Thematic review on infants under 1-year-old, covering seven rapid reviews from August 2019 to March 2020. Cases involve infants who suffered abusive head trauma, fractures consistent with non-accidental injury and concerns in relation to neglect, substance misuse and domestic abuse. Learning includes: children aged 0-2-years-old are not always visible to services; the totality of commissioned services for infants needs to be mapped and a gap analysis completed in order to strengthen earlier identification of need and risk; the single point of access for children's services needs to be embedded and thresholds well understood and applied consistently; improving the knowledge and skills of practitioners to observe and assess the lived experience of pre-verbal and non-verbal children; information sharing continues to create challenges for professionals, including misunderstandings of data protection legislation; the need to understand and assess the emotional and physical risk to babies and children of being present in a household where there is known domestic abuse; professionals need to robustly consider the likelihood of future risk to children, considering how parental mental health concerns, substance misuse and domestic abuse can fluctuate over time; professionals should challenge colleagues if new information is not sufficiently considered which may lead to a safeguarding risk; fathers or co-parents need to be an equal part of assessments, support and plans in order to ensure that the needs and risks to a child are known and met; professionals need to know when a formal pre-birth assessment needs to be undertaken, and provide challenge if this does not happen.
      
    Serious Case Review No: 2023/C9779  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     1  Thematic Local Child Safeguarding Practice Review of Infants under 1 Year Executive Summary March 2022     2 Contents 1. Introduction Page 3 2. Methodology Page 4 3. Context Page 4 4. The Parent’s Voice Page 5 5. The Review Findings Page 5 6. Positive Practice Page 5 7. What needs to be done differently to prevent harm occurring in similar circumstances Page 5 8. What needs to happen to ensure that agencies learn from this review? Page 7 9. Evidence of changes since the thematic review commenced Page 8 10. Conclusion Page 9 11. How will this learning be disseminated? Page 9    3 1. Introduction A Thematic Local Child Safeguarding Practice Review of Infants under 1 year old was commissioned by a Local Safeguarding Children Partnership. This Executive Summary provides an overview of the process and scope of the thematic review, sets out the findings from the thematic review, the key recommendations and the learning for practice including the dissemination of the learning. 1.1 Incidents which led to the Thematic Child Safeguarding Practice Review Between the period of August 2019 and March 2020 there were seven Rapid Reviews1 completed by the Local Safeguarding Children Partnership relating to children under the age of one. It is important to note that not all of the cases met the criteria for a Child Safeguarding Practice Review, however there were some common themes identified in all of the Rapid Reviews.  Two of the infants suffered Abusive Head Trauma, an additional two had fractures consistent with Non-Accidental Injury and the remaining lived in household with concerns in relation to Neglect, Substance Misuse and Domestic Abuse. All the families were involved with Early Help Services and two of the parents were care experienced parents.  The key themes identified during the Rapid Reviews included: • The quality, timeliness and appropriateness of early help assessments  • The lack of and/or limits of multi-agency working and how this affects professionals’ expectations when a number of agencies are involved • An over reliance on what parents say • Timeliness and quality of referrals, including any follow up • Escalation and professional challenge • Our professional response to disclosures of domestic abuse • Care leavers and cross boundary working 1.2 Scope of the Review As agreed in the submissions to the National Review Panel, the Local Safeguarding Children Partnership agreed to complete a thematic review in order to better understand recurring themes and identify learning for all agencies working with children and families. The following themes were identified from the seven rapid reviews and were agreed as the focus for the review with the National Panel.   The key themes identified for the Rapid Review and agreed with the National Review Panel include: ➢ Professional Challenge, Curiosity & Escalation  ➢ Voice of the child (pre-verbal children)                                                            1 Locally, safeguarding partners must make arrangements to identify and review serious child safeguarding case which, in their view, raise issues of importance in relation to their area. Serious child safeguarding cases are those in which abuse or neglect of a child is known or suspected or the child has died or been seriously harmed. The Rapid Review process involves the initial scoping and analysis of information to ensure a child’s safety, identify learning for the system.    4 ➢ Quality and Timeliness of Early Help Assessments (EHA), including parental experience of the EHA process ➢ Domestic Abuse The other key themes identified were already being addressed as part of the strategic business plan for the Local Safeguarding Children Partnership. It was also agreed that the work completed as part of the Rapid Review process would not be duplicated but inform the thematic review. 2. Methodology The thematic review was led and authored by Stephanie Nightingale. The fieldwork for the review involved practitioner focused groups relating to each of the themed areas. Practitioners involved in the seven cases were invited to attend the themed focus group alongside other practitioners that expressed an interest in that area. Professionals that were unable to attend a focus group were contacted by email in order to collate their views and enhance this particular line of enquiry. The parents of the seven children were also invited to contribute to the thematic review and one parent spoke to the lead reviewer. Their responses are included in this executive summary. 3. Context All the Rapid Reviews were completed before the first Covid lockdown (March 2020) therefore Covid would not have been a contributing factor within the Rapid Reviews. The thematic review was a holistic review which included children who were the subject of a Rapid Review but not all of the cases met the criteria for a Child Safeguarding Practice Review. The lockdown impacted on the capacity of the local areas to progress the thematic review. In addition, practitioners experience of safeguarding children in lockdown was a powerful experience and provided an additional lens to the discussions in the focus groups.  4. The Parent’s Voice It was important that the parent’s views were also captured as learning for the local area’s safeguarding systems. The parent feedback provided important areas for services to consider including ensuring parents have telephone numbers and consideration of the environment when domestic abuse is discussed.   “There have been so many Social Workers, changed so many times. I’ve got the email for the Social Worker but not a telephone number. This would be helpful.” “I think parents like me should do a parenting course before the baby is born NOT just focus on preparing for the birth.”  “If I saw a professional somewhere else I feel I could have talked about what was happening more. Because he was there all the time I couldn’t talk about the domestic abuse. Nobody gave me the opportunity to talk about it.”   5 5. The Review Findings - How agencies worked together and learning from this The review found that there was evidence of positive practice and areas for improvement and recommendations have been made for practice improvement across the safeguarding systems. 6.  Positive practice  ✓ There is evidence of collaborative working and good professional relationships in some situations. ✓ Clearly defined tier two early help services are working well. In addition, the Early help quality assurance process was described as not being compliance lead. The starting point is ‘tell me about this child.’ ✓ Practice standards have improved timeliness of assessments and there is better consistency. ✓ Practitioners believed they took a holistic approach to the welfare of children. ✓ Low level professional challenge was something that practitioners were comfortable practicing as part of their day to day regular work, questioning decisions made by others, and asking what the rationale for the decision. ✓ Practitioners noted that generally professionals challenge decisions and practice comfortably and helped to train more junior members of staff and those new to organisations to have the confidence to do so within an open and supportive working environment. ✓ One agency demonstrated advocating for young children going above and beyond due to professional curiosity. ✓ Evidence of good practice by asking manager to attend on joint visit when complex concerns emerged.  ✓ Evidence of working with families requiring interpreter services and adapting to cultural practices to engage parents. ✓ Whilst prioritising life-saving medical treatment also parallel work to have a sense of the story behind the child’s journey and potential for safeguarding concern. ✓ Restorative practice being rolled out and promoting to partner agencies, will strengthen professional relationships. 7. What needs to be done differently to prevent harm occurring in similar circumstances • Children aged 0-2 are not always visible to services. At the time of the review fewer universal groups existed and practitioners explained that not enough services offer support directly to parents of new babies other than Midwifery and Health Visiting services.  • The totality of commissioned services for infants needs to be mapped and a gap analysis completed in order to strengthen earlier identification of need and risk.  • The single point of access for Children’s Services needs to be embedded and threshold well understood and applied consistently across the partnerships with the emphasis on ensuring ‘children are receiving the right service at the right time.’ • Practitioners need to report safeguarding concerns through the single point of access and not through the early help lead when an early help plan is in place.  • The knowledge and skills of practitioners to observe and assess the lived experience of pre-verbal and non-verbal children needs to be improved including understanding child development.   6 • Information sharing continues to create challenges for professionals and an ongoing misunderstanding of data protection legislation including GDPR and consent.  • The emotional and physical risk to babies and children of being present in a household (not necessary in the room where the incident occurred) where there is known domestic abuse needs to be understood and assessed.  • All professionals across and within agencies need to robustly consider the likelihood of future risk to the children. Parental mental health concerns, substance misuse and domestic abuse can fluctuate over time, and therefore require a dynamic view of the risks.  • Professionals should avoid assumptions about attendance and progress made at Domestic Abuse Recovery Programme course and ensure that the professionals running the course are an integral part of the assessment of risk and team around the child/ren.  • It is the responsibility of all professionals to challenge their colleagues if new information is not sufficiently considered which may lead to a safeguarding risk. There needs to be a culture of respectful uncertainty and challenge between professionals if risks are not adequately considered or addressed by any agency.  • Professionals across agencies must challenge their own practice as well as the practice of colleagues to ensure that their assessments of risk are not based on self-reporting from parents; that they consider the impact of parental history of drug misuse, domestic abuse and mental health; and that they are not over-optimistic in their analysis. • Fathers or co-parents need to be an equal part of assessments, support and plans in order to ensure that the needs and risks to a child are known and met.  Professionals need to consider how they can meaningfully engage with a father/ co-parent. • All professionals need to know when a formal pre-birth assessment needs to be undertaken, and provide challenge if this does not happen. • All professionals that work with children and families are essential to keeping children safe and improving their outcomes. The contribution that all professional’s offer needs to be valued and respected.     7 8.  What needs to happen to ensure that agencies learn from this review? The following recommendations will be progressed through action plans by the Local Safeguarding Children Partnership.  1. Map and publish the multi-agency pathway from conception to two-year-old and identify any gaps in current provision. 2. The Local Safeguarding Children Partnership should assure themselves that the standards set in the Public Health England health visiting and school nursing service delivery model published in May 2021 are being met  3. Promote the early help services within communities to ensure that families that need the services know how to self-refer. 4. Ensure all professionals know how to escalate concerns and are supported to do this. 5. Seek assurance from training providers to ensure that all domestic abuse training offered to partners takes account of the emotional and physical risk to infants and children. 6. Seek assurance from Domestic Abuse Commissioning Board that the current offer of Domestic Abuse Perpetrator Programmes considers risks to children and how they are monitored.    8 9. Evidence of changes since the thematic review commenced Across the Local Safeguarding Children Partnership, the learning from the Rapid Reviews was disseminated and the change particularly at a strategic level has been identified in the following areas since the reviews were completed. 9.1 Referral Processes and Front Door The reviews identified that changes to an on-line referral process the front doors in the local area was challenging for practitioners. This may have been due to initial implementation issues but practitioners were unsure if their referrals had been accepted.  Children’s Services implemented a new approach at their Front Doors based on the work of Professor David Thorpe. The new approach removes the focus on risk and ‘child protection’ and moves to Early Help and preventative services and support. There has been a move away from agencies making written referrals and more of an emphasis on meaningful phone conversations with experienced social work consultants. 9.2 Early Help Offer At the time of the Rapid Reviews Early Help was underdeveloped in one of the local authority areas. However, as part of the DfE improvement work they have since developed and launched their Early help and prevention strategy and implemented the THRIVE model, a relationship-based and restorative approach to practice and has been working closely with local communities to implement early help across the locality. 9.3 Domestic Abuse offer including Recovery Programmes  The local area published the Domestic Abuse Strategy 2021-2024, which is based upon the Domestic Abuse Act 2021 which recognises children as victims of domestic abuse. The multi-agency strategy promote the safeguarding of vulnerable individuals, families and children, seeking and listening to the voice of the child. The Local Safeguarding Children Partnership will seek assurance to ensure the impact of strategy is effective in safeguarding children at risk of Domestic Abuse.  9.4 Commissioning of 0-19 services The reviews coincided with the recommissioning of 0-19 health services in line with the National Commissioning Framework. There were some concerns initially expressed particularly from health practitioners that the new services may not meet the needs of families in the respective communities. Since then the CCG Executive Director of Nursing and Quality has advised the Local Safeguarding Children Partnership that there is no documented evidence that the 0-19 commissioned service is not fit for purpose but that the CCGs, and subsequently the ICS, will continue to monitor this.      9 10. Conclusion  Restorative and trauma informed practice has been identified as an effective approach to child protection in the locality and focus group feedback sees the value in this being considered as crucial knowledge for all professionals working with babies, children and families, underpinning family assessments and care plans, with an aim of preventing harm to babies and children.  As key agencies move into Integrated Care Systems (ICS) there is the prospect of joined up, meaningful working together and with that an increased understanding and trust of each other’s specialism and knowledge. There is a willingness and appetite for this to improve and there has been progress made since these rapid reviews were completed. This will continue to be monitored by the Local Safeguarding Children Partnership. 11.  How will this learning be disseminated? In addition to the strategic changes identified above, on a practice level the learning has been and will continue to be incorporated into training, lunchtime learning bites, 7-minute briefings and the review of relevant policies and guidance. It will also be disseminated through briefings for staff in individual agencies.  11.1 Take the Learning into your Practice Take the issues raised in this thematic review into your supervision, team meeting and single or multi-agency group supervision for discussion. Consider the following:  • Do I consider the likely ‘lived experience’ of children, including how to capture the voices of pre-verbal and non-verbal children? • Do I consider the longer-term risks to children if parental mental health issues and/or domestic abuse reoccurs?  • Do I ensure that all relevant professionals providing services to the adults in the family are represented at meetings and contribute to plans for children? • Do I follow up concerns, escalate professional disagreements, and keep the child’s welfare at the heart of all communications? • Do I always engage both parents/carers regardless of their gender and ensure I seek their views independently?  • Do I always challenge myself and others to ensure that our practice is not based entirely on self-reporting from parents and if the analysis is over-optimistic?   • Am I clear about when and why a specific pre-birth assessment should be undertaken? • Do my strengths-based assessments robustly consider and focus on any risks and vulnerabilities? 