual management reviews contain reference to relevant research in a number of areas and the independent author has had the opportunity to review that research and its bearing on this case, as well as reviewing other guidance and research independently.  Those sources of research are fully referenced at the end of this report.  All IMRs received by the SCR Panel were certified by a senior officer in each individual agency as having been completed to the standard required by Working Together (2010) Paragraph 8.35.  2.22 A Learning Event was conducted on 19 August 2013 facilitated by the independent chair of the panel and the independent author.  The aim of the event was to involve relevant staff in the SCR process, based on restorative practice principles, and to gain their insights into why events happened as they did, and to assist in identifying and disseminating learning from the case.  A total of 14 professional staff attended the event with representation from across the safeguarding agencies involved in this case. 2.23 A health overview report comprising information derived from the IMRs of the various health agencies involved was compiled by the designated nurse for safeguarding children.  This report was accepted by the SCR Panel as the health overview report on behalf of the Clinical Commissioning Group in its role as commissioner of health services in accordance with requirements in Working Together (2010) Paragraph 8.35. 2.24 The SCR independent overview author has prepared this overview report based on the IMRs received by the SCR Panel, the detailed discussions in panel meetings, the content of the learning event, and relevant guidance and research. 2.25   A meeting of the Solihull Local Safeguarding Children Board (LSCB) held on 16 September 2013 considered an initial draft of this overview report.  As a result of those considerations the Board issued a request for additional work on the review.  2.26 This additional work was commissioned by the LSCB Chairperson which was carried out under the leadership of the Independent SCR Panel Chair and in conjunction with the Independent Overview Report Author. 2.27 The aim of this was to inform the LSCB approach to embedding the learning identified in the Overview Report and focused upon:   • Testing out the hypothesis originally formed • Exploring what had got in the way of embedding learning into practice in the past • Focus on the ‘why’ question with the aim of identifying root causes or influences on front-line practice • Identifying any cultural norms or patterns of practice affecting service delivery • As appropriate, producing outcome focused recommendations 8  • Critically appraising the extent to which agency IMRs address the ‘why’ question and, make additional  outcome focused recommendations for individual agencies, as required 2.28 The work involved front-line staff and first line managers as well as senior managers and was to be completed within three months. 2.29     In order to address these additional terms of reference the Chair of the SCR Panel and the Overview Author undertook a further four learning events with personnel directly involved with the case.  The learning events took the form of small group workshops aimed to engage directly with the professional staff involved with the case in order to focus specifically on why events had taken place as they did.  These events were held on 20 December 2013, 23 December 2013, 8 January 2014 and 10 January 2014.  A total of twenty nine professional staff members across the agencies attended these events. 2.30 The results of the additional work have been integrated into the report which has been produced for full publication.  The report focuses on the professional involvement and inter agency working with the family.  3  PARALLEL INVESTIGATIONS   3.1 West Midlands Police conducted an investigation into the death of Child S and subsequently passed information to the Crown Prosecution Service (CPS). Ms M and Mr N were charged with murder, causing or allowing the death of a child and neglect.  Their trial took place between November and December 2014 and both Ms M and Mr N were found guilty of causing or allowing the death of a child.  4 FAMILY INVOLVEMENT IN THE SERIOUS CASE REVIEW   4.1 The mother and father of Child S were informed of the decision to conduct this SCR.  4.2      Following the criminal trial, Solihull Local Safeguarding Children Board (LSCB) invited Ms M, Mr N and maternal grandmother Mrs K to meet separately with the independent author to contribute to the Review.  The Independent Author and the LSCB Business Manager interviewed all three adults separately to inform this Review. 5.  KEY TO PERSONS LISTED   Child S Subject Child Child T Child S’s Half sibling   Ms M Child S’s Mother Mr N Child S’s Putative Father Mrs J Child S’s Maternal Great Grandmother Mrs K  Child S’s Maternal Grandmother Ms A Child S’s Maternal Aunt Mr L Child’s Maternal Grandfather PGM Paternal Grandmother PGF Paternal Grandfather   Ms E Previous partner of Mr N and mother of Child T Mr W Previous partner of Child S’s Mother 9  6 GENERAL FAMILY BACKGROUND   6.1 Child S was born in April 2011 and died in February 2013.  He lived with his mother throughout his life and had regular contact with his mother’s extended family.  His putative father reportedly moved into the family home in October 2012.  His mother describes Child S as a lively, happy child.  He had a fish tank in his bedroom and he enjoyed feeding the fish.  Professionals reported that Child S had made good developmental progress during his short life. 6.2 Child S’s ethnicity is dual heritage as is his mother and father’s. 6.3    Ms M, the mother of Child S, had informed the overview report writer that she has experienced traumatic incidents as a child and an older teenager and that she has had on-going difficulties with depression.  She also experienced domestic abuse during relationships prior to and following Child S’s birth.  She had significant issues with substance misuse, including cannabis, crack cocaine and heroin.  Her parents had separated but she remained in contact with both of them.  Ms M had been arrested on ten occasions which resulted in criminal convictions for nine offences committed between October 2009 and August 2010.  Much of her criminality appears to have related to her drug use. 6.4 Ms M served a short prison sentence in 2010 during which she discovered she was pregnant with Child S.  She described the pregnancy as unplanned but was positive about becoming a mother. 6.5 Mr N, the father of Child S, was looked after by a different local authority as a child.  He returned to live with his mother as an older teenager.  Mr N had a long term relationship with Ms E with whom he had a child and Ms E also had two other children.  Mr N was known to Adult Services as a carer for Ms E.  There were reports of domestic violence in this relationship.  Mr N had known Ms M for many years.  He did not see Child S until the baby was six months old when he and Ms M resumed their relationship. 6.6 Mr N has accepted he was the biological father of Child S (although paternity has not been proven).  Between September 1999 and June 2011, prior to Child S’s birth, Mr N was arrested by West Midlands Police on seven occasions resulting in nineteen convictions for drug related issues.  He also has convictions for robbery, theft and assault.  Mr N has allegedly continued involvement in the use and sale of drugs but he has consistently denied this.  He has admitted to regularly using cannabis.  7 CHRONOLOGY OF SIGNIFICANT EVENTS IN RELATION TO THE INVOLVEMENT OF THE AGENCIES   7.1 The chronology below describes what the authors consider to be the key events in the case in relation to contact with and involvement of agencies with the family.  It is not intended to be a comprehensive record and does not include all of the events, visits or actions undertaken by the professionals or others involved.  7.2 The chronology seeks to capture an illustrative summary in order to provide a framework for the detailed analysis and to assist learning from the case. 7.3 In August 2010 Ms M was convicted of theft from her own maternal grandmother, Mrs J, for which she received a short custodial sentence.  Her pregnancy with Child S was confirmed during her sentence.  While in prison she participated in a detoxification programme.  Just prior to release Ms M was linked with the Solihull Integrated Addiction Services (SIAS) to assist her to continue her drug abstinence, particularly in light of her pregnancy. 10  7.4 Upon release from prison in 2010, Ms M went to stay with family members including her mother, Mrs K, and her sister, Ms A.  Ms M made a homelessness application to Solihull Community Housing and was granted a tenancy with effect from December 2010. 7.5 Two referrals were made to Children’s Social Work Services from Midwifery Services in November 2010 due to concerns about Ms M’s substance misuse difficulties and her pregnancy.  A risk assessment was carried out by Children’s Social Work Services which resulted in a decision to take no further action. 7.6 During this period Ms M was seen on an intermittent basis by professionals at ‘Welcome’ a substance misuse service.  There was a pattern of missed appointments. Ms M initially led ‘Welcome’ staff to believe that she was free of drugs.  7.7 In December 2010, following a referral from the Welcome service, Children’s Social Work Services undertook an initial assessment of Ms M’s unborn child (Child S) because she was approximately five months pregnant and her lifestyle had potential consequences for the health and welfare of the baby. Ms M admitted lapsing into cocaine use.  The outcome of the initial assessment was a judgement that Ms M would be able to meet the needs of her child when born and no further action was taken. A third referral from the midwives was completed on 21st December 2010. 7.8 At the end of December 2010 drug testing was undertaken by the Bridge Service (Birmingham and Solihull Mental Health Foundation Trust) and proved positive for a number of ‘Class A’ illegal drugs. Ms M disputed the validity of the tests citing the use of a urine sample she had submitted being some weeks old.  7.9 In January 2011 the Bridge wrote to Solihull Children’s Social Work Services to confirm that Ms M was continuing to use crack cocaine and to smoke cannabis on occasions. A ‘team around the family’ (TAF) approach was adopted in order to work with Ms M.  7.10 A child in need plan was drawn up by the social worker (SW5) which required Ms M to work with the local authority and other agencies, including substance misuse services, undertake weekly drug screening and attend all of her ante natal appointments. 7.11 Later in January 2011 ‘The Bridge’ undertook a drug test of Ms M which proved negative.  Ms M had stated that she would attend drug treatment services for testing to satisfy the requirements of Children’s Social Work Services.  She did not believe that she needed treatment or support for substance misuse.  Because of the criteria for the service, the Bridge specialist drug worker explained to Ms M that this meant they could no longer work with her. 7.12 In February 2011 the case was reallocated to SW7 by the local authority Children’s Social Work Services as the previous social worker had left the authority.  While the possible relapse into drug usage was recognised by the professionals involved, drug screening at this time had proved negative.  7.13 The social worker (SW7) commenced a pre-birth core assessment in late February 2011 to assess the potential risks to the unborn child from drug misuse and domestic violence, both of which had historically been difficulties for Ms M. 7.14 During the assessment process SW7 was told by Ms M that the father of her unborn child was a perpetrator of domestic abuse and she did not wish him to know about the pregnancy.  She also confirmed she was in another relationship.  She did not give details of the father to agencies although there is a child in need plan which includes the first name of the father. 11  7.15 In order to complete the core assessment SW7 undertook a total of two visits to Ms M and one visit to her mother Mrs K. Child S was born in April 2011. 7.16 The core assessment was completed by SW7 in early May 2011.  The assessment indicated that Mrs K, Child S’s grandmother and Ms M’s new partner, Mr W, were viewed as sources of support and the case could soon close.  7.17 In late May and June 2011 Child S was seen by the health visitor (HV5), no concerns were recorded and a ‘good relationship’ was noted between the mother and child. 7.18 This view was confirmed by Children’s Social Work Services in July 2011 when SW7 received supervision on the case from Assistant Team Manager (ATM4).  It was noted that Welcome had had one telephone contact with Ms M and had discharged her from the service. 7.19 Child S was seen by SW7 throughout this period April – July 2011, and although observed to be often left in a baby chair, the child was assessed to be well. 7.20 During late July 2011 the Police visited the home responding to a referral about domestic violence.  The incident was not reported to Children’s Social Work Services or Public Protection Services and would be the first of five visits to the home in 2011 made by the Police responding to allegations of domestic abuse. 7.21 In August 2011 Child S was noted by HV5 to be gaining weight appropriately, feeding well, smiling and laughing and was clean and well dressed.  HV5 recorded no concerns. 7.22 In August 2011 Children’s Social Work Services received an anonymous allegation of drug misuse at Ms M’s home which was investigated by both Children’s Social Work Services and the Police.  Limited evidence was available to support the allegation and Children’s Social Work Services decided to commence closure of the case. 7.23 In late September 2011 the Police and Children’s Social Work Services’ professionals became involved again when Mr W, who was living in the household, was arrested for being drunk and disorderly and an anonymous allegation was received about drug dealing and loud arguments at the home.   7.24 SW7 in conjunction with the ATM5 decided that the case should remain open with a pattern of unannounced visits.  A safety plan was put in place and a ‘signs of safety’ evaluation completed. 7.25 HV5 carried out a home visit in early November 2011 and recorded Child S as clean, appropriately dressed, able to crawl, roll both ways and vocalise.  Appropriate weight gain was noted and Child S then weighed just over 8 kilograms from a weight of 4.2 kilograms twenty days after birth.  The health visitor expressed no concerns. 7.26 In November 2011, during a visit from the SW7, Ms M was noted to have sustained scratch injuries to her face.  She stated that these injuries were self-inflicted and minimised them, denying that domestic abuse had taken place.  A referral was received by Children’s Social Work Services from the Public Protection Service within the Solihull Local Authority with a total of eleven incidents over the previous month listed of alleged noisy arguments, drug abuse and domestic violence. 7.27 SW7 consulted the Team Manager (TM1) who directed that a further core assessment be undertaken.  SW7 met with Ms M who admitted she had relapsed into heroin use and was 12  having loud, aggressive arguments with her partner Mr W.  SW7 warned that if the aggressive arguments continued a child protection conference would be called. 7.28 Welcome re-engaged with Ms M at this time although she missed several appointments with them.  When she was seen in late December 2011 she admitted only to the use of cannabis. 7.29 In December 2011 SW7 undertook a home visit following a police referral because Mr W had damaged the property and left.  Ms M confirmed the relationship between herself and Mr W was over and he had gone abroad. 7.30 SW7 left the local authority at the end of December 2011 and the case was reallocated to SW11. 7.31 In January 2012 a Children’s Social Work Services’ service user made an allegation that Ms M was smoking heroin in front of Child S.  In response SW11 made three unannounced visits to the home during January, all of which were unsuccessful.  A substance misuse worker from ‘The Bridge’ visited on 23 January 2012 and also found no one in.  Professionals later understood that Ms M had taken Child S out of the country to see Mr W, and had subsequently returned. Ms M and her mother have informed the independent author that Child S stayed with his maternal aunt during this period. Ms M was seen by staff at ‘The Bridge’ later on 23 January 2012. 7.32 It is unclear when SW11 saw Child S, if at all, in the period between taking on the case in December 2011 and late March 2012. 7.33 In late March 2012 a record of supervision between SW11 and ATM5 note a number of unannounced home visits had taken place as well as checks with the health visitor working with Ms M and Child S.  The case was discussed with an indication for closure.  No records of the visits or their content are available to support this account. 7.34 Also in late March 2012 Ms M’s GP and Children’s Social Work Service were informed that she had been discharged from Welcome and The Bridge as being ‘drug free’, using the national definition of this term. 7.35 During April 2012 SW11 met with Ms M and Mr W (who had returned to live with her) at the Children’s Social Work Service’s office to discuss another two reported incidents of domestic violence which had been notified to Children’s Social Work Services.  7.36 Following supervision between SW11 and ATM5 on two occasions in May and June 2012, a closure summary was completed on 20 June 2012.  The reason for closure is unclear in the information available to this review. 7.37 In July 2012 the Police contacted the emergency out of hour’s service in social care as Ms M had alleged to them that her family was keeping Child S away from her.  The extended maternal family informed the Police that they were concerned that Ms M was using drugs and was incapable of caring for her son.  Police protection powers were not used and the Police appear to have focussed on the adults involved rather than the impact of the adult’s behaviour on Child S.  7.38 There is a lack of clarity about the detail of the arrangements put in place.  Police reported that arrangements were made for Mrs K, maternal grandmother, to look after Child S over the weekend and an agreement was made not to return Child S to Ms M before the involvement of Children’s Social Work Services.  Mrs K does not accept that such arrangements were put in place and in fact she returned Child S to Ms M the following day.  13  7.39 At this time, in July 2012, Child S had not been seen by the health visitor for a period of several months.  The last contact Child S had with professional staff was with Children’s Social Work Services prior to their closure of the case in June 2012.  7.40 Following the referral from the Police to Children’s Social Work Services, a family support worker (FSW1) became involved together with a duty social worker SW9 and a different assistant team manager ATM 7. 7.41 Information was gathered by Children’s Social Work Services that Ms M was no longer in a relationship with Mr W.  A family member alleged that Ms M had threatened suicide and was using illegal substances. ATM7 directed that a risk assessment be completed, and if Ms M failed to comply then reallocation of the case would be considered together with what would be a third core assessment.  On the same day an anonymous referral to Children’s Social Work Services alleged Ms M was again using heroin and cocaine. 7.42 An unannounced home visit was attempted four days later but Ms M was not in. Contact with family members established that they were unsure of the whereabouts of either Ms M or Child S and therefore the Police were informed of the situation by Children’s Social Work Services.  Subsequently a strategy discussion was held on 20 July 2012 and a Section 47 investigation undertaken. Ms M and Child S were located at the home of Ms M’s grandmother. 7.43    An initial child protection conference was called and Child S was made the subject of a child protection plan under the category of emotional abuse in early August 2012.  The conference was poorly attended, was not quorate, and key personnel, for example the Police and Welcome, were not present. 7.44 At the conference Ms M stated that she had had contact with Child S’s birth father, Mr N, although she was not interested in having a relationship with him or him with her. Ms M contradicted the information she had previously given about him as him being ‘abusive’ and ‘dangerous’ saying she was referring to another previous partner.  Ms M refused to give any details of the father’s identity at the conference. 7.45 The social worker (SW3) who attended the conference informed the Police Child Protection Unit by telephone that Child S had been made the subject of a Child Protection Plan.  However, this phone call did not trigger the action intended by SW3 of the placing of a ‘Flag’ in the police information system.  The aim of the flag was to alert officers attending the home of the child protection status of the child.  The accepted protocol that Children’s Social Work Services generate an email or fax to inform the Police and trigger a ‘flag’ did not occur, therefore officers attending the home subsequently had no knowledge of the child protection plan in place for Child S. It is significant that there was also no marker on the address in respect of domestic violence. 7.46 A series of core group meetings were planned as part of the child protection plan.  Child S was not allocated to a social worker (SW10) until September.  A further core assessment, the fourth in the timeframe of this review, was directed by ATM7 in accordance with the decision taken at the initial child protection conference.  7.47 Child S was seen during home visits during this period, and although home conditions were dirty Child S was always found to be clean, well fed and demonstrated good interaction with Ms M.  In October 2012 Ms M confirmed that Mr N, the birth father of Child S, was living with her.  SW10 began to undertake checks on Mr N in mid-October 2012. 14  7.48 A working agreement was put in place between Children’s Social Work Services and Ms M which included an expectation that Mr N would not be in the home property at the same time as Child S.  Mr N was not asked to sign the agreement which did not include any contact arrangements for Child S and Mr N. 7.49 A risk assessment of Mr N (separate to the core assessment) commenced in late October 2012.  Ms M was thought to be continuing to use substances intermittently throughout this period and Welcome confirmed that the last appointment Ms M had attended was in August 2012. 7.50 On 8 November 2012, the Police received an anonymous referral that Ms M was using drugs and that Mr N was dealing drugs from the address.  The caller also stated that Child S was on a child protection plan.  The police officer involved did not refer this information to Children’s Social Work Services or visit the family. 7.51  The core assessment was completed in mid-November 2012 and recommended that Ms M engage in relapse prevention work in respect of her drug misuse, the completion of a risk assessment of Mr N, and work with Ms M on protecting herself and Child S from domestic abuse. 7.52 In January 2013 the Social Care Duty Assessment and Referral Team (DART) were contacted by the Police regarding a domestic violence issue at Ms M’s home.  There was some confusion as to who the alleged perpetrator was. Ms M denied that it had been Mr N and minimised the incident.  The Police appear to have focussed on the adults involved rather than Child S and the possible effects of the domestic abuse on the child. 7.53 ATM7 and SW10 agreed that the referral did not require a strategy meeting.  Ms M reported that the incident had been a ‘joke’, and that the alleged perpetrator was an old school friend, not Mr N.  This explanation was accepted by the ATM7 and SW10.  It was agreed that the risk assessment of Mr N should be completed by February 2013, and that ‘signs of safety’ work should be completed with Ms M.  It was recorded that the thinking at the time was that Mr N did not pose a physical risk to Child S.  7.54 Child S was only seen once by a GP after being made the subject of a child protection plan; this consultation took place on 11 January 2013, “following a minor fall”.  The GP was aware of Child S’s status as subject of a child protection plan and therefore potentially vulnerable.  The GP confirmed that she was satisfied with the mother’s explanation for the minor injury and was reassured by her observations of the relationship between mother and child. 7.55 Child S had begun to attend a nursery in December 2012.  Child S did not attend nursery on 11 January 2013 (Ms M informed them that he had sickness), 31 January 2013 (he was reported to have sickness and diarrhoea) and 15 February 2013 (no reason was provided for this absence). Also, the nursery had noted that Child S was collected from nursery by Mr N on 8 February 2013.  7.56    The Police received a further anonymous call about domestic violence on 6 February 2013 reporting that a man was assaulting a woman at Ms M’s address.  Two police officers attended and found no signs of any violence. Child S was seen asleep on a man’s lap.  The officers did not record the names of the adult or child in their record.  The call was considered malicious, the incident was not recorded as a domestic abuse incident and there was no referral to Children’s Social Work Services or other agencies. 7.57   A core group meeting was held on 12 February 2013 although there is no record of the meeting. SW10 contacted an anti-social behaviour (ASB) Officer from Solihull Community Housing prior to the meeting in response to the ASB5’s telephone contact.  The anti-social behaviour worker raised concerns about the welfare of Child S although there is no record outlining the reasons for 15  those concerns.  The ASB Officer was not invited to the core group meeting although the social worker indicated the officer would be in the future.  The risk assessment of Mr N was shared with the couple at the meeting; they were unhappy about it although nothing was recorded as to why this was. 7.58 SW10 made an announced visit to the family home on 13 February 2013. Ms M and Child S were seen and no concerns were raised.  7.59 Child S died on 20 February 2013.  8 ANALYSIS OF AGENCIES’ INVOLVEMENT   8.1 This review considers and reflects upon events and the actions taken with hindsight, and with the aim of learning lessons hopefully to prevent similar events from occurring in the future.  Every effort has been taken to avoid hindsight bias and to consider the wide variety of situational factors that the participants in the case have experienced such as time constraints, capacity issues, budgetary constraints, system inflexibility or other contributory factors 8.2 In order to minimise hindsight bias it is important to consider not only what happened in the case but why it happened. In this SCR it has not always been possible to answer the ‘why’ questions for a number of reasons including the departure of staff (so therefore unavailable for interview), poor or missing records, or simple lack of staff recollection of events.  The author has reflected on the information available within the individual management reviews, the integrated chronology, together with the benefit of discussion, facts, and opinion expressed within the Serious Case Review Panel Meetings and formed hypotheses on possible causes.  The accuracy of the hypotheses has been strengthened by the opportunity to hold direct conversations with some of the professional staff involved in the case through their inclusion in a total of five separate agency learning events.  Root cause analysis techniques were used in the learning events by the chair and overview author of this SCR which have lent considerable validity and substance to the hypotheses formed. 8.3 It is the role of the independent overview author to gather the information, views and analysis, and analyse them from an independent perspective. 8.4 In such a complex case rather than addressing the individual terms of reference in isolation, the author has approached the analysis by identifying a number of key themes present in the terms of reference and considered them under those headings.   These are: • Thresholds for intervention • Assessment and analysis of risk  • Development, implementation and review of safeguarding plans • Management systems Thresholds for Intervention 8.5 In Solihull the threshold criteria for the involvement of agencies with children and their families is widely available and published as part of the overall safeguarding procedures.  The criteria includes a proportionate response to each child and family’s needs moving from relatively low level support through to statutory involvement where children need to be made the subject of 16  child protection plans or taken into the care of the local authority. 8.6 Children’s Social Work Services have a primary role in supporting children in need and safeguarding children as defined in the Children Act 1989.  It is essential that Children’s Social Work Services work with other agencies to ensure a multi-agency approach to assessment, planning, intervention and reviewing of services to children and their families.  The evidence in this SCR indicates that in this case Children’s Social Work Services operated a high level ‘gate keeping’ function where access to the service was difficult to achieve and exit facilitated at the earliest opportunity. 8.7 The early referral of Ms M and her unborn baby by the Prison Worker and subsequently by midwifery and substance misuse workers to Children’s Social Work Services was entirely appropriate and an example of effective practice. 8.8 The Heart of England Foundation Trust (HEFT) IMR reported that professionals in the Trust experienced ‘mixed messages’ about what response they could expect from Children’s Social Work Services and noted that staff “are conscious that Local Authorities are encouraged to manage cases outside of child protection processes where possible”.  It seemed reasonable to the midwives, working in this context, to progress the ‘Team around the Family Approach’ and see how Ms M responded to the intervention”. 8.9 The use of supportive frameworks such as the “Common Assessment Framework” to assist families with low level needs has been a well-established starting point in work with children and their families.  This approach was used in the early period of involvement with Ms M who at the time was pregnant with Child S. ‘The “Team Around The Family” approach relies on a ‘lead’ professional to co-ordinate a group of local professionals to focus on helping and supporting the family.  The lead professional does not need to be a social worker although it was in this case. The risk of de-sensitisation and generalisation/ the importance of assessing each individual child and family  8.10 During interview for this SCR, an Assistant Team Manager commented that this case was similar to so many the service currently deals with.  It is of concern that professional staff may have developed a general view of families and a tolerance over time to some of the risks to children they see due to the prevalence of difficulties they encounter in the families they are working with.  8.11 At the learning events, staff acknowledged that the saturation effect was a real issue and that the poorer care of some children in the community had the potential to become ‘normalised’ when viewed and assessed by agencies involved in safeguarding. 8.12 Professional staff described a large number of ‘Child in Need’ cases, which theoretically they knew were of higher priority but in practice represented such a large group that only when they were designated ‘Child Protection’ were they allocated a higher priority for focus across the agencies. Feedback and Communication 8.13 Davies and Ward (DfE 2011) note in the key findings in respect of their research into identifying and responding to child maltreatment, “There is insufficient agreement and clarity over thresholds for referral to children’s social care and initiating procedures in the family courts.  Poor feedback from professionals working in these settings to other professionals can have a detrimental effect on inter agency working”. 17  Multi- agency Early Help 8.14 It is important that there is coordinated service provision at every level of agency involvement.  While there were discussions internally in Children’s Social Work Services, there is no record that a formal multi-agency meeting took place to develop and review any plans or progress of intervention between October 2010 and July 2012.  However, there are references in reports to Team Around the Family (TAF) meetings taking place. 8.15 There is reference to consideration of a parenting course for Mr W; although this never took place before the couple’s relationship ended.  There is also reference to plans for attendance at a children’s centre for Child S but no evidence that this was achieved. The Threshold for Child in Need and Child Protection Intervention 8.16 By December 2010 the specialist midwife made a total of three referrals to Children’s Social Work Services over a short time period about concerns for Ms M’s circumstances and pregnancy. 8.17 The initial assessment carried out in December 2010 concluded there were no concerns regarding Ms M’s ability to meet her child’s needs when the baby was born.  This finding was made less than two weeks after a report that Ms M was lapsing into using heroin and crack cocaine.  The social worker contacted the specialist midwife to confirm that Children’s Social Work Services intended to close the case.  While the specialist midwife did challenge the social worker personally, being unhappy with the decision because of the concerns, the matter was never escalated within the Trust (HEFT) despite there being policies and procedures in place for this to happen 8.18 The evidence in this SCR demonstrates that in this case Children’s Social Work Services operated a high level ‘gate keeping’ function where access to the service was difficult to achieve and exit facilitated at the earliest opportunity.  It is the authors’ view that the thresholds for intervention in this case in respect of a child protection response were high.  As a result the level of risk to which Child S may have been exposed appears to have been quite high before a Section 47 investigation was triggered or a child protection conference called.  8.19 During the period of this review professionals identified significant risk factors to Child S which met the criteria for a formal Section 47 investigation.  For example, in November 2011 and December 2011, when Ms M had broken working agreements with Children’s Social Work Services, Section 47 investigations or strategy meetings should have taken place but did not.  Children’s Social Work Services were not pro-active in becoming involved in the case despite clear concerns being expressed by fellow professionals such as midwifery.  What followed was a series of events including the results of assessments detailing no concerns, occasions where the case was discussed for closure or in June 2012 where it was actually closed despite outstanding concerns and unknown and unassessed males being part of the household and their risk to the child unknown. 8.20 There was a lack of clarity in the Police and Emergency Duty Team (EDT) response to the incident on 6/7 July 2012 and their recording at the time of the event.  This is reflected in very different accounts of the response to Child S going missing.  The West Midlands Police IMR notes that the Police contacted the EDT whose initial response was to confirm that Child S was not in care.  The Police IMR suggests  that the Police Service were left to handle the report of a missing vulnerable child, probably involving safeguarding issues on what had been an open case to the Children’s Social Work Services only a few weeks before.  The addendum to the Local Authority Children’s Social Work Services IMR describes a more proactive response by the EDT worker who made checks by consulting their records and verbally agreed a plan of action with police colleagues, 18  subsequently agreeing a temporary placement for Child S with Mrs K.  There were missed opportunities for joint working; EDT staff did not make a joint visit with the Police, a written agreement was not drawn up with family members and the family was not visited by a social worker until Monday two days later.  The Police IMR clarifies that the police officers and social workers did not speak directly to each other but communicated through the Police call handlers. 8.21 This situation warranted at least a strategy discussion and a joint Police and EDT home visit to the home of Mrs K later on 7 July 2012 to ensure that Child S was adequately safeguarded.  Child S was made the subject of a child protection plan only three weeks after this incident therefore illustrating the escalating concerns. 8.22   A strategy discussion was eventually held on 19 July when social workers had been unable to locate Child S and his mother.  It would have been appropriate to hold a further strategy meeting whilst Child S was residing with Mrs. K.  This was another opportunity for professionals to reflect on Child S’s situation and plan proactively rather than reactively.  It would have been appropriate for Children’s Social Work Services not to have allowed Ms M to return to her home with Child S before the child protection conference was held on 8 August.  8.23    There were further occasions when child protection procedures could have been initiated but were not.  It would have been appropriate for a strategy meeting to be held following the Police notification of a domestic abuse referral on 8 January 2013 and also when the Anti-Social Behaviour Officer shared concerns with the social worker in February 2013. Assessments and the Analysis of Risk 8.24 During the period under review, child in need and child protection assessments were carried out by social workers using the national assessment framework for children in need and their families (2000).  Following recommendations made in the Munro report (2011) initial assessment and core assessments have been combined into one single assessment process in Solihull but were separate in 2012. 8.25 The first of many assessments Children’s Social Work Services carried out in respect of Ms M and her then unborn child (Child S) was completed in November 2010 using the “signs of safety” methodology.  Despite concerns expressed by midwives at the time and Ms M’s history of substance misuse, the assessment identified ‘no current concerns’ and resulted in ‘no further action’.  Assessments should consider any current needs or indications of significant harm but also the likelihood of significant harm in the future.  8.26    A further “signs of safety risk assessment” was carried out in late November 2010 which concluded that an initial assessment of the unborn baby was required.  Holistic Assessment 8.27 All assessments should be multi-agency and should encompass the three dimensions of the Assessment Framework – child development, parenting capacity and the wider family and environment.  It is a common criticism of assessments of children that too little attention is given to the wider family and the child’s environment and this is a feature of this case.  • A comprehensive genogram was not available to the Review Panel at the outset of this process.  • Ms M received significant support from her birth father Mr L who was diagnosed with a terminal illness during the period under review.  There is no evidence that he was involved in any of the assessments under review.  19  • Ms M’s mother, Mrs K, was involved in the early child in need planning and work in 2011 but does not feature in the child protection planning after August 2012.  The information provided suggests that Mrs K continued to be in regular although reduced contact with Child S and Ms M during the last 6 months of Child S’s life.  Child S had been in the care of his maternal grandmother for three days in February 2013; he had eventually returned home with Ms M on 17 February 2013. • It is essential that fathers and any other men who are significant in a child’s life are included in assessment work.  The social worker did not meet Mr W, Ms M’s partner, who was involved in the early care of Child S for some time and had recommended closing the case before doing so.  There was limited and delayed assessment work with Mr N when it was established that he and Ms M had resumed a relationship.  The role of Mr L in supporting Ms M and the lack of exploration of this has already been mentioned. • There has been no information provided to this Review about the other adults, family friends and/or other adults with substance misuse problems who regularly came into contact with Child S.  • Ms M had financial problems related to the funding of her substance misuse but there was no consideration or planning in respect of this reported in any of the agency individual management reports. The Use of Chronologies 8.28 There is no evidence that a simple up to date chronology was produced or maintained by professional staff working with Child S and his family.  Such a chronology can greatly assist multi-agency assessment of a child’s circumstances.  This may be a systemic issue linked to the limitations of the electronic records systems and/or a wider training issue more linked to professional practice.  The Assessment Process 8.29 A total of four core assessments were carried out in respect of Child S within the period of this case review.  The fundamental stages of children’s social work are assessment, planning, intervention and review.  In many ways they mirror work completed many years ago by Kolb and Deming in respect of learning theory which also highlighted four steps -. Plan, Do, Check, Act.  20  8.30 Instead of progressing through the cycle, successive social workers, assistant team managers and in one instance a team manager contributed to a pattern of unnecessary repeated assessment, rather than following assessment with planning, putting an intervention in place and then reviewing its effectiveness and adjusting the plan and services as necessary.  8.31 The concept of the ‘start again syndrome’ (Brandon et al 2008) whereby prior knowledge and case history, and case ‘experience’ is discounted in favour of searching for new information, is an established phenomenon.  It is the author’s view that there is a pattern of ‘starting again’ evident in this case.  After the Initial Child Protection Conference in August 2012, a fourth core assessment was recommended despite there being a wealth of assessment information already available. 8.32 The importance of high quality assessment cannot be overstated and this view is supported by research findings.  “While it is not always straightforward to show that good outcomes for children necessarily follow from good assessments, there is certainly evidence to support the link and conversely, to demonstrate that bad or inadequate assessments are likely to be associated with worse outcomes”.  ‘Social work assessment of children in need: what do we know? Messages from Research’ (DfE 2011) 8.33    The quality of the core assessments completed is an issue in this case.  The Local Authority Children’s Social Work Services IMR concluded that the core assessment completed in November 2012 (three months prior to Child S’s death) was “high quality and robust in terms of risk assessment”.  However, the Overview author disputes this as the assessment did not consider one of the major risks to Ms M and by implication Child S.  It did not explore Ms M’s relationship history, which included a number of partners over time who perpetrated domestic violence against her and not considering the impact on Child S. Adult Risk Assessment 8.34 Ms M was the focus for professional intervention throughout this review period with little focus on the potential vulnerabilities for Child S from her and Mr W and Mr N’s behaviours 8.35 The completion of the risk assessment of Mr N took too long.  A risk assessment of Mr N began as soon as Children’s Social Work Services became aware of his presence in the household in October 2012. However, the process took four months to complete.  Children’s Social Work Services’ professionals did attempt to take protective action during the four month period; Ms M was asked to ensure that Mr N left Ms M’s home where he had been living in October 2012 and a working agreement was put in place.  However, the onus placed on Ms M to ensure that Mr N left the family home was inappropriate given her experience of domestic abuse in this and other relationships. 8.36 The social worker did not know the correct procedure for seeking police information about Mr N and instead sought to complete Criminal Records Bureau checks which contributed to the delay in the risk assessment of Mr N. Use of the Signs of Safety model  8.37 The use of the “signs of safety” model in Solihull includes the completion by social workers of a risk assessment tool which contains questions around a number of domains.  The answers provided lead on to a numerical score between 1 and 10 where 1 is extreme concern and 10 is no concern.  The model is based on research (Turnell) 1997 and “uses the ethos of solution-focused work, building on strengths and enabling families to find their own solutions. It encourages the use of solution-focused techniques, including scaling questions and goal-setting 21  as the vehicle for obtaining good quality assessments.”  The model is referenced in The Munro Review of Child Protection (2011). 8.38 An NSPCC review of the ‘signs of safety’ approach has noted that the model is ‘designed to be the action plan and central case record for organising interventions right from the beginning of a case through to closure’.  The tool was used on two occasions in this case as part of a brief and ‘one off’ risk assessment intervention by duty social workers.  It was not implemented as part of a longer term multi-agency intervention where the veracity of the answers elicited from Ms M could be verified or in any way tested.  No long term relationship existed between the workers and Ms M where trust had had time to develop based on Ms M’s response to interventions.  In the author’s view, there may be pitfalls in using this form of risk assessment in this manner. In this case there was a reliance on the self-reported views of Ms M  a woman who was in denial about her drug dependency and the level of domestic abuse in her relationships and how this was detrimental to her child’s well-being and safety.  Other family members and other professionals were not always consulted within this process.  8.39    There is also an issue about the interpretation of the scoring system in the risk assessment tool.  In November 2012 an overall numerical score of six was recorded; in interview, the assistant team manager interpreted this score as indicating, “a situation moving toward improvement”. However, the score is in the ‘middle range’ of the scale.  8.40 The overview author would also challenge the basis of the score which is not supported by a review of the facts of the case over time using a skeleton chronology or application of basic safeguarding knowledge.  The assertion made by the assistant team manager is not credible.  The author is concerned that the model has not been accurately used to interpret and identify the risk and needs of Child S.  Strengths led practice and the Rule of Optimism 8.41 The overarching philosophy of the ‘signs of safety’ approach used in this case promotes a strengths led approach. Commentators, including Tuck (2011), have raised a note of caution about the growth of the ‘strengths led approach’ in child protection work.  There is a need for balance in considering strengths and deficits.  Tuck notes that “condemning the notion of coming to a realistic view of non-compliant behaviours is to run the risk of partial and unbalanced assessments of children’s circumstances”.  8.42 Professionals need to be mindful in their work of the potential for ‘fixed thinking’ about children and families and also for an over optimistic view of a child’s circumstances and parents’ potential for change ( the latter often referred to as ‘the rule of optimism’).  This would not be disputed by the architects of the ‘Signs of Safety’ approach. 8.43 The facts of Child S’s case do support a hypothesis that professionals involved very much wanted to see Ms M succeed in her parenting of Child S and assumed that she would.  8.44     The Bridge discharged Ms M in March 2012 and although the term ‘drug free’ used in a discharge letter has a nationally agreed definition, the BSMHFT IMR author noted that the term did not accurately reflect the circumstances ‘because (Ms M) failed to attend a number of appointments prior to her discharge and subsequently her drug status was, in fact, unknown’. The Service could have highlighted that Ms M ‘had failed to attend appointments, had stopped collecting her medication and felt that she no longer needed a service (which) would have reduced the chance of other professionals misconstruing mothers discharge as successful and planned’.  22  8.45   The Local Authority Children’s Social Work Services closure record in late June 2012 states that ‘A period of stability, engagement with The Bridge and successful completion of treatment’ and ‘Case no longer requiring Children’s Services intervention’.  The facts contained in the case history at the time did not support such an analysis. 8.46    The decision by Children’s Social Work Services to allow Ms M to return with Child S to the family home on 23 July 2012 is a further example of an over optimistic view of Child S’s circumstances.  Child S and his mother had been missing since his grandmother had returned him to Ms M’s care on 8 July.  The Police and social workers had been very concerned about home conditions to the point that Police arranged for forensic photographs to be taken. Ms M had admitted to a relapse in using drugs and it had been reported by extended family that she had debts and was concerned about being sought out by debtors.  In these circumstances, it would have been appropriate to have implemented the written agreement and ensured that Child S resided with his grandmother until the initial child protection conference took place. 8.47   The Local Authority IMR author highlights ‘differing perspectives’ between social work and health professionals in that the health professional viewed the family situation from a more positive viewpoint than the social work professional, who in turn was beginning to sense that Ms M was manipulating that situation. 8.48 There were some sharp differences of opinion between professionals in respect of fundamental issues such as the condition of the family home.  The health professional did not seem concerned about the condition of the home over time acknowledging it as ‘messy’ but suitable for a child.  However, a number of different social workers and indeed police officers expressed concern about the state of the property.  8.49 The HEFT IMR author concluded that the Health Visitor may have had difficulty in revising her original positive opinion of Ms M despite clear evidence of mounting concern.  Information about Ms M’s previous history in relation to substance misuse and domestic abuse was not initially communicated to the health visiting service from the midwifery service due to a clerical system error which has since been addressed.  A liaison form had been mislaid in the system and as a result did not reach the health visitor. 8.50     Although there was significant evidence of on-going issues around domestic abuse, substance misuse, fluctuating parental cooperation and periodic concerns about home conditions, the Health Visitor maintained a view that she had no concerns about the care of Child S throughout conferences and core groups. 8.51 The ‘Learning Together’ model of “systems focused serious case reviews” developed by the Social Care Institute for Excellence (SCIE) notes a facet of human reasoning as “once we have formed a view on what is going on there is a surprising tendency to fail to notice or to dismiss evidence that challenges that picture”. Other Assessment Tools used by Agencies 8.52 Welcome, in their role as a single point of contact, used a Pan Birmingham Tool for needs and risk assessment to assess Ms M.  The IMR gives little detail about what form the assessment took although for each assessment action plans were formulated around Ms M’s needs which aimed to assist her with her substance misuse problems, gaining employment and housing. 8.53 There is little detail regarding how Welcome’s assessment linked into other assessment processes, for instance the Children’s Social Work Services core assessments.  In April 2012 Ms M was discharged from the Bridge service and whatever the misinterpretation of the terminology 23  ‘drug free’ followed, no multi-agency discharge plan was drawn up in respect of Ms M which was a missed opportunity to challenge her about her current drug use and to confirm that professionals involved were clear about her pattern of drug usage at that time. Placing the Child at the centre of professional interventions         8.54 There was no clear pattern of regular visiting to see Child S when he was a young baby regarded as a child in need.  When Ms M left the country in December 2011, agencies appear to have assumed that Child S travelled with her.  However, the family state that Child S was cared for by his aunt Mrs A. 8.55 When a child is subject to a child protection plan, the lead social worker should see a child at least once every 28 calendar days in the family home and this is explicit in procedures for all child protection cases.  In the author’s view it would have been helpful if the visiting arrangements and frequency had been made clear and explicit for professionals and the family at the child protection conference. 8.56 Planning in respect of substance misuse issues appears to have been insufficiently child focussed and in some instances lacked co-ordination.  Welcome had little contact with Ms M in February and March 2012 prior to her discharge from the service in April 2012.  This was due to staff sickness and annual leave.  Contact took place largely by telephone and reports that Ms M had ceased taking drugs were dependent largely on her own self reporting.  There were no observations of her parenting or relationship with Child S. 8.57 Child S was not seen by the Police or Emergency Duty Team workers over the weekend of 7 and 8 July 2012.  A duty social worker attempted to visit on the following Monday.  However, the home visit was unsuccessful and professional contact with Child S and Ms M was not achieved until 20 July 2012. 8.58     Events in July 2012 following the closure of the case by Children’s Social Work Services highlight that the knowledge of Child S’s circumstances by key professionals at that time was limited.  The health visitor had not seen Child S for over 4 months at this point. 8.59 The Health Visiting Service contact with Child S and Ms M appears to have been quite minimal.  It appears that the Health Visitor focused on the physical presentation of Child S when seen more than the risk factors present in Child S’s circumstances.  Apart from a visit to the clinic in March 2012, the health professional did not see Child S until 30 July by which time developmental checks had been missed three times.  There is no record that Child S’s 8-12 month old developmental checks were ever carried out.  8.60    There were delays in social workers making home visits following reports of domestic abuse in late 2012 and early 2013.  It is not clear whether this was due to workload pressures or a positive view of the case which mitigated against a more appropriate urgent response. Professional Challenge, Respectful Uncertainty and Healthy Scepticism  8.61 Ms M and Mr N independently and in different ways have both described to the Overview Author that they felt trapped in their involvement with Children’s Social Work Services. Both parents have stated that they were afraid that Children’s Social Work Services would remove Child S from their care if they were honest with agencies about their situation.  Ms M told the second Overview Author and the LSCB Manager that she could not be honest about her substance misuse for these reasons.  It is clear that Ms M did not cooperate with professionals or comply with child protection plans or written agreements.  24  8.62 The pattern established by Ms M over time was one of resistance to making changes in her lifestyle, sporadic attendance for services such as drug testing or counselling, minimisation of her use of drugs and exposure to domestic abuse which is now, in hindsight, clear.  However, it may have been considerably less clear for those working with the family at the time, when two factors, ‘disguised compliance’ and the rule of optimism’ came together.  8.63 Ms M’s non-attendance at the Welcome service should have been challenged by Health professionals and social workers.  The Children’s Social Work Services’ IMR author acknowledged that “more might have been done to challenge the lack of engagement and the impact this might have had on increasing risk to the child”.   8.64 There were several examples of Ms M attempting to dictate the terms of her cooperation with services: • Ms M did not attend appointments with the specialist midwife for peri-natal mental health on 28 January 2011 or 3 February 2011 • Ms M only wished to undertake drug tests with the Bridge in 2011 and did not want treatment or counselling; the lack of motivation to tackle her drug misuse even at this early stage would have been obvious • She later wanted to have a naltrexone implant and would not agree to take the medication in tablet form • On one occasion, Ms. M refused to attend SIAS because she did not have a rain cover for her pushchair and stated that if it rained the following day, she would only attend if a taxi was provided            These examples present a picture of non-compliance or barely disguised compliance.  The Health Overview author highlights that in total there were eight missed health visitor appointments or failed contacts.  It was reported at the criminal trial that Mr N would hide in a bedroom during, or leave the home prior to, visits by professionals to conceal his presence in the home. 8.65 The overall approach of the professional staff involved was one of ‘high support and low challenge’, where the urge to help seems to have dominated the thrust of the work with the family.  There was an absence of a more sceptical approach through the adoption by social workers and health professional of what Laming in 2003 termed an “open and inquisitive approach with professional curiosity” and ‘respectful uncertainty”.  Managing risks to children in families where domestic violence is taking place 8.66 Two of the major risk factors to Child S presented by Ms M, and Mr N were domestic violence and drug misuse. 8.67 The first responders to many incidents involving both of these issues were West Midlands Police. The Police IMR highlights at least six separate incidents of domestic abuse which were attended by officers over a relatively short period of time. 8.68 In respect of domestic violence, the Police IMR is clear in its analysis that the officers attending the incidents at the home of Ms M were “often task driven and focussed upon Ms M” and “appear not to have adequately considered the possible consequences of the subject child’s wellbeing”.  The overview report author supports that view.  8.69 It is essential that the Police make referrals promptly to Children’s Social Work Services.   25  8.70 The Police IMR has shown that the child protection risk was not identified in every reported incident and that on a number of occasions there was a failure of officers to appropriately notify Children’s Social Work Services of domestic abuse concerns.  Police officers were not consistent in their decisions about when to complete Domestic Abuse, Stalking and Harassment risk assessment forms.  From February 2011, officers were permitted to exercise professional judgement, dispensing with the need for DASH forms to be completed where no crime had occurred or where the domestic incident was very minor (such as a verbal altercation).  Officers were inconsistent in reaching judgements about the level of risk present in situations they were responding to.  Professional judgement should always be used in judging levels of risk and not reliance on the score reached through use of any assessment tool. 8.71 On some occasions the officers who attended the family home appeared  to be more concerned about evidential matters i.e. about whether a particular assault had taken place or not, rather than a consideration of the effects the domestic violence could have on Child S who was present at the time. 8.72 The Police IMR author notes “several reports where specific allegations concerning physical abuse of Ms M involving  Mr W and later Mr N were received.  On the evidence found in some cases police did not record the incidents as a domestic incident or do not appear to have challenged accounts given by Ms M to establish the truth”.  8.73 The Police IMR highlighted a cultural norm in the force of referring to children in Child S’s position as ‘safe and well’.  It notes that this term is unhelpful in conveying meaningful information yet the use of the term has become a norm among police officers. 8.74 Some of the uniformed police officers involved in the case attended a learning event held with the chair of this SCR and the overview author.  They explained that they regularly attend potential domestic incidents with little or no knowledge of the previous history at the property they are about to visit.  Antecedent history such as the number of previous incidents of domestic abuse or information about vulnerable children in the household is often not readily available.  West Midlands Police have clarified that officers should always make robust enquires whilst at the incident in order to establish what has occurred and who is resident there.  These enquires would include establishing if any children normally live at the address and if there are any discernible risks.  Intelligence can become less accurate as time passes and so good investigative and professional practice is always preferable to relying too heavily on intelligence.  Basic and necessary intelligence checks are generally available over the personal radio but these are generally only sufficient to inform immediate decision making.  There is now an emphasis on ensuring that officers are aware of the importance of making comprehensive intelligence checks once they return to the police station and prior to completing the initial investigation.  In the event that those checks led to the identification of a significant risk to the welfare of any of the parties involved, especially to children or vulnerable persons, then immediate action by the officer to reduce the risk is expected.  This may well include returning to the address. 8.75 During the period post August 2012 the officers were unaware that Child S was the subject of a Child Protection Plan as the fact was not flagged on the Police Information System.  Normally the presence of such a flag would have been notified to them by radio en route to a call out.  While the social worker (SW3) had notified this to the Police CPU by telephone it had not been noted on the Police Information System.  Also the Child Protection Conference Service confirmed that the information had not been sent to the police in the normal way by email or fax which was an oversight.  It has not been possible to establish why receipt of the telephone call from SW3 providing the necessary information verbally did not trigger a ‘flag’ on the Police Information System. 26  8.76 In November 2012, and in January and February 2013, prior to Child S’s death, the police answered calls from neighbours to the home address but were effectively persuaded by Ms M and Mr N that no problems had occurred.  Without the previous history to alert them to the chronic problems in the family, (including the child protection status of Child S although one caller shared this information) they were unaware of the difficulties and therefore may have been more easily persuaded by Ms M that all was well.  This may not have been the case had they had further information. 8.77 The lack of information available to front line police officers attending difficult domestic situations, often out of normal office hours, is of concern.  It has been reported to the Overview Author that while police officers are in radio contact with a central control the information they receive is often limited and is only available if individual officers specifically request further details.  It has been suggested that that the use of the radio to elicit further information during call outs was discouraged on the basis that radio contact with control incurs additional costs for the Police Service. 8.78 There was a lack of accurate and timely inter agency communication between the Police and Children’s Social Work Services in respect of whether or not Mr N was continuing to spend time at the home with Ms M.  The facts surrounding incidents which occurred in both November 2012 and January 2013 are confusing and different interpretations are given of events in both the West Midlands Police IMR and the Local Authority Children’s Social Work Services IMR surrounding Police visits to Ms M’s home on these dates.  8.79 Communication difficulties between the Police and Children’s Social Work Services in late 2012 and early 2013 led to missed opportunities to verify that Mr N was living at Ms M’s home.  If Mr N’s presence had been verified, the failure to cooperate with the child protection plan and the risk posed to Child S could have been substantiated and action taken.  Had a police representative been present at the conference this would have potentially provided a further route into the police systems and provided a ‘failsafe’ in notifying the Police Information System of Child S’s protection plan status. 8.80 The local arrangements for considering domestic abuse referrals in Solihull are through a joint agency ‘screening’ system where personnel from the Police, Children’s Social Work Services and Health Agencies meet regularly to share intelligence, grade the needs of the child involved and to take these forward for further assessment or action where necessary. 8.81 The screening or ‘triage’ system depends on a number of processes including an initial grading by Children’s Social Work Services of the severity of the incident of domestic abuse that officers have attended, a discussion at a panel, a further grading of severity into four scale categories and onward action or ‘no further action’ by the agencies.  The system was originally developed by Barnado’s and its use began in Solihull in 2009, and is linked to the Solihull Domestic Abuse Strategy published by the Solihull partnership in 2011. 8.82 The system, in a variety of forms, is in operation in a number of LSCB areas.  When the system is operating well it can be a helpful way of focusing on children in complex domestic abuse situations.  8.83 At points where the Children’s Social Work Services representative acknowledged Ms M as a service user who was an ‘open case’ to the service, the procedure was for the panel representative to feed back the information to the case worker involved with the family.  There was a lack of clarity in the screening meetings as to what action would then result from the referral back to the worker and poor recording practice in terms of outcome, with little or no feedback to the panel. 27  8.84 Following an audit in 2011, a number of changes to the screening process were piloted from December 2012 until February 2013.  They included ensuring that some of the most serious cases discussed by the panel, involving children, (deemed level 4 in the triage process) should be the subject of a strategy meeting.  One of the criterion for the triggering of a strategy meeting was that a case was already an open case to Children’s Social Work Services, or that the child of the family was subject to a plan of support or a child protection plan.  The changes to the triage system should have strengthened the process.  8.85 It is the author’s view, based on the evidence from this case and from the 2011 audit that the use of the screening system tool as outlined in the Police IMR is potentially problematic. 8.86 Triage Panel members were in an excellent position to monitor the regularity and severity of the incidents of domestic violence in Child S’s family home.  However, the recording of incidents by the panel appears to have been inadequate in providing what would have been a valuable overview.  If this situation pertains to all cases valuable trend information could be missed not only in this serious case but also others.  8.87 None of the professionals involved in the panel escalated concerns about the safety of Child S either within their own organisation or with others. 8.88 One of the inherent dangers of systems designed to promote safety, such as the domestic abuse screening process is that its very existence leads to a misplaced sense of security both for the users of the system and wider organisations.  Solihull LSCB will want to satisfy themselves that action taken since the audit in 2011 has been effective in addressing the concerns and acting on the recommendations of both the audit and this serious case review. 8.89 This Review has raised concerns that police officers are not referring cases involving domestic abuse immediately to Children’s Social Work Services for action and there may be a delay until a panel meeting. 8.90    There was no referral for a multi-agency risk assessment conference (MARAC) for Ms M and no risk management strategy was put in place.  There was also no referral of Ms M to domestic abuse support although it is recognised that she may have declined such a service.  It appears that because not all incidents were recorded as domestic abuse and because individual incidents were reviewed in isolation, opportunities to assess the pattern of incidents and the escalating level of risk were missed.  Solihull operates the MARAC process for high level domestic abuse cases in line with national guidelines.  The decision to refer into the process remains one of professional judgement. Managing Risk where parents use drugs 8.91 This review has highlighted a lack of coordinated working between Children’s Social Work Services and the Specialist services provided by Welcome and The Bridge through the SIAS partnership, and a need for improved understanding of professional roles and responsibilities and a shared common language. 8.92 The Welcome IMR author highlights that the initial care episode involving Ms M during her early pregnancy with Child S did not incorporate a joint plan between The Bridge (BSMHFT) and Welcome as would have been expected. Joint care plans were in place for the other two episodes of treatment although the IMR author notes during the second treatment episode that “there is no reference to how low engagement (from Ms M in respect of her substance misuse treatment) might increase risk to the child that this might cause”.  8.93 There was a high degree of liaison between The Bridge (BSFMHT), Welcome and social workers 28  which is highlighted in the Welcome IMR as good practice.  However, there was no integration of plans between the services which could have enabled them to address together central questions about how committed Ms M was to her treatment, how she was responding to the treatment she was receiving and whether her progress or lack of progress over time was increasing or decreasing the risks to Child S. 8.94 The lack of an integrated plan at an early stage which all agencies were signed up to was very significant.  A co-ordinated approach under the Common Assessment Framework or Child in Need procedures should have taken place. 8.95 The IMR author highlighted that a ‘Think Family’ approach had not been embedded in the specialist substance misuse services.  The Children’s Social Work Services professionals clearly recognised an adult focus and felt that they had insufficient knowledge and were therefore reluctant to challenge the expert knowledge of their colleagues.  8.96 Children’s Social Work Services professionals explained that they were of the view that because Ms M’s involvement with the SIAS partners (Welcome and the Bridge/BSMHFT) was of a voluntary nature, they were also reluctant to challenge either Ms M about her involvement and progress with her substance misuse or Welcome and The Bridge (BSMHFT).  This reluctance appears to have persisted even when Child S became the subject of a Child Protection plan. 8.97 A social worker involved at the time explained that reports on Ms M’s progress had been obtained from Welcome and the Bridge (BSMHFT) to provide a check on accuracy of information from Ms M.  However, the information contained in these reports was based upon Ms M’s own self reporting.  The fact that it did not provide a professional assessment of progress was not clearly understood. 8.98 The issue of a reliance on ‘self-reporting’ by substance misuse professionals was discussed at a learning event.  Their view was that throughout their involvement with Ms M, compulsion for treatment was not an option and that methodologically they worked on the basis of a trusting relationship with Ms M in relation to reports of her improving condition.  Professional staff from The Bridge (BSMHFT) and Welcome explained for instance that it was not normal practice for them to undertake home visits to their service users.  Therefore they were totally reliant on the information and the presentation of a service user at their premises.  8.99 It appears that each agency had its own method of working which was not understood by the others.  While inter agency communication took place, the safeguarding of Child S was hampered by a lack of real challenge or questioning between the agencies in order to keep Child S as a focus of the interventions. 8.100 Both social workers and specialist workers recognised that Ms M’s involvement with Welcome and The Bridge (BSMHFT) were voluntary.  However there appears to have been insufficient recognition and focus on the implications of non-cooperation for the welfare of Child S.  Through the review process, substance misuse workers confirmed that they had voiced concerns about Ms M to Children’s Social Work Services staff on occasions throughout the review period but had not persisted in pursuing their concerns, thinking that perhaps they were not serious enough to warrant action from Children’s Social Work Services. 8.101 Substance misuse also formed a significant focus for the Police as first responders.  Ms M and Mr N (Child S’s natural father) were heavily involved in drug usage and in the case of Mr N, the suspected supply of drugs. 29  8.102 The Police IMR highlights a lack of any correlation between the use and supply of drugs such as heroin and cocaine and safeguarding concerns in respect of Child S in the mind of police officers attending the home of Ms M.  These factors should have been seen as triggers which should have prompted joint assessment processes. 8.103 The link between drug abusing parents and safeguarding concerns for children has been the subject of considerable research.   8.104 The Solihull Integrated Substance Addiction Service (SIAS) service is commissioned by the Solihull Partnership and is a partnership between Birmingham and Solihull Mental Health Foundation Trust and Welcome.  8.105 Welcome provides a general advice service and The Bridge forms part of the Birmingham and Solihull Mental Health Foundation Trust offering a specialist prescribing service for drug users. These agencies were primarily involved with Ms M in respect of her substance misuse problems.  Ms M’s contact with the services commenced as she left prison and continued during her pregnancy and following the birth of Child S. 8.106 The overview author has recommended a more effective communication strategy in order to clarify the relationship between Welcome and The Bridge (BSMHFT).  The commissioning, structure, eligibility criteria for service, reporting pathways and accountability of the different aspects of the organisation, should be clarified for local professionals and service users. 8.107 Three treatment episodes encapsulating lengthy time periods are identified by both The Bridge (BSMHFT) and Welcome and an assessment was carried out by Welcome and is referred to in the Welcome IMR.  8.108 There was no clear understanding of the extent of drug misuse by Ms M and Mr N and the case raises issues about how best to engage reluctant parents or parents who do not provide accurate information. Maternal Mental Health and Mood 8.109   Ms M consistently reported to professionals that she had suffered from depression since her teenage years and this is reflected in agency records and reports.  It is recorded that she was prescribed anti-depressants when she was in hospital in 2010.  She was offered two appointments with the peri-natal mental health service in early 2011 which she did not attend. Ms M periodically attended her GP to discuss her mood and mental health and was prescribed medication– in January 2011, September 2011, and August 2012.  In January 2013 Ms M was prescribed medication by her GP when she reported that she was having difficulty sleeping. 8.110   There is no evidence that information about Ms M’s mental health or related treatment/ medication were communicated to social workers or considered and reviewed in the core assessments undertaken or as part of the reviews of the child protection plan by the core group.   8.111  This was a complex case and it is essential in such circumstances that professionals carefully consider all of the issues which could negatively impact on the parenting that a child receives. The Development, Implementation and Review of Safeguarding Plans 8.112 Good assessments can lead to sound planning which must include all of those professionals involved with the family and the family members themselves.  Plans need to be put into action and their effectiveness critically reviewed. 30  8.113 The Local Authority IMR refers to the existence of a Child in Need Plan but the IMRs do not detail agency input into the plan, the roles to be performed or monitoring arrangements.  The author could find no recorded review of this plan involving any of the agencies.  The Initial Child Protection Conference 8.114  The initial child protection conference in respect of Child S held on 6 August 2012 was poorly attended.  Some of the key personnel with knowledge of Ms M, Child S and the family situation were absent, for example the Police and the Welcome service, although they did send a written report.  Apologies were received from two community paediatricians and the family GP did not attend the conference. Inevitably the poor attendance at the conference will have hampered informed discussion, planning and decision making. It contributed to a continuing cycle of repeat assessments by ordering another core assessment be completed.  At this juncture three previous core assessments were available on which to base initial plans.  8.115  The meeting did little to focus planning on the case.  It failed to set objectives or the required outcomes for the family. Importantly, the visiting frequency was not specified for either the social work professional in the case or the health professional.  This was a poor start to a child protection intervention and seems to have failed to give sufficient focus to the risks posed to Child S despite a considerable amount of history in the case for the chair of the conference to draw upon. 8.116 The recommended actions were not SMART (specific, measurable, achievable, realistic or timely).  They did not always identify professionals responsible for the action and did not include completion dates for each action. 8.117 The lack of attendance by some of the agencies at the initial child protection conference, core groups or other meetings was discussed at length with professional staff at the learning events. A general consensus emerged that the short notice period for attendance at some meetings was an issue together with high with personal workload issues.  It struck the author of this review that the reasons for and importance of attendance at key safeguarding meetings such as initial child protection conferences was unclear to some of the professionals across the agencies.  8.118 Professional staff attending the Learning Events highlighted difficulties in agency representatives attending child protection conferences.  There was a shared belief across the partner agencies represented at the event that there was a lack of understanding about the importance of attending conferences in some agencies and the belief that sending an information report was adequate. 8.119 The poor attendance at conferences was confirmed as causing longer lasting problems because core group dates were set at the initial conference and those agencies absent were often unable to commit to the dates thus having a knock on effect to the core group meeting cycle with the result that they in turn were poorly attended. 8.120 Inquorate meetings have been a common problem in the period under review and not limited to this particular case.  The options available to a Conference Chair are to proceed or to postpone conferences putting interim protection plans in place to manage risks.  At the learning event, the perception of conference chairs and Children’s Social Work Services staff was that there was a lack of inter-agency understanding of the importance of such meetings and a lack of prioritisation of child protection conferences.  General, poor or sporadic attendance by a number of agency personnel at child protection conferences raises concerns about a systemic dysfunction in this key part of the safeguarding system more widely applicable than just in this case.  31  8.121 Following the initial child protection conference, Child S remained unallocated for a month before a social worker (SW10) took on the case and commenced another core assessment.  The delay in allocation meant that the initial core group meeting was chaired by a duty social worker which was less than satisfactory.  Core Group Working 8.122 The initial core group developed a child protection plan for Child S but also failed to set visiting patterns for the key professionals.  The core groups which reportedly followed have been poorly recorded and there was a lack of clarity of expectations of Ms M and subsequently Mr N by agencies involved to reduce risk to Child S and promote his safety.  This situation arose despite there being a well-structured Core Group Meeting minutes template which was introduced in January 2012 by the Solihull LSCB. 8.123 The housing provider for the family and also the nursery which Child S attended from December 2012 should have been invited to become a member of the core group. 8.124  Crucially in October 2012 a decision to prevent unsupervised contact between Child S and Mr N was taken but apparently ineffectively communicated to the couple. The Child Protection Review in November 2012 8.125   The Child Protection Review for Child S was held within statutory timescales.  Agency attendance was again poor.  The social worker and health visitor attended and apologies were received from the GP and SIAS counsellor.  There is no indication that either the GP or SIAS provided a report for the conference.  Given the concerns about home conditions, it would have been appropriate to have invited the housing provider to the conference and to have included them as a member of the core group.  Given the concerns about domestic abuse, it would also have been appropriate for the Police to have attended the conference and to have provided a written report. 8.126  There was no systematic review of all the recommended actions within the child protection plan or challenge as to why they had not been completed.  The conference noted that Mr N should not reside in the family home but did not clarify or record a current address for him. 8.127   At the review, Mr N stated that he wished to have as much contact with Child S as possible. Contact arrangements had not been addressed in the written agreement drawn up with Ms M prior to the conference and there was no recommendation at the conference setting out contact arrangements or charging the social worker and core group with agreeing a contact plan within a brief timescale following the meeting.  8.128  The recommended actions were not SMART (specific, measurable, achievable, realistic or timely).  They did not include completion dates for each action.  8.129  A date for a core group meeting was agreed and a further child protection review was planned for April 2013 which would have been well within statutory timescales.  8.130  The date at the end of the review conference minutes is 20 February 2013.  This is the day that Child S died and the conference minutes therefore were not circulated to agencies including core group members within three months of the meeting. Contingency Planning 8.131  It is important for professionals and family members to be clear what the contingency plan will be if parents do not cooperate with a child protection plan or there is insufficient progress to 32  safeguard and promote the welfare of a child.  There was no contingency plan agreed and recorded at the initial child protection conference. 8.132  The following recommendation was agreed at the review child protection conference; ‘The Children’s Social Work Team will consider seek Legal Advice if (Ms M) does not work openly and honestly in terms of her drug misuse’.  It would also have been appropriate to record that legal advice and further action to safeguard Child S would have been considered if either Ms M or Mr N did not cooperate with the child protection plan. Written Agreements 8.133 The use of ‘Working or written Agreements’ by professionals was ineffective in safeguarding Child S.  The agreements appear to have been insufficiently detailed and the agreements were only partially adhered to or not adhered to at all by Ms M, Mr W and Mr N. 8.134 A working agreement and safety plan was drawn up in November 2011 which outlined expectations of Ms M and Mr W to engage with drug services and refraining from aggressive arguments.  8.135  The use of a written agreement between Ms M and Mrs K following Ms M’s referral to the Police on 6 July 2012 could have avoided any confusion about the care arrangements for Child S and agency expectations of family members.  Unfortunately, there was no direct contact with the family or any agreement drawn up. 8.136   A written agreement was drawn up later in July 2012 stating that Child S would reside with his maternal grandmother and it would have been appropriate for this to have been implemented until the initial child protection conference in August but it was set aside within three days. 8.137   There was a working agreement in October 2012 for Mr N to leave the home and a safety plan in which work is to be completed with Ms M in respect of domestic violence and its impact upon children. 8.138   The Local Authority IMR author notes for example “It is not evident that any risk assessment sessions had taken place with Mr N bar the initial session on 24 October 2012.” 8.139   The Local Authority IMR notes that “The working agreement did not determine contact arrangements between Mr N and the Subject Child and nor was it a requirement for Mr N to sign the working agreement.  SW10 reflected during interview that it would have been good practice for Mr N to have signed the written agreement.  With regard to contact between him and the Subject Child, SW10 stated that Mr N should not have been having contact but accepted that the working agreement was not clear regarding this and that Ms M may not have been clear about this requirement either.” 8.140 Audit activity was completed within the Solihull LSCB in September and October 2012 and shows an example of the use of such agreements.  One finding in respect of a case states “there were a plethora of working agreements on the children’s social work file which related to constantly changing contact arrangements for children with their parents, brought about by on-going instability both in respect of where they lived and the circumstances of contact.  The working agreement did not appear to be shared with the core group and were limited to children’s services and parents”. 8.141 The Local Authority IMR states that the social worker suspected that Mr N had been with Ms M over the Christmas period but there was no plan of announced and unannounced visits over the holiday period to clarify the situation.  33  8.142 The lack of clear plans, clear decision making, and minutes of the Core Group meetings copied to Ms M and Mr N and all professionals, in this case, did not hold the parents to account and probably made it easier for Ms M and Mr N to manipulate situations. The use of research and the assessment of Actual and Likely Significant Harm 8.143 The Children’s Social Work Services IMR author highlighted a key point that while a plethora of research exists on the effect of substance misuse, the incidence of domestic violence and mental health difficulties, the focus for actual professional activity in safeguarding children such as Child S often relies on waiting until actual harm has taken place, rather than clearly identifying and acting upon the ‘likelihood’ of harm using research evidence to prove a case.  8.144 Despite a variety of concerns developing about  the family situation, Child S was seen to be well cared for, well fed, cleanly clothed, well stimulated and with an appropriate attachment to his mother, Ms M.  The police officer logs include the comment ‘seen safe and well’ despite the child having been exposed to numerous episodes of domestic violence. 8.145 The safeguarding system often concentrates on actual harm to a child rather than the likelihood of harm being fully considered.  The Children’s Social Work Services IMR author notes that “As it stands the multiagency system does not readily allow for the use of expertise or research to predict future harm. Interventions are evidence based, and the difficulty in evidencing emotional harm within infants and very young children is a clear inhibitor to full risk assessments.  In some respects the wider safeguarding system does not support interventions until children, especially those that are very young, display the impact of significant harm.  The relevance of research when completing assessments of infants and young children where domestic abuse, drug misuse and mental ill-health are factors cannot be underestimated.  It is imperative that practitioners feel empowered to use research as evidence of harm and predictor of future harm when considering the risks posed to very young children whose physical care needs appear to be being met.” 8.146 Professionals undertaking assessments could have evidenced the likely harm caused by domestic abuse and drug misuse through the use of research evidence.  The facility to consider the ‘likelihood’ of significant harm promoted within the Children Act 1989 and its guidance was not sufficiently used in this case. 8.147 At the learning event, practitioners across disciplines described a number of organisational ‘hurdles’ within the local authority which encouraged an approach of further assessment, described as “thresholds within thresholds”.  In practice this meant that in order to escalate a case in terms of safeguarding action in order to demonstrate actual harm, further assessment was frequently ordered as more and more evidence was required in order to move the case past the next ‘gate’.  The consensus about the effect of this approach was that it encouraged repeat assessments and militated against proactive safeguarding action in all but the most obvious ‘emergency’ situations. 8.148 The LSCB partnership will want to examine the issue further in order to discover the drivers behind the approach. Management Issues Workload Management/ Caseloads 8.149 Workload issues, temporary or agency staffing, sickness or lack of capacity have not been raised explicitly in the agency reports for this SCR. 34  8.150 Children’s Social Work Services described a system of managing unallocated cases on a duty basis although no details of the type or number of cases is described.  Child S’s case was managed on a duty basis for a period in the summer of 2012 and remained unallocated for a month following Child S being made the subject of a child protection plan.  Dealing with the case in that way over the time period was, in the author’s view unsatisfactory.  Given that the case had been closed in late June 2012 only to reach crisis point some four weeks later should have signalled difficulties and should have resulted in immediate reallocation. 8.151 The effects of the case being dealt with on a ‘duty’ basis were numerous.  A number of different social workers together with different assistant team managers were involved in dealing with the case.  The absence of a consistent manager or worker with a building knowledge of Child S’s circumstances at a key time may have led to an inconsistent approach and contributed to repeat assessments.  Within the context of the climate of ‘disguised compliance’ discussed earlier, this potentially allowed a situation where different workers could be told different things by Ms M which in turn could be viewed differently by different managers. 8.152 The delay in allocation may have contributed to the situation whereby a duty social worker who convened the first Core Group failed to rectify deficits in the child protection plan such as specifying the frequency for the professionals to visit.  This will likely have hampered the social worker eventually allocated the case in September 2012 as the parameters for working the case had recently been set, or rather not set, by another worker.  Children’s Social Work Services staff confirmed at a learning event that operational difficulties caused by staff shortages at the time had led to the delay in allocating Child S’s case but that all current Child Protection cases have an allocated Social Worker. 8.153 The community midwife involved in Ms M’s care had a caseload of approximately 115 at the time with no reported staffing, sickness or capacity issues identified at the time.  It is recommended that caseloads should not exceed 98, however 110 being an acceptable average (RCM 2009).  The combination of heavy workload and the increasingly complex nature of the work is, in the author’s view likely to impact on professionals in terms of the saturation effect described earlier.  The potential effect of this may impact on how they view thresholds for intervention or the ‘severity’ of safeguarding situations within a given set of circumstances.  8.154 The HEFT IMR highlights the perception of the health visitor as having “a heavy child protection workload”.  Evidence provided in the IMR, that the health visitor had no more than three child protection cases and a working week of 32 hours per week did not support that contention.  8.155  The overview author was struck that while workload was not highlighted by the authors of the IMRs as an issue in this case, workload pressures were mentioned frequently by professional staff who indicated that these hampered the allocation of cases, limited case recording, prevented attendance at some meetings and restricted appropriate time for case reflection.  Supervision 8.156 A number of the agencies involved in this SCR confirmed in their individual management reviews that safeguarding supervision policies were in place.  These included HEFT, Welcome, the Bridge (BSMHFT) and the Local Authority Children’s Social Work Services.  The actual effectiveness of the safeguarding supervision process was hard to judge from agency IMRs as it was insufficiently covered.  The quality of reflection and challenge provided during the supervision of this case was more difficult to determine, and was agreed by those staff participating in the learning events to have been variable. 8.157 Welcome identified that while supervision takes place for its staff the recording of it is largely 35  absent which requires addressing. 8.158 The Health Overview Report author notes that “Child protection supervision was provided to the Health Visitor over the time frame covered by the review and practitioners are given reflective time to discuss specific cases.” Because of organisational changes there have been problems identified with the supervision policies which are being addressed. 8.159 The term ‘supervision’ has a particular meaning in the context of Local Authority social work and there is a wider debate about what the exact support, oversight, challenge and advice to those professional staff working in safeguarding require.  The Health Overview Report author touches on the need for the inter relationship of these elements to be more clearly defined. 8.160 Lord Laming (2009) refers to supervision as the ‘cornerstone of good social work practice” and Munro also highlighted its importance in her review of child protection in 2011. 8.161 There is evidence in this case that the supervisors across the agencies did not provide sufficient challenge to their front line staff.  They did not provide feedback that was accurate, diagnostic and reasonably timely or sufficiently provide new insights and lessons from mistakes.  It appears that they too provided ‘high support and low challenge’ thus mirroring the safeguarding practice of the frontline professionals.  8.162 During July 2012, the supervision of neither the health visitor nor the social worker provided a reflective overview of what was actually happening in the family at the time. 8.163 The volume of work of both practitioners and supervisors was a key reason given for the lack of time available to reflect on case issues and case analysis.  The supervision of child protection cases was given priority over cases involving children in need. 8.164 The judge in the criminal trial described SW10 as a relatively newly qualified social worker in his summing up of the case.  Social worker 10 had been qualified for almost two years and the Children’s Social Work Services IMR does not raise any issues about the level of experience of social workers allocated to the case of Child S.  8.165 There was insufficient shared understanding across agencies about what the task of safeguarding supervision actually was and how it contributed to keeping children safe.  It was also difficult to determine through discussions what level of skill and expertise those supervising front line safeguarding activity actually had. The recording systems in Children’s Services 8.166 At a learning event, Children’s Social Work Services professionals recognised the importance of keeping clear records. 8.167 Both social workers and team managers clearly stated that the format of the assessment available on the electronic client information system presents a number of challenges and is often problematic to operate: • It is not possible to ‘amend’ or update an assessment as the system default requires a new assessment to be completed; this may explain why so many assessments were found on the electronic system that appeared to have been cut and pasted. • The professional staff also felt that the free flow of an assessment was hampered by the rigid electronic fields or prompts that the system demands.  Some staff resorted to creating separate ‘Word’ documents in order to allow a more fulsome format and approach to assessment.  The negative of this approach was that there was a danger of the creation of 36  disparate documents and potentially not all the information on a child and family was kept in one place.  The chair and author of this SCR were concerned to hear that such ‘workarounds’ were required to compensate for the electronic system’s inflexibility.   8.168 These problems were compounded by the existence of paper based files, containing information which was not on the electronic system.  The existence and location of the paper based files were not identified on the electronic system to alert a system user to their existence or whereabouts.  Staff believed the problem had arisen because there is a limited resource available to scan in the paper files onto the electronic system at its introduction, although the system has this facility.  If this is indeed the case, it is of concern and is a potentially unsafe way of working, reducing the service’s ability to fully protect children. 8.169 The chair and authors of this SCR have noted that the introduction of an electronic system intended to streamline and improve record keeping and assessment practice had in fact had a number of unintended consequences.  At a learning event, reference was made to the use of the electronic system as a process of ‘feeding a beast’. 8.170 The importance of key records such as core group minutes in safeguarding children generally and Child S in particular cannot be overstated.  Social workers described being under considerable time and work pressure and therefore on some occasions minutes had not been produced for Core Groups and rather just rough notes which were not circulated.  Children’s Social Work Services staff described reluctance by other agency partners to take minutes at core groups with a culture prevailing that such tasks were always the role of social workers or managers.  Social work staff stated that they had raised the issue with line management.  In any event the issue seems not to have been sufficiently recognised or remedied by managers. 8.171  The absence of minutes of meetings when working with difficult parents exhibiting ‘disguised compliance’ behaviour is of particular concern.  It may have made it considerably easier for Ms M and Mr N to play each agency off against the other and harder for agencies to stand their ground about safeguarding issues in the absence of a clear written statement outlining progress on actions within the child protection plan and what had been discussed, agreed and expected.  8.172   Professional staff described difficulties in creating a ‘chronology’ in a case using the electronic system format as the system was difficult to manipulate to generate the correct amount of detail.  To create a chronology in the format intended by Lord Laming would require the creation of a separate document and a trawl of the electronic file which was thought too time consuming. Information sharing, the conduct of police checks and the interpretation of Data Protection Legislation 8.173 The Overview author has drawn to the attention of the LSCB an apparent perception across the agencies involved that a lot of information necessary for the protection of children is not shared because of a particular interpretation of information sharing and data protection guidelines and a perception by social workers that colleagues in both health and the police are reluctant to be open about information, for example pertaining to the male partners in families where domestic abuse may be an issue. 8.174  The social worker tasked with completing the risk assessment of Mr N did not understand the correct process to request background information from the Police and attempted to undertake checks through the Criminal Records Bureau (now the Disclosure and Barring Service) rather than directly from the police as partners in the safeguarding process.  8.175 The government has published information sharing guidance in March 2012 and recently in 2015 which emphasises that Data Protection legislation is a support and not a barrier to the effective 37  safeguarding of children.  However, this review has revealed that local practitioners in Solihull may perceive or experience something different, which is likely to require work with the local Caldicott guardians in particular. Audit Activity and Multi-agency Child Protection Training 8.176 To assist with this SCR, the author has been provided with a number of documents reflecting audit activity within the Solihull LSCB including the results of a review of the domestic violence screening ‘triage process’, a pro forma for core group structure and of a case mapping exercise. These documents have been very useful and aspects of their findings run parallel to the findings in this SCR.  It appears that the learning contained within other reviews and audits has been insufficiently embedded into actual safeguarding practice across the LSCB agencies.  8.177 It appears that there has been an absence of systems in place to ensure the effective dissemination of developing best practice, This was exemplified by recent developments in substance misuse services which were described during the learning event and which were pertinent to the way the service was said to be developing.  However, these developments were unknown to other agencies for which they had potential relevance.  A clinician attending one of the learning events found it difficult to identify how the content of the work of the service in which he worked was being effectively communicated across the agencies many of whom were undoubtedly key stakeholders.  8.178 The issue of a lack of understanding of the roles and expectations between agencies was commonly highlighted during the learning events.  There had been limited inter-agency child protection training available prior to April 2012 due to a vacancy in the learning and development role and there had also been poor take up of training in the nine months prior to the commencement of this review.  Inter-agency training can be an effective method of overcoming organisational barriers and promoting role clarity. 8.179 It has been reported to the panel that since 2013 that the provision of multi-agency training has been on target and that take up of multi-agency training has been much improved with a number of recent courses fully subscribed.  9 CONCLUSIONS   9.1 A jury has concluded that the parents of Child S were guilty of causing or allowing the death of their child.  The author is sure that those professionals involved with Child S took actions and made decisions in the case that they thought to be in the child’s best interests at the time.  The author has not identified specific instances of good practice which he would wish to highlight and which could be defined as practice of a quality over and above that which would normally be expected.  9.2 The review has identified and highlighted a series of serious failings in professional practice and weaknesses in safeguarding systems in Solihull.  Ms M, the mother of Child S, clearly had a variety of difficulties including mental health issues, drug misuse problems and being subjected  to domestic abuse by a number of partners.  These issues were all well known to a number of agencies.  The initial response to reports of domestic abuse was inadequate and the potential impact of domestic abuse on Child S’s welfare and safety were not properly considered by the systems and processes set up to consider the issue.  9.3 The developing risks to Child S were not sufficiently recognised or acted upon.  The reluctance of Ms M, Child S’s mother, to work with professionals to address her problems and the lack of 38  honest cooperation by Ms M or Mr N were not effectively highlighted by the assessments conducted by professionals across the agencies.  9.4 There is considerable evidence of the rule of optimism influencing professional practice in this case:  • The case was inappropriately discussed within Children’s Social Work Services for closure on a number of occasions and was eventually closed following a mistaken judgement that Child S’s situation was improving.  This conclusion was not supported by any reasonable interpretation of the facts of the case, which were available to those involved in that decision at the time  • Specialist substance misuse workers and the other professionals recorded and shared Ms M’s self-reported abstinence from using drugs without critical commentary • The health visitor and social workers appeared to focus on Child S’s physical development and not the range of risk factors in his circumstances • Police officers accepted denials of any domestic abuse by Ms M and her partners without reflecting on the pattern of call outs following referrals from a variety of sources 9.5      The combined impact of Ms M’s background of domestic violence and substance misuse on her mental health and her parenting and care of Child S, and the risks to which Child S was exposed as a result, were insufficiently recognised.  The risks presented by Mr N’s presence in Child S‘s life were not fully identified or assessed in a timely manner. 9.6    Professionals did not set out clear expectations of both parents through the use of written agreements and child protection plans.  There was also insufficient scrutiny of the adults’ compliance or, more accurately, non-compliance with the agreement and plans. 9.7 There were opportunities for investigative and protective action in respect of Child S based on the evidence of the mother’s lifestyle which professionals did not take.  This culture of optimism was compounded by an inter-agency misunderstanding of the term ‘drug free’ in respect of Ms M.  This misunderstanding aside, Ms M’s progress in ceasing her drug misuse was largely self-reported with little evidence to support Ms M’s statements of progress.  Assessments were not timely or comprehensive. 9.8 Both the author and the SCR panel were particularly concerned about the reliance the professionals placed on Ms M’s ‘self-reporting’ of progress in addressing her drug misuse and domestic violence problems.  Professionals did not test or triangulate information which could have ascertained an accurate picture of what was actually happening.  Professionals did not demonstrate what Lord Laming called ‘respectful uncertainty’ and ‘healthy scepticism.’ 9.9 The misunderstanding by social workers following the use by a Bridge worker of the National Treatment Agency defined term ‘drug free’ highlights the need for improved understanding between agencies of the terminology.  Clear differentiation between self-reported information and independently verified information is necessary. 9.10   When the case eventually progressed to a strategy meeting, child protection investigation and child protection conference, the processes which should have enhanced Child S’s safety did not do so.  The conduct of the initial child protection conference, the delayed allocation of a lead social worker, the quality of child protection planning and multi-agency core group working to monitor the plan all fell below a standard that it would be reasonable to expect. 39  9.11 This Review considers that Child S’s death was not predictable.  The Child Death Overview Panel (CDOP) will further consider whether or not the death of Child S was preventable and consider any modifiable factors for example in the family and environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level”, in line with the guidance contained in Chapter 5 (Working Together 2015).   9.12 There are a number of significant and potentially modifiable factors which have been identified within this review.  These include improvements in the assessment of the likely risks to Child S, an increased child focus, coherent joint case planning, the timely and proactive assessment of the risk Ms M’s partners posed to Child S, increased challenge of his mother’s denials of domestic abuse and drug use and the use of positive protective action at key junctures and in particular when important ‘working agreements’ were not adhered to by parents. 9.13    Changes in any or all of the areas of service outlined above would have likely improved the safety of Child S over time.  Child S could have been better safeguarded collectively by the local services working with him and his family.  10 LESSONS LEARNED  10.1 This review of agencies’ involvement with Child S and the circumstances of his death has revealed a significant amount of learning for all of the agencies involved in safeguarding children in Solihull.  It has highlighted errors in professional judgement and weaknesses in the systems to safeguard children in Solihull.  Agencies have reassured the Board that work has been undertaken with individual practitioners involved in working with Child S and his family to ensure that personal learning and development have taken place as necessary.  This section outlines key learning about the child protection processes and systems in Solihull.  10.2     The key learning points are: Domestic Abuse I. When incidents of domestic abuse are reported or detected it is essential that prompt referral and investigation takes place and that follow up action is timely, clearly child focussed and takes into account existing research into the impact domestic abuse may have on the safety and well-being of a child (including babies and very young children).  It is also important that patterns of domestic abuse are considered as well as individual episodes. II. The ‘Triage’ system in place to ensure appropriate responses to domestic violence and abuse should enable agencies to identify high risk cases early, alert the relevant professionals and act as an information hub which stimulates and monitors the actions of the agencies, escalating concerns in the agencies where necessary.  Good record keeping and communication between agencies are required to support the efficiency and effectiveness of the system.  The system should also not provide false assurance.  III. Ms M was not referred to a Solihull Multi-Agency Risk Assessment Conference (MARAC) and therefore the criteria for referral to MARAC should be considered further. IV. The Police who provide an immediate response to domestic violence should ensure that frontline officers are provided with adequate background information before undertaking visits and understand the research findings about the potential implications of domestic abuse, mental health and/or drug misuse on parenting and the likely effect on children in 40  the home where these issues arise.  Officers should be alert to repeat low level calls which if looked at together show a pattern of behaviour and offer an opportunity for pro-active intervention. V. Research evidence in respect of the long term damaging effects of domestic abuse on children should be considered and used by all professionals in working with families. Despite domestic abuse being an on-going theme in the life of Ms M and her partners, by the agencies working with her and Child S did not challenge her or address the issue sufficiently or the collective impact of domestic abuse alongside parental substance misuse. Substance Misuse VI. The commissioning processes for substance misuse treatment for adults needs to specify how the safeguarding of the children of substance misusing adults will be achieved, and how the partners being commissioned relate to each other.  They need to ensure close collaboration with partner agencies such as Children’s Social Work Services and joint care planning for the children of those adults they are working with is likely to assist in this process and ensure there are clear lines of communication and accountability built into the system. There must be careful consideration of the evidence required to provide reassurance about parent’s self-reported stability or abstinence from substance misuse and safe withdrawal or closure by specialist services. Eligibility criteria and the operation of thresholds for services VII. The eligibility criteria for access to both child in need and child protection services needs to be fully embedded, understood across agencies and operated consistently.  The threshold for access to services needs to take into account the historical and current concerns of the partner agencies. Assessment Practice VIII. The review has highlighted that the practice of repeating rather than developing or updating assessments several times wastes resources and does not drive safeguarding action for children forward.  IX. Multi-agency assessments led by social workers or lead professionals need to be thorough, to clearly identify risk and need, and to lead to clear plans which have a clear outcome focus and include specific interventions built into them against which progress toward improved safeguarding can be judged.  X. Assessments must be holistic and include consideration of the child’s wider family and environment.  Professionals need to consider the impact of domestic abuse, substance misuse and/ or mental health issues on parenting and share the outcome of any specialist assessments to inform the single assessment for the child.  XI. The key features of quality assessments are that they are relevant, timely and contain all of the elements of potential risk to a child including an analysis of those living in the home with a child or believed or confirmed to be spending significant periods of time there, and that they lead to explicit plans of action to meet the needs and risks identified by the assessment.  XII. Before progress can be recorded, information and evidence about progress needs to be checked and triangulated.  It is essential that verifiable information from professionals  is 41  considered alongside self-reported progress by parents or carer and that there is not over-reliance on the latter. XIII. The ‘tools’ that are available to assist professional staff, such as the ‘signs of safety’ risk assessment, are valuable assets although they are fallible.  They need to be applied only when sufficient training in their use has been completed and users are confident of their value as an aid.  The results they register should be used in conjunction with the professional judgements of their users and should not be used to override those professional judgements or relied on as giving assurance when the evidence does not support that.  Agency roles and multi-agency working XIV. There was an insufficiently robust shared understanding of the roles each agency plays in the safeguarding process particularly where there are concerns about parental substance misuse.  Increased joint safeguarding training should be commissioned and multi-agency protocols reviewed to ensure the required shared understanding of professionals’ complementary roles. Information sharing XV. The use of information sharing protocols that facilitate the prompt sharing of information between agencies which may potentially safeguard children was not sufficiently effective and information which could be vital to safeguarding children may potentially not be shared.  The protocols which are in place need to be understood by all the professional staff in the agencies   and effective in allowing the free flow of relevant information between them.  Where information blockages occur there needs to be mechanisms to allow the problem to be solved quickly.  Supervision XVI. Professional consultation and supervision is a key mechanism by which staff involved in safeguarding children can reflect on their work with families and its effectiveness.  The quality of the support and challenge provided by skilled and experienced supervisors is vital in countering the potential effects of over optimism or the saturating effects of dealing with the complexities of the safeguarding task. Audit and Review XVII. Solihull’s on-going audit and review activity is one mechanism by which the Board can seek reassurance that the recommended actions are implemented and improve the quality of practice and management necessary.  It is essential that when learning is revealed, such as that which occurred through the ‘Peer Review’ audit mechanism, it is widely shared, embedded across the agencies involved in safeguarding to ensure service improvements.   42  11 RECOMMENDATIONS  11.1 The overview author makes the following recommendations in respect of issues identified in the review.  Given the strategic overview role in respect of safeguarding held by the Solihull Local Safeguarding Children Board these recommendations will be most effectively achieved on a multi-agency basis under the auspices of the Board.                                      Learning Point 1 Difficulties have been identified by the review in respect of the use of a range of the ‘tools’ available to professional for working with children and families across the agencies.  Recommendation 1  A review of the ‘tools’ used in child protection cases, should be undertaken on  a multi-agency basis focusing in particular on those for the implementation of the ‘signs of safety’ model and also including: •Triage Processes •Single Assessment/Risk Assessment Processes •Domestic Abuse, Stalking, Harassment (DASH) tools. The review should take account of the operational situations in which the tools are used, the appropriateness of training in their use and their relationship to the level of expertise of the practitioners using them.  An underlying tenet of the review and subsequent training in the use of these tools should include an highlight the false assurances such tools can potentially provide. Expected outcome Professional staff will have an improved understanding of the benefits and limitations of the tools they are using.  They will improve their abilities to assess risk situations based on an interaction between their own professional expertise, knowledge and experience and the evidence and indications gathered by using the tools at their disposal and the precedence their professional expertise must take in decision making.  43                                Learning Point 2. The content of the review has highlighted a number of difficulties across the agencies involved in this case in respect of working with non-compliant individuals or those who disguise their compliance while working with agencies undertaking safeguarding activities with children.  These difficulties resulted in an overly optimistic prognosis of outcomes for the child. Recommendation 2  An inter-agency initiative, based on research evidence should be mounted to examine and develop the local response and expertise in working with non-compliant individuals in child protection settings. Expected Outcome Professional staff involved in safeguarding activity across the agencies will develop a greater understanding of risk analysis and risk management.  The concept of triangulating information to either support or discount the hypotheses about the ability of parents to safeguard their children will become embedded leading to both high support and high challenge and to safe and realistic planning for children. Learning Point 3  The review has identified significant weaknesses in the communication and working arrangements between the Police and Children’s Social Work Services. Recommendation 3  In light of the major review of public protection arrangements in the West Midlands Police Service, the working arrangements between the Police and Social Work Services, in particular the Emergency Out of Hours service (EDT) should be considered as part of that overall review.  The review should include a focus on the effectiveness of information systems which can be jointly interrogated by each agency together with the development of clear joint information protocols which are clearly understood and communicated across the agencies. Expected Outcome There will be clear protocols about the working arrangements between the Police and Social Services (in this case Children’s Social Work Services and the Emergency Duty Out of Hours Service) in respect of joint visiting in safeguarding cases and increased access to relevant information in both agencies will be made available. 44                                Learning Point 4 The review has highlighted considerable misunderstanding between agencies in respect of what information about the antecedent history of Adults who may pose a safeguarding risk to children can be gained from the Police records, the method by which that information can be obtained and in what timescale. Recommendation 4.  Systems for sharing information between agencies in child protection cases should be clarified and improved.  These systems should include paper and electronic systems together with a focus on the way professional staff verbally communicate information between agencies.  The results should be widely communicated to professional staff within the relevant agencies, and should include check mechanisms to ensure that staff have fully understood any changes or developments and have implemented them. Expected Outcome Agencies such as Children’s Social Work Services will have improved access to information from Police Service records on Adults about whom they have concerns in respect of posing safeguarding risks to Children. Learning Point 5. The attendance of all appropriate agency representatives at Initial Child Protection Conferences and attendance at Core Groups is significantly problematic. Recommendation 5. A review of the booking system for initial Child Protection Conferences should take place.  The review should ensure that a booking system is in place where a minimum notice period is given to professional staff across the agencies to allow for attendance.  The review should highlight the importance of attendances at conferences and core groups and promote a wider understanding of the significance of such meetings in safeguarding children.  The review should consider systems which include arrangements for substitutes to attend where necessary, the provision of reports to be presented in cases of unavoidable absence and arrangements for non-attendees to be available to present information or opinion by conference telephone call where applicable or necessary.  The review should also include the provision of systems to ensure that the taking of minutes of key meetings such as Core Groups are facilitated and resourced on a multi-agency basis.  Expected Outcome Understanding of the importance of Initial Child Protection Conferences improves as does the attendance at such conferences and subsequent core group meetings.  Minutes of all such meetings are taken accurately and circulated to all members of core groups in a timely way. 45                The Overview Author makes the following Recommendation in respect of West Midlands Police specifically:                Learning Point 6 The review has highlighted that there was insufficient  shared understanding across the agencies involved in safeguarding about what the task of supervision in safeguarding cases actually was and how it contributed to keeping children safe.  It was also difficult to determine through discussions what level of skill and expertise those supervising front line safeguarding activity actually had.  Recommendation 6 Using examples of national best practice underpinned by relevant research the Solihull LSCB should mount an inter-agency development initiative for those supervising front line safeguarding practice.     The initiative should include a focus on the importance of shared analysis and challenge within the supervisory relationship process.  Those facilitating the initiative should not only focus on improving individuals supervisory skills but also an improved multi agency understanding of the importance of supervision and its key role in refining safeguarding assessment, planning and review. Expected Outcome Individual member agencies of the Solihull LSCB acting collectively will be confident that each agency has in place robust practical arrangements, supported by that agency, to ensure that relevant and challenging safeguarding supervision is being accessed by all those involved in safeguarding cases. Learning Point 7 Police officers attending domestic violence and aggression incidents often have limited information about the antecedent history of incidents of DV or of the involvement of other services into the household they are visiting when responding to a call out. Recommendation 7 The West Midlands Police should improve the information available to front line officers when attending actual or suspected DVA incidents.  The force may wish to consider using the results of this SCR and existing information on the Pilot Scheme on the introduction of new technology (Tablet Computing) to assist in this aim.  Improved information gained from Recommendations 3 and 4 above are likely to assist this process in the future. Expected Outcome Front line Police officers will be provided with increased information on which to base their assessments in suspected DVA cases.  Where those Adults involved are in denial and potential safeguarding children concerns are evident antecedent history will be readily available to provide a fuller picture of previous events. 46   Appendix 1: LSCB Action plan; Position statement.  SOLIHULL LOCAL SAFEGUARDING CHILDREN BOARD                               This is a summary of progress made to address the recommendations in this serious case review.  As this review took 2 and a half years to produce, the LSCB did not wait for publication to deliver on recommendations but began implementing them as soon as possible.  Below is a summary of actions carried out, the current position and what the LSCB aims to do to sustain improvement in relation to each of the recommendations made.  Action plans for each agency were also produced and will be audited under Section 11 of the Children act 2004, in the Autumn of 2015 and Spring of 2016. SCR Learning Point  Recommendation 1 Action Current position  To sustain improvement Difficulties were identified by the review in respect of the use of a range of the ‘tools’ available to professionals for working with children and families across the agencies. A review of the ‘tools’ used in child protection cases should be undertaken on a multi-agency basis focusing in particular on those for the implementation of the ‘signs of safety’ model and also including Triage processes, Single assessment/risk Assessment processes and Domestic Abuse, Stalking and Harassment (DASH) tools. Revision of tools has been carried out by the Practice and Procedures sub-group. Thresholds guidance has been agreed in November 2014 and a leaflet produced in March 2015.A comprehensive training review has resulted in a new integrated workforce strategy incorporating various assessment tools. A sound evidence based rational for the development of the graded care profile in social care is in the final stage of production. It is included in the workforce development strategy for social workers.  While the use of the tools is clear in LSCB procedures and case audits 2014-2015 have established that progress has been made, continuous work is needed to embed in practice. The threshold document has been widely distributed. The LA aims to increase the cohort of social workers having “graded care profile” training. Specific Multi-agency training on the use of tools has been set up. Case audits 2015-2016 will establish application by practitioners. The LSCB will ensure regular communications to practitioners and managers. A conference in November for managers will ensure they embed this in practice. Training evaluations will indicate practitioners understanding of tools and the thresholds. 47   SCR Learning Point  Recommendation 2 Action Current position  To sustain improvement The content of the review has highlighted a number of difficulties across the agencies involved in this case in respect of working with non-compliant individuals or those who disguise their compliance while working with agencies undertaking safeguarding activities with children. These difficulties resulted in an overly optimistic prognosis of outcomes for the child.   “An inter-agency initiative, based on research evidence should be mounted to examine and develop the local response and expertise in working with non-compliant individuals in child protection settings.” Over 400 practitioners took part in the training review, some of whom indicated non-compliance as a continuing training need. The LSCB neglect strategy was approved by the LSCB. This Includes the use of the “graded care profile” and working with families with a combination of factors, parental mental health, substance misuse and domestic violence as well as non-compliance. Addressing non-compliance is a continuing feature of all LSCB safeguarding training.     The training review has resulted in new core safeguarding competencies and a new multi-agency workforce strategy incorporating the learning from this review. A new training faculty has been created to actively engage practitioners in training plans and design to ensure training is in line with practice needs and a more direct engagement of the LSCB with front line practice.  Common standards for supervision have been agreed and are being audited by the case audit sub-group. Case studies used in training feature families with complex combinations of features. Detailed evaluation of the training will be carried out post course and retrospectively to establish practitioner understanding.   Case audits will establish practice application.  Case audit will also examine practitioners’ confidence in recognising and challenging non-compliance and supervision in providing challenge and reflective practice. 48   SCR Learning Point  Recommendation 3 Action Current position  To sustain improvement The review has identified significant weaknesses in the communication and working arrangements between the Police and Childrens Social Work Services  “In light of the major review of public protection arrangements in the West Midlands Police Service, the working arrangements between the Police and Social Work Services, in particular the Emergency Out of Hours service (EDT) should be considered as part of that overall review. The review should include a focus on the effectiveness of information systems which can be jointly interrogated by each agency together with the development of clear joint information protocols which are clearly understood and communicated across the agencies.” New arrangements, developed in 2013, include quarterly meetings between the Assistant Director in children services social care and the Police Detective Inspector.  A “Dip sampling” of 354 children receiving services in Solihull was carried out in 2014 and involved police, social care, health and education. This work highlighted the benefits of a local Multi Agency Safeguarding Hub (MASH). Findings also led to agreement on more effective triage of notifications from the police incidents involving children. There are clear protocols in place in the LSCB procedures. The emergency duty team have access to relevant information. There is clear evidence of immediate escalation and management of emerging concerns. Co-location of police with social care in a Multi-Agency Safeguarding Hub plans are at the advanced stage.  A new Multi-Agency Safeguarding Hub will be operational from October 1st and will ensure direct and immediate communications at front-line operational levels. New arrangements to manage police notifications of incidents involving children have been set up and this process will work alongside the MASH team allowing immediate escalation of serious child protection concerns. New multi-agency training improves competencies on communications and information sharing. The LSCB monitors MASH developments with direct reports from social care and police. The LSCB monitors progress through scrutiny of the performance data set, discussion and analysis. 49   SCR Learning Point Recommendation 4 Action Current position Sustaining improvement The review has highlighted considerable misunderstandings between agencies in respect of what information about the antecedent history of adults who may pose a safeguarding risk to children can be gained from the Police records, the method by which that information can be obtained and in what timescale.  “Systems for sharing information between agencies in child protection cases should be clarified and improved. These systems should include paper and electronic systems together with a focus on the way professional staff verbally communicate information between agencies. The results should be widely communicated to Professional staff within the relevant agencies, and should include check mechanisms to ensure that staff have fully understood any changes or developments and have implemented them.”            AD social care and Police DI have revised processes in 2014 and raised awareness in their respective agencies. Police capability has been enhanced and systems embedded through training to enable information sharing on adults who may pose a risk to children with particular reference to CSE but which also includes child protection risks. MASH plans have been agreed allowing faster access to police computer systems.             Formal structured information sharing on adults who may pose a risk to children takes place in Multi Agency Risk Assessment Conference (MARAC), the Children Missing and Operational group and in child protection conferences and strategy meetings. The Multi-agency Safeguarding Hub is operational on 1st October. From 1st October 2015 MASH will be operational with agreed information sharing protocols and systems. This will ensure that Childrens services have improved access to information from Police Service records on Adults about whom they have concerns in respect of posing safeguarding risks to Children. The early help performance framework will monitor DV incidents and report regularly to the LSCB executive. LSCB multi-agency training places emphasis on information sharing.    50   SCR Learning Point Recommendation 5 Action Current position Sustaining improvement The attendance of all appropriate agency representatives at Initial Child Protection Conferences and attendance at Core Groups is significantly problematic.    A review of the booking system for initial Child Protection Conferences should take place. The review should ensure that a booking system is in place where a minimum notice period is given to professional staff across the agencies to allow for attendance. The review should highlight the importance of attendances at conferences and core group and promote a wider understanding of the significance of such meetings in safeguarding children. The review should consider systems which include arrangements for substitutes to attend where necessary, the provision of reports to be presented in cases of unavoidable absence and arrangements for non-attendees to be available to present information or opinion by conference telephone call where applicable or necessary. The review should also include the provision of systems to ensure that the taking of minutes of key meetings such as core groups are facilitated and resourced on a multi-agency basis. Logistics, administration and communications around child protection conferences have been revised in 2014 and attendance at CPPC is monitored directly by the LSCB. The LA re-structure in social care means that all child protection issues are dealt with by the child protection team, providing consistency and continuity. The role of the social worker in chairing core groups has been made clear. A template to record notes of core groups has been developed and is monitored internally.    There has been overall steady improvement in attendance at child protection conferences. Core group management and logistics is managed by team managers and regularly audited. The multi-agency training programme includes child protection conferences and core groups.   Child protection conference attendance will continue by be part of the LSCB quality assurance process. The Case audit programme for 2015-2016 will identify practitioners’ experience of core groups, child protection conferences and other information sharing meetings. Training evaluations will provide information on practitioners understanding of the importance of prioritising, preparation for, reporting to, and taking part in child protection conferences and core groups as well as recording. 51   SCR Learning Point Recommendation 6 Action Current position Sustaining improvement The review has highlighted that there was insufficient shared understanding across the agencies involved in safeguarding about what the task of supervision in safeguarding cases actually was and how it contributed to keeping children safe. It was also difficult to determine through discussions what level of skill and expertise those supervising front line safeguarding activity actually had.     “Using examples of national best practice underpinned by relevant research the Solihull LSCB should mount an inter-agency development initiative for those supervising front line safeguarding practice. The initiative should include a focus on the importance of shared analysis and challenge within the supervisory relationship process. Those facilitating the initiative should not only focus on improving individuals supervisory skills but also an improved multi-agency understanding of the importance of supervision in its key role in refining safeguarding assessment, planning and review”. Supervision standards were developed by the policy sub-group using national research and have been included on the LSCB website. A case audit showed variation in models of supervision used by partner agencies.  The Case audit group further devised an agreed set of auditable standards, including minimum frequency, enabling reflective practice and providing challenge.  The training programme incorporates a module on safeguarding supervision for those supervising front line practice.    The case audit group is currently auditing against agreed standards. A training programme for managers on analysis and judgement in safeguarding children will deliver training to supervisors and managers on their role in enabling sound reflective practice and providing challenge to front line practice. The outcome of case audit will inform LSCB so that individual member agencies can be confident that each agency has in place robust arrangements to ensure relevant challenge to practitioners. The safeguarding faculty informs the LSCB more directly on the needs of practitioners in relation to supervision and training.  A conference for managers in November will deliver this key message. 52   SCR Learning Point Recommendation 7( police) Action Current position Sustaining improvement Police officers attending domestic violence and aggression incidents often have limited information about the antecedent history of incidents of DV or of the involvement of other services into the household they are visiting when responding to a call out. West Midlands Police should improve the information available to front line officers when attending actual or suspected DV incidents. Flagging of addresses to alert officers attending is now embedded in police operational practice.  All incidents involving children are effectively triaged alongside the MASH team and within the Early Help framework.   Revised policy, published Dec 2013 means that safeguarding officers within PPU must add a SIG marker/check to medium and high risk incidents. All officers have access to intelligence systems/OASIS and PNC prior to their arrival at an incident. Sig markers are used to identify risk and vulnerability of persons and addresses.    Quality assurance to the LSCB will take place through the monitoring of  Early help triage Case audit Training evaluations Section 11 audit will require police to report on this recommendation and whether the expected outcome has been achieved.   53   Appendix 2: Individual Agency Recommendations   The following recommendations have been made by the IMR authors who completed their report in September 2013 and are supported by the overview author and the Serious Case Review Panel.  Many of these recommendation will have been delivered.  This will be assessed as part of a wider audit by the LSCB under Section 11 of the Children Act 2004.  Birmingham and Solihull Mental Health Foundation Trust (BSMHFT);  1) BMHFT to have clear and useable child protection policy accessible on the intranet site. 2) BSMHFT - Safeguarding Governance across SIAS is clarified with commissioners and The Bridge has a clearly defined understanding of Governance and their role within this structure. 3) The Bridge must improve their management of cases worked jointly within SIAS. 4) The Bridge Clinical Leads (with the help of SIAS Safeguarding Working Group) will embed the ‘Think Family and Early Help Principles’ into all interventions for Service users who are parents or carers of Children and Young People.  Heart of England Foundation Trust (HEFT); 1) Information shared as part of the discharge process between Maternity staff and Health Visitor and GP colleagues should be reviewed to ensure that children’s safeguarding issues are being properly identified and shared appropriately by maternity staff at discharge. 2) To see if existing Maternity Liaison processes are fit for purpose. 3) To establish an agreement regarding resource to ensure Child Protection Supervision for all community midwifery teams is in place. 4) To hold a briefing event for HVs and MWs in relation to learning from the case. 5) To undertake a review of the health visiting records and record keeping guidance. 6) Review current supervision policy and produce revised policy, supervision documentation and monitoring arrangements. 7) To launch the new Trust Domestic Abuse Policy 2013 and implement awareness raising in the ED.  The Welcome Service 1) The Welcome Child safeguarding policy should be reviewed and Welcome should continue to review the policy annually in line with LSCB protocols.  The Policy should also be reviewed alongside that of SIAS partners to ensure consistency. 2) Welcome needs to improve the management of cases across the SIAS partnership. 3) HR processes and procedures in response to staff absence should consider consistent case management, particularly in relation to high risk cases. 4)  Management supervision should be expanded to address safeguarding.  NHS England; 1) The surgery adopt the suggestion in the RCGP’s Safeguarding Children and Young People in respect of recording the name of the accompanying adult and if possible identifying the relationship to the child and this recommendation is cascaded to all GP practices in Solihull.  2) The surgery adopt the point in the Toolkit for General Practice in respect of establishing a system to mark the records of a parent of a child (as a significant adult) on the child protection register as well as the child’s records to prevent de-escalation.   Whilst this is dependent on receipt of this information from Social Services this information could be actively sought following case conferences.  That this recommendation is cascaded to all GP practices in Solihull. 3) CCG 3 - That the surgery considers its practise with regard to filtering records of children on the Child Protection Register in order to ensure they have a holistic view of issues and that this recommendation is cascaded to all GP practices in Solihull. 4) The CCG Chief Nurse will discuss with the Director of Nursing at NHS England’s Area Team (health visiting commissioned through NHSE) the limitations regarding Health Visitor deployment.  Specific recommendations will be identified and agreed to ensure system wide learning as a result of this SCR.   Solihull Community Housing (SCH); 1) For all cases involving substance misuse, SCH’s frontline housing management teams will routinely refer to the Joint Service Protocol re: Families and Children Affected by Parental Drug / Alcohol Misuse, when assessing potential referrals due to safeguarding concerns. 2)  Investigate the basis for perceptions within the ASB context that information sharing and multi-agency working can be improved.   West Midlands Police (WMP); 1) Police officers acquire knowledge of the risks to children associated with domestic violence and can identify the elements of a robust investigation and its effect in protecting vulnerable adults and children. 2) By deploying current systems to their full potential, we will reduce the need for multiple intelligence checks of systems when dealing with public protection matters, by attaching to a nominal record an up to date summary of current risk assessments and protection plans and strategies identifying known risk factors and protective factors. 3) WMP will ensure that necessary information and full participation as partners in key decisions to safeguard and promote the welfare of children is delivered. 4) To provide West Midlands Police officers and staff with essential information about the potential for children to be at immediate by alerting them to the existence of Children who are the subject of a Child Protection Plan (CPP).  Solihull Council 1) The local assessment protocol considers the requirement, timeliness and threshold for assessment. 2) Implementation of a single comprehensive assessment tool for social work services. 3) Effective and comprehensive Quality Assurance Framework in place. 4) Use of chronologies is standardised.  5) A standardised template for Core Groups is considered by the LSCB.  55   6) The addition of visiting frequency / arrangement for seeing a child subject to Child Protection Plans is considered by the LSCB. 7) Sponsored placements are routinely informed of who can and cannot transport a child to and from their provision.   Health Overview Report 1) Health Commissioners and NHS providers (BSMHFT & HEFT) make arrangements to ensure that the services they contract out to others are provided having regard to the need to safeguard and promote the welfare of children (Children Act 2004, Section 11 (2) (b)). Where standard NHS contract (including information requirements) are not used, then the commissioner and/or provider should have in place a contractual agreement and/or service specification/ formal arrangement to ensure and secure safeguarding quality assurance through formal written arrangements with all providers that are commissioned and/or sub contracted. 2) All thirty two Solihull CCG Member Practices facilitate formalised practice meetings where families of concern can be discussed in a formalised way, evidencing components of key principles, actions and effective practice. 3) An audit of current learning opportunities, including in-house domestic violence training should be undertaken by the NHS agencies participating in this review to establish that it addresses the recognition & management of cases where substance misuse, domestic violence & mental health issues are seen as a cluster; and to ensure that the organisational learning opportunities promotes collaborative working to respond to children and victim’s needs.    56   Appendix 3:  Roles of Agencies   1.1 Whilst local authorities play a lead role, safeguarding children and protecting them from harm is everyone’s responsibility. Everyone who comes into contact with children and families has a role to play.  1.2 Safeguarding and promoting the welfare of children is defined for the purposes of this guidance as: • protecting children from maltreatment; • preventing impairment of children's health or development; • ensuring that children grow up in circumstances consistent with the provision of safe and effective care; and • taking action to enable all children to have the best outcomes.  1.3 Local agencies, including the police and health services, also have a duty under section 11 of the Children Act 2004 to ensure that they consider the need to safeguard and promote the welfare of children when carrying out their functions.  1.4 Under section 10 of the same Act, a similar range of agencies are required to cooperate with local authorities to promote the well-being of children in each local authority area.  This cooperation should exist and be effective at all levels of the organisation, from strategic level through to operational delivery.  1.5 Professionals working in agencies with these duties are responsible for ensuring that they fulfil their role and responsibilities in a manner consistent with the statutory duties of their employer.  Solihull Local Authority Children’s Social Work Services  1.6 Local authorities have overarching responsibility for safeguarding and promoting the welfare of all children and young people in their area.  They have a number of statutory functions under the 1989 and 2004 Children Acts which make this clear.  This includes specific duties in relation to children in need and children suffering, or likely to suffer, significant harm, regardless of where they are found, under sections 17 and 47 of the Children Act 1989.  The Director of Children’s Services and Lead Member for Children’s Services in local authorities are the key points of professional and political accountability, with responsibility for the effective delivery of these functions.   1.7 Solihull Borough has a resident population of approximately 50,200 children and young people aged 0 to 19, representing 24.4% of the total population of the area.   1.8 An initial response to service users is provided by the Duty, Assessment, and Referral Team (DART).  When cases are deemed to require longer term interventions they are moved onto other teams such as the Child in Need Team.  Heart of England Foundation Trust (HEFT)  1.9 HEFT is a large, multi-site, NHS Trust providing acute and community care to an ethnically diverse and predominantly urban population of approximately one million. Heart of England NHS 57   Foundation Trust has maternity units across three sites; Birmingham Heartlands Hospital (BHH), Good Hope Hospital (GHH) and Solihull Hospital (SH).   Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT)  1.10 The Trust was established on 1 April 2003.  The function of the Trust is to provide secondary mental health care to the population of Birmingham and Solihull.  It provides both in-patient and community mental health services to adults (All those over the age of 18).  In Solihull, Solihull Integrated Addiction Service or “SIAS” provides the addiction provision.  This is a partnership of both statutory and third sector addiction services commissioned by Solihull MBC.  It offers a range of drug and alcohol interventions via different providers.  Within SIAS, BSMHFT provide a specialist prescribing service, known as The Bridge.   Welcome  1.11 Welcome is a small local charity with the function of providing drug and alcohol treatment services and family support services in the borough of Solihull.  Welcome is commissioned by Solihull MBC to deliver services in partnership with BSMHFT and other partners in the umbrella body, Solihull Integrated Addiction Service (SIAS).  The Welcome service provides a single point of contact for those wishing to access treatment services and provides a drop in facility, psychosocial interventions, counselling service, employment support and a structured day care programme.  A prison through care and after-care programme is also provided.   Solihull Clinical Commissioning Group 1.12 Solihull Clinical Commissioning Group (Solihull CCG) was authorised to lead the local NHS by commissioning (planning, buying and monitoring) high quality healthcare services for the people of Solihull from April 2013.  It is also responsible for improving the quality of primary care services but it is not responsible for the commissioning of primary care, this lies with NHS England.   1.13 It is comprised of GPs from every practice in Solihull, and Church Road practice in Sheldon, and has a governing body of GPs, CCG executives and lay members.  Prior to authorisation, services in Solihull were commissioned by Solihull Primary Care Trust.  The designated nurse for safeguarding is employed by Solihull CCG and the CCG has supported the practice involved in this case with its individual management review.  West Midlands Police  1.14 West Midlands Police is the second largest police force in the country.  1.15 The region sits at the very heart of the country and covers the three major centres of Birmingham, Coventry and Wolverhampton.  It also includes the busy and thriving districts of Sandwell, Walsall, Solihull and Dudley.  1.16 The force deals with more than  2,000 emergency calls for help every day, as well as patrolling the streets and responding to incidents 24-hours-a-day, seven days a week. 58     Appendix 4:   Glossary of Terms  Initial Assessment  An initial assessment is defined as a ‘brief assessment...should address the dimensions of the assessment framework.... determining if the child is in need and the nature of any services required’. (National Assessment Framework 2000). Core assessment:         A core assessment is defined as ‘an in-depth assessment which addresses the central or most important aspects of the needs of a child and the capacity of his or her parents or caregivers to respond appropriately to these needs within the wider family and community context’.  The end purpose of the core assessment is defined as ‘At the conclusion of this phase of assessment, there should be an analysis of the findings which will provide an understanding of the child’s circumstances and inform planning, case objectives and the nature of service provision’.  The definition leads on to outline the multi-agency requirement of a core assessment, “while it is led by social services invariably it will involve other agencies... (who will) contribute specialist knowledge or advice or specialist assessments”. Disguised compliance  In their publication “Beyond Blame”, Reder, Duncan and Gray define disguised compliance as “a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention”. The phenomenon features significantly as an issue in working with families as outlined in forty seven case studies analysed in The Biennial Study of Serious case Reviews 2003-2005 (Brandon et al). Hindsight Bias Dekker (2010) notes that “hindsight causes us to oversimplify history; relative to how people understood events at the time they were happening”. Shiller, (2000) describes it as “a tendency to think that one would have known actual events were coming before they happened, had one been present then or had reason to pay attention.  Hindsight bias encourages a view of the world as more predictable than it really is”. Professional Learning and Supervision In her review of child protection in 2011, Munro usefully reflects Klein’s (2000) work on ways in which experts learn: • Engaging in deliberate practice, and setting specific goals and evaluation criteria; • Compiling extensive experience banks • Obtaining feedback that is accurate, diagnostic and reasonably timely and • Enriching their experience by reviewing prior experiences to derive new insights and lessons from mistakes  In respect of the children’s services profession, Munro goes on to say, “This account of professional expertise is crucial for thinking about how both individuals and the profession as a whole can be supported to develop their knowledge and skills in helping children and families”.  59   Rule of Optimism Dingwall, Eekelaar and Murray (1983) highlighted the rule of optimism as meaning” that professional staff want to think the best of those they work with and want things to work out, exhibiting a positive bias in that direction”.  Start Again Syndrome  The concept of the ‘start again syndrome’ (Brandon et al 2008) whereby prior knowledge and case history, and case ‘experience’ is discounted in favour of searching for new information, is an established phenomenon in child protection work.    60   Appendix 5:  Bibliography  Advisory Council on the Misuse of Drugs (2003) Hidden Harm – responding to the needs of children of problem drug users  Advisory Council on the Misuse of Drugs (2007) Hidden Harm Three Years On: Realities, Challenges and Opportunities  Cleaver, Unell and Aldgate (2011) Children’s Needs – Parenting Capacity Child Abuse, Parental Mental Health, Learning Disability, Substance Misuse and Domestic Violence 2nd edition HMSO.  Davies. C & Ward. H (2012) Safeguarding Children Across Services: Messages From Research. Kingsley Publishers : London.  Dekker. S (2010) The Field Guide to Understanding Human Error.  Surrey: Ashgate.   Department for Education. (2012) New learning from serious case reviews: a two year report for 2009-2011. London: DfE.  Department of Health, Department for Education and Employment and Home Office (2000). Framework for the Assessment of Children in Need and their Families, page 32. London: The Stationery Office.  Department of Health, Cox A. and Bentovim, A. (2000) The Family Assessment Pack of Questionnaires and Scales. London: The Stationery Office.  Dingwall.,R Eekelaar. J and Murray. T (1983) The Protection of Children: State Intervention and family life. Blackwell Oxford : England.  Fish, Sheila and Munro, Eileen. (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews (Report 19). London: SCIE  Galvini. S (2015) Alcohol and Other Drug Use. The Role and Capabilities of Social Workers MMU   HM Government (2015) Information sharing. Advice for practitioners providing safeguarding services to children, young people, parents and carers. Crown Copyright  Kadushin, A. (1992) Supervision in Social Work, Third Edition. New York: Columbia University Press  Laming. H et al (2003)   The Victoria Climbie Inquiry Report. London : TSO  Laming. H (2009) The protection of children in England: a progress report. London: TSO  Munro, E. (2011) The Munro Review of Child Protection: Final Report A child-centered system. London: The Stationery Office  National Children’s Bureau (2013) The role of Independent Reviewing Officers in England    London.  Ofsted (2008). Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008. London: Ofsted.  Reder. P Duncan. S and Gray. M (1993) Beyond Blame : Child Abuse Tragedies Revisited  Tuck, V. (October 2011) ‘Resistant Parents and Child Protection: Pointers for Practice and Implications for Policy. Child Abuse Review.    Turney, D., Platt, D., Selwyn, J. And Farmer, E. (2011). Social work assessment of children in need: what do we know? Messages from research, Executive Study. London: Department for Education, School for Policy Studies, University of Bristol.  