Serious harm caused to a 12-year-old over a number of years, identified in July 2013 when serious concerns were raised concerning poor home environment and Child H's presentation, including impaired vision. Medical examination revealed that Child H had a cataract with no vision in their left eye, requiring urgent medical attention. Child H was taken into the care of the local authority and mother and mother's partner were charged and sentenced to 30-months imprisonment for child cruelty. Child H was diagnosed with Juvenile Idiopathic Arthritis (JIA) when 5-years-old. JIA can lead to eye problems, which, if not detected and treated early, can cause permanent visual damage, including blindness. Child H was found to have early indicators of uveitis at an ophthalmology appointment in 2011; Child H did not attend any further ophthalmology appointments until July 2013. Children's social care received three referrals between 2011 and 2013 and concerns had been raised by a number of professionals regarding hygiene and attendance at school and medical appointments. Issues identified include: the system for screening children with complex eye problems is not designed around the needs of the child, with the appointment system implying Child H was making informed choices about not attending, rather than parents' non-attendance being seen as an indicator of neglect; and failure to recognise the history and pattern of concerns regarding Child H. Identifies learning outcomes, including: children with medical needs necessitating a range of specialists, require a nominated lead professional to maintain coordination of services, in particular, the role of the school nurse should be developed to engage with children and parents and to assist schools in understanding the impact of specific conditions. Makes various recommendations and includes a multi-agency action plan.
      
 Title:  Serious case review report: Child H. LSCB: Stockton-on-Tees Local Safeguarding Children Board Author: Stockton-on-Tees Local Safeguarding Children Board 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.                                   Serious Case Review Report  (Part 1) Child H           This report will be published in line with statutory guidance. In order to preserve the anonymity for the children in this family, the author has: • used initials to represent people • made no reference to the gender  children • avoided the use of exact dates • not used any details about local services which could lead to  recognition of the children and family   Until publication of the report on 4th August 2015 it is confidential and must not be shared with non relevant parties.  SLSCB SCR ‘H’     1   Contents 1 Introduction ...................................................................................................................................... 2 2 Methodology .................................................................................................................................... 4 3. Overview of what was known to Agencies .................................................................................. 6 4 Analysis Leading to Learning ...................................................................................................... 12 5 Learning Outcomes ...................................................................................................................... 23     SLSCB SCR ‘H’     2   1 Introduction  1.1 This Serious Case Review (SCR) concerns Child H who was twelve years of age when the incident which gave rise to this SCR occurred.  Child H was the eldest of two children born to the mother (MH). MH and Child H’s father (FH) separated when Child H was approximately nine years old and Child H remained living with MH. MH went on to meet a new partner (PMH) and together they had a further child (S1), a half sibling to Child H when Child H was ten years old. Child H was living with MH, PMH and S1 when the critical incident occurred.   1.2 As a young Child, Child H was diagnosed with Juvenile idiopathic Arthritis (JIA). Many children with this diagnosis are able to live a life free of medical interventions, for others however symptoms of the illness can be pronounced and make everyday tasks such as walking, bending and self-care more difficult.  Children with JIA can also develop eye problems either as a result of the disease itself or, rarely, as a side effect of some medicines. The most common eye problem that can develop is uveitis which is an inflammation of inner parts of the eye. If the inflammation is not detected and treated early, scarring and permanent vision problems can occur. Glaucoma, cataracts, and permanent visual damage, including blindness, are all complications that could result from severe uveitis.   1.3 Aged five years, Child H experienced swelling and pain to the knee and attended a rheumatology appointment for the first time.  After a short period of hospital treatment, Child H was discharged to community health services for ongoing treatment and which included ongoing oral medication and regular injections directly to the joint. Child H was also referred to Ophthalmology services to monitor any developments to the eyes.   1.4 From aged six years, some rheumatology appointments began to be missed for Child H, and there was sporadic attendance at ophthalmic appointments. Child H had a long series of physiotherapy interventions aged seven where compliance with appointments was not an issue of concern.  Aged eight years, Child H began to refuse injections when attending rheumatology appointments and at subsequent appointments the Consultant Rheumatologist observed that MH found it difficult to manage Child H’s behaviour.   1.5 Child H was almost ten years in 2011, when taken to an Ophthalmology appointment. At this appointment, Child H was found to have ‘keratic precipitates’, which is an early indicator of Uveitis in the left eye.  Child H was not seen for any further appointments by Ophthalmology until after the critical incident.   SLSCB SCR ‘H’     3  1.6 Between September 2011, and July 2013, three referrals were made to Children’s Social Care in respect of Child H. The first two referrals were made by the child’s Consultant Rheumatologist and the third was made the child’s G.P. The first referral expressed concern about Child H’s poor hygiene and the associated risk of infection because Child H took medication which suppressed the immune system, as well as concerns about Child H refusing critical blood tests which MH appeared unable to help manage. The second referral eleven months later referenced the issues of concern from the previous referral and stated further concern that Child H had not been brought to three scheduled follow up appointments in rheumatology and the Consultant Rheumatologist was concerned that the JIA was not being treated adequately.  The third referral was eleven months after the second referral and raised further concern that Child H was not being taken for treatment as was necessary for the medical condition. None of the referrals indicated that Child H also needed ophthalmic care nor that Child H had not been taken back for review since keratic precipitates had been discovered.  1.7 The response to the first referral by Children’s Social Care was to take no further action; the response to the second referral was to undertake an Initial Assessment which resulted in no further action.  The third referral resulted in a second Initial Assessment during which a Social Worker visited the family home. When the Social Worker saw Child H, the Social Worker noted that the child’s left eye was extremely cloudy and that the vision was impaired.  When the Social Worker questioned MH about Child H’s presentation, MH stated that she had not noticed. In addition to the presentation of Child H, the Social Worker was extremely concerned about the conditions within the family home and initiated a joint child protection investigation with the police. Photographs taken by the police on the day the Social Worker raised concerns about the conditions of the family home reveal extremely poor home conditions characterised by rotting food, lack of bedding, broken toys, unhygienic sanitary provision and faeces smeared to the wall of Child H’s bedroom. A medical with a Paediatrician revealed that Child H had a cataract to the left eye with no vision which required urgent medical treatment.  1.8 Child H and S1 were taken in to the care of the Local Authority and MH and PMH were both charged and subsequently sentenced to 30 months imprisonment for child cruelty.   1.9 The case was referred to Stockton-on-Tees Local Safeguarding Children Board (SLSCB) for consideration as to whether a SCR or a Learning Review should be undertaken. It was considered that Child H may have been seriously harmed by an adult and there was cause for concern about the way in which local professionals and services had worked to together to safeguard and promote the child’s welfare  The crux of the determination for the SCR was whether Child H’s eye sight had been permanently impaired due to neglect from failure to SLSCB SCR ‘H’     4  respond to the child’s medical and environmental needs taking into account missed medical appointments and the poor home conditions.   1.10 Communication took place with Child H’s Consultant Ophthalmologist who indicated that it was difficult to provide a definitive prognosis of Child H’s long term vision pending surgery, which Child H was at that time refusing.  The Consultant was asked to review Child H’s medical records to provide expert opinion as to whether Child H’s eye condition could have been avoided if consistently taken to medical appointments and complied with treatments. The Consultant Ophthalmologist confirmed that non-attendance for ophthalmic review appointments between 2011 and 2013 had an effect on Child H’s condition. Once this information was received, the SLSCB determined that the criteria for a SCR was met because: • Neglect of Child H was known •  Child H had been seriously harmed and there is cause for concern as to the way in which the Local Authority, their Board partners or other relevant persons have worked together to safeguard the child. A decision was then taken by the Chair of the SLSCB that a Serious Case Review would be undertaken.   2 Methodology  2.1 The SLSCB appointed two Independent Reviewers to facilitate the Review. The two Independent Reviewers divided the role of chairing the Review Panel and authoring the report, and worked together to facilitate two practitioners events. This Review was overseen by a Panel of senior officers from participating agencies which included: • South Tees Hospitals NHS Foundation Trust • North Tees & Hartlepool Hospitals Foundation Trust • NHS England Area Team (Durham, Darlington and Tees) • Early Years & Complex Needs - Stockton-On-Tees Borough Council • Children’s Social Care, Stockton-On-Tees Borough Council • Cafcass • Cleveland Police  2.2 The Review Panel did not set specific Terms of Reference from the outset, instead, the Review was permitted to identify the key issues as they unfolded through the detailed scrutiny of professional practice. Each agency submitted a timeline of interventions at the start of the Review and this was chronoIated to illuminate the multi-agency activity, who knew what and when. It was agreed that the general timeline for the Review would cover the period between September 2011 and August 2013. An early Panel meeting reviewed what appeared to be the most significant events arising from the multi-agency timeline and it became clear that the key SLSCB SCR ‘H’     5  episodes of multi-agency practice centred around the three referrals to Children’s Social Care. In addition, the Review Team wanted to ensure there was a focus on what was known about the physical conditions of the family home and whether indicators of neglect were present for Child H. To this end, four home visits, two by a Health Visitor and two by a Social Worker were also considered as key points of practice, along with Child H’s experiences in education.    2.3 The first practitioner’s event brought together professionals from each agency that had worked with Child H. The opportunity to take part in a multi-agency event of this nature was new to most participants, however, there was a commitment to learning together. The practitioners used the timeline as a means of exploring the key issues of practice as they unfolded in this case, and multi-agency professionals shared the context within which events had happened. Effectively, the group undertook a live multi-agency audit from which Child H’s case was reviewed.  2.4 Once the key episodes of practice were determined, each Agency completed a focussed report addressing the agency perspective on the significant events in the context they were understood to have occurred as well as identifying single agency learning and recommendations. The Review Panel undertook a genuinely and robustly challenging approach to the whole process, this provided strong evidence of open communication at a senior level between participating agencies and contributed significantly to the Reviewers understanding of local cultures and practice.   2.5 The Review was mindful of the parallel process of criminal proceedings, but also keen to involve key family members in the Review. FH met with one of the Independent Reviewers early into the process and as MH and PMH were awaiting criminal trial charged with Child Cruelty, the advice from the Crown Prosecution Service was to wait post trial for direct consultation. MH and PMH were both sentenced in September 2014 and both were seen in prison by one of the Independent reviewers and the SLSCB Business Manager in December 2014.  2.6 The Review Panel also wished to invite Child H to have a direct voice in the Review. This was discussed in some detail with FH. It was agreed that FH would discuss this possibility with Child H and also that  the Independent Reviewer would write to Child H explaining what the Review was and asking whether Child H  would want to meet to have further discussion or alternatively forward any questions or thoughts in written form. Child H was described as a quiet and studious child, and it was felt by those who best knew the child’s character that Child H would find it difficult at this stage to contribute to the Review.  It is also the case that as a child of parents separated acrimoniously, Child H can struggle with divided loyalties and so does struggle to talk about all that has happened. During the Review, Child H did not take up the opportunity to meet the reviewers, but the child will be offered a further opportunity after SLSCB SCR ‘H’     6  completion of the report to be helped to understand the report and its significance prior to publication.   2.7 The Review was extremely well supported by the SLSCB Business Manager and Administrator which ensured that the process was well managed and efficient.   3. Overview of what was known to Agencies 3.1 Outside of the timeframe for the Review, it became clear from agency records that when Child H was six years old and living in another Local Authority area with MH and FH, that there was concern about Child H’s school attendance and hygiene.  An Education Welfare Officer made a referral to Children’s Social Care in that area when Child H was nine years old. The referral stated that Child H had JIA and the home conditions were ‘appalling’ with no heating, cold and damp, a mouse infestation and a risk of ceiling collapse. Additionally the referral stated that Child H’s personal hygiene at school was poor. An Initial Assessment was undertaken over a nine day period which recorded that Child H’s attendance was poor because of hospital appointments and that although the home was found to be cluttered and untidy, the worst of the conditions was considered to be issues in relation to the fabric of the building that required the intervention of the landlord. The Social Worker did look around the whole property, and it was noted that Child H’s bedroom was ‘tidy and comfortable’ a further social work home visit  was made two months later at which point  home improvements and Child H’s presentation in school was noted as vastly improved,  and the case was closed to Children’s Social Care. Notably, the information in the assessment about Child H’s medical appointments was self-reported and the Consultant Rheumatologist was never consulted or advised that an Initial Assessment had taken place. Ten months after the closure to Children’s Social Care, two further Attendance Meetings were held before Child H moved school and area three months later.   3.2 Child H moved to Stockton-on-Tees during primary school year 5, and attended a Primary School for four school terms until the end of Year 6.  The Primary School had made contact with Child H’s previous school upon enrolment and discovered that there had been some concerns about attendance. During Child H’s time at the new Primary School however there were no concerns about attendance, on the contrary, Child  H‘s attendance was considered to be excellent. There were occasions when Child H arrived as school in what was describes as a ‘grubby’ state; these occasions were infrequent and months apart and are described by the school as not significant in themselves.  The instances did not raise any ongoing cause for concern, particularly as when the Deputy Head Teacher spoke to MH about this, the matter was quickly resolved.   SLSCB SCR ‘H’     7  During the summer prior to Child H’s last year in Primary School, PMH moved into the family home.   3.3 One months later the first referral was made to Children’s Social Care by the Consultant Rheumatologist. The referral contained the following information: • That Child H had JIA which responds well to a specific injected medication methotrexate which weakens the immune system • That Child H is unwashed, smelly and very dirty when attending clinic • That Child H gets repeated infections, and the referrer is concerned about poor hygiene standards , as MH has not responded to this feedback • That the referrer suspects parental discipline is a problem • That Child H refuses to co-operate with blood tests  3.4 The referral was received by Children’s Social Care through the First Contact Team. This Team screens referrals and determines whether it is forwarded to the Referral and Assessment Team (RAT) where an Initial Assessment would be undertaken or an  alternative course of action is pursued, including no further action. The First Contact Team contacted Child H’s primary school who reported no concerns about Child H’s welfare. The Team Manager from the First Contact Team passed the referral to the RAT Team because there remained indicators in the referral that Child H’s medical needs were being compromised relating to medications and poor hygiene. Upon receiving this referral, the Team Manager of the RAT Team made a decision to take no further action on the basis that the concerns expressed about Child H’s personal hygiene were not substantiated by the school and on this basis took the view that there was no role for Children’s Social Care. When closing the referral, no contact was made with the Consultant Rheumatologist to explore the context of the concerns nor was the referrer advised of the outcome of the referral. The outcome was not known to the Consultant Rheumatologist until some five months later when the Consultant made contact with Children’s Social Care to establish the outcome of the referral and was advised that no further action had been taken.   3.5 In addition to the referral to Children’s Social Care, the Consultant Rheumatologist made a referral to the Child and Adolescent Mental Health Service (CAMHS) to seek support for Child H and the family with regard to behavioural issues that were emerging. The hospital records indicate that this referral was deemed to be outside of the criteria for the service and advice was given to make a further referral to a Clinical Psychology Service. A referral to Clinical Psychology was duly made by the Consultant Rheumatologist however the Psychological Service reported that as the client did not want the service, Child H would not be allocated for assessment.   SLSCB SCR ‘H’     8  3.6 Two months after the referral to Children’s Social Care, Child H attended for an appointment with the Consultant Rheumatologist. On this occasion it was noted that Child H’s personal hygiene was much improved, however, after initially agreeing to blood tests, Child H then refused to have them done. This meant that the methotrexate medication could not be administered despite this being considered necessary to manage Child H’s physical symptoms to the knee.   3.7 Three weeks later, Child H attended for physiotherapy.  Child H was not brought to the first scheduled appointment but was taken to the second.  Child H’s main problem was stiffness to one knee and the beginning of stiffness in the other knee. The Physiotherapist provided exercise to be done at home, however, Child H became distressed at not wanting to do the exercises. A further appointment was made for two weeks later but Child H was not taken and was then discharged to the service.  3.8 Child H’s half sibling was born some weeks later.  Shortly before and approximately two weeks after the birth, a Health Visitor made visits to the family home. The first visit was as part of a general breast feeding advice session to expectant mothers and the second visit was the primary health care visit for S1. Records reflect some concerns about the home conditions describing an unclean odour and some replacement furnishings needed. The Health Visitor was aware that Child H had JIA. There was no communication from the Health Visitor to the School Nurse about the potential impact of the home conditions on Child H’s Welfare.  No further Heath Visitor home visits took place.  3.9 A month after the birth of S1 and approximately five months from the previous appointment, Child H attended an appointment with the Consultant Rheumatologist. On this occasion Child H reported no pain or difficulties and a further appointment was arranged for two months later.  The Consultant Rheumatologist contacted Children’s Social Care to enquire as to the outcome of the referral and was told that the case had been logged and closed. Child H was not taken to the next scheduled appointment.  3.10 Child H’s next contact with medical services was three months later. Child H attended the GP practice and was diagnosed with conjunctivitis to the left eye. The GP was aware that Child H had an eye condition, however the GP was not aware that Child H had not attended appointments with Ophthalmology. It should be noted that conjunctivitis has a different presentation to uveitis; conjunctivitis is an inflammation or redness of the lining of the white part of the eye and the underside of the eyelid while Uveitis is inflammation of the middle layer of the eye, the uveal tract. Child H was prescribed a course of treatment, and MH was told to bring the child back if the infection did not clear up. SLSCB SCR ‘H’     9   3.11 Child H was at this point in the last term of primary school.  FH made an application to the Family Proceedings Court for Parental Responsibility and a Contact Order. The application alleged that MH had stopped FH from having contact with Child H following an argument between the two parents. There was a human error of non-compliance with Cafcass procedures that led to the Stockton-on-Tees Local Authority checks not being commissioned or followed up by Cafcass.  Cafcass are confident that their systems have developed considerably since this occurred so as such a mistake could not be repeated. At a Court hearing, an agreement was reached that Child H would have contact with FH and the matter was closed to Cafcass until three months later when MH stated that Child H did not want to comply with the contact as agreed.  3.12 At the end of the school term, the Consultant Rheumatologist wrote to MH as Child H had missed two scheduled appointments. This was around the time that the family moved home. The letter stressed the importance of Child H attending appointments and a further appointment was scheduled during the summer holiday period. This appointment was not attended, and the Consultant Rheumatologist made a second referral to Children’s Social Care just before Child H began Secondary School.  The Referral stated that Child H had JIA, and referenced the previous referral made. It indicated that JIA can lead to chronic disability if not adequately treated and that Child H had now missed three appointments.   3.13 The referral was considered by the First Contact Team Manager and passed to the RAT Team for follow up because of concerns in relation to the possible neglect of Child H’s medical needs. The referral was allocated to a Social Worker to undertake an Initial Assessment. Ten days after allocation, the Social Worker undertook a home visit with MH, PMH and Child H present. MH stated that she had not received medical appointments because the family had moved house and agreed to contact the GP to advise of the change of address and request a re-referral to the Rheumatology. MH advised that the GP continued to prescribe medication and Child H confirmed that this was being administered when seen alone by the Social Worker. Child H was observed to be dressed in clean and appropriate school uniform and the home conditions were described as being of an acceptable standard. The observations of the home reflected time spent in the downstairs communal areas only. At this stage no direct contact was made with the Consultant Rheumatologist.   3.14 Four weeks into term, the Secondary School contacted MH as Child H had been found giving money to other pupils. MH acknowledged that money had gone missing from home and attributed the actions of Child H to anxiety about contact with FH. MH stated that she was concerned about Child H’s behaviour and the fact that bed-wetting had begun again.  This issue SLSCB SCR ‘H’     10  was considered resolved after consulting with MH, and was seen as isolated incident with no indicators of bullying.   3.15 Three months into Secondary School, the Cafcass Officer saw Child H, not in the family home, to establish the child’s wishes and feelings. At this meeting, Child H indicated that living with MH and PMH felt ‘safe and good’, and indicated positive feelings for both MH and FH.   The report of the Family Court Advisor (FCA) recommended continued contact with FH with extended contact during school holidays. Contact duly resumed.   3.16 At the beginning of the New Year, Child H commenced the second term in Secondary School.  Child H was considered to be polite, studious and was well liked by peers and teachers.  At this time, a Deputy Team Manager recorded in supervision notes that the Initial Assessment in relation to Child H some four months earlier remained incomplete and needed to be completed and closed given that there were no concerns about Child H.  No further activity in relation to the Initial Assessment took place at this time.   3.17 One month into the second term, the school noted that Child H smelt of urine and had become upset when other children commented on this.  MH was contacted and repeated earlier assertions that bed-wetting was as a result of visits to FH.  It would appear that MH took corrective action and is it believed that the concern did not re-present.  3.18 Towards the end of the second school term, a new Team Manager in Children’s Social Care identified that the Initial Assessment was still not completed. At this point, a second home visit was undertaken. The Social Worker informed MH that she had checked with the Consultant Rheumatologist’s secretary who had informed her that they had not been notified of a change of address or received a re-referral from the General Practitioner in respect of Child H. MH stated that she had completed a change of address form with the GP practice following the last home visit but agreed to contact the GP again to check this had been done and to ensure a re-referral was made to Rheumatology. MH and Child H confirmed that the GP continued to prescribe medication which was taken by Child H. The home conditions were again described as acceptable, but again this reflected time spent in the downstairs communal room only. This visit took place approximately four months prior to the children being removed.  The Social Worker contacted the School Nurse who provided the Social Worker with information about historical concerns related to cleanliness and absence from school when Child H lived in the previous area. The School Nurse did not make arrangements to review or follow up the concerns with either the school of within the medical profession despite the referral reason being a failure to attend medical appointments and concerns regarding the consequences. The school was not contacted at this point and therefore the information about Child H smelling of urine was not SLSCB SCR ‘H’     11  known to the Social Worker and not addressed within the Initial Assessment.  MH reported no concerns about bedwetting or worries about Child H’s contact with FH. The Assessment concluded that MH had provided a ‘plausible’ reason for missing medical appointments and had taken steps to ensure that the current address was known to medical services. The Initial Assessment was then closed eight months after it began. The Consultant Rheumatologist was given no information about the outcome of the referral.  3.19 The following month the Consultant Rheumatologist expressed concern in an e-mail to the Safeguarding Children Team within South Tees Hospitals NHS Foundation Trust that Child H had missed three appointments and also that there were risks to Child H’s vision from Uveitis.  The South Tees Trust shared the concerns with the North Tees and Hartlepool NHS Foundation Trust who requested that the school nursing service provide an update on Child H.  The Rheumatologist also wrote to Child H’s GP. The letter expressed the following pertinent issues: • Concern that Child H was not being treated for JIA and was not being screened for Uveitis • That Child H had not been seen for over a year by rheumatology  • That Children’s Social Care have been made aware but MH states that Child H is being treated  • That the Trust Safeguarding Team has been made aware • That in discussion with a Paediatrician at the hospital, the Paediatrician suggested that Child H was referred to Paediatrician at either South Tees or North Tees hospital.  The Consultant Rheumatologist went onto explain that Child H will no longer come under the care of her clinic given because the care of children with JIA had been moved to a regional centre in Newcastle. The Rheumatologist was concerned that Child H would become lost to follow up appointments if not pursued vigorously.   3.20 After four weeks, the Senior Nurse for Safeguarding Children contacted the school nursing service again to request information about Child H.  The School Nurse advised that there had been a delay in accessing information because although records had been requested, they were stored off site.  Two weeks later, information was provided to the Senior Nurse that had been provided to the Social Worker three months earlier, that before moving to the current area, there had been concerns about cleanliness and school attendance.  The Senior Nurse requested that the school nursing service provide support to Child H’s family and that a health assessment was carried out for Child H. This request was made at the point the school was finishing for summer.   SLSCB SCR ‘H’     12  3.21 The day following receipt of the letter from the Consultant Rheumatologist, the GP sent a letter to MH requesting attendance at an appointment at the surgery.  The GP placed a note on the letter asking for the practice administration staff to inform the GP if the appointment was not kept. The appointment was not kept and approximately four weeks after the first letter, a second letter was sent which received no response. Approximately seven weeks after receiving the letter from the Consultant Rheumatologist, the GP made a referral to Children’s Social Care expressing concern regarding the possible impact on Child H’s health needs of non- attendance for health appointments.   3.22 The referral from the GP stated that Child H had a potentially crippling illness that was not being treated or monitored. The referral was considered by the Team Manager, First Contact and forwarded to the RAT Team where it was allocated for Initial Assessment. The Social Worker arranged a planned home visit to the family home a week following the initial telephone contact, this was cancelled by MH and re-arranged for the following week.  When the Social Worker visited on the rescheduled date, no one was at the home. A letter was hand delivered later that day which advised MH that if she did not make herself available two days later then child protection procedures would be instigated. The Social Worker made the visit two days later, and this is when Child H was found with impairment to the left eye and the home conditions were considered unsuitable for the children to live in. MH refused to accede to the Social Workers request to see the upstairs of the home and the Social Worker returned to the office, initiated a Strategy discussion with the police and began an immediate joint investigation under Section 47 of the Children Act 1989. That day Child H and S1 were removed from the care of MH.   4 Analysis Leading to Learning  4.1 The examination of single and multi-agency working leading up to the precipitating incident of this Serious Case Review has identified several aspects of single and multi-agency learning alongside some significant reflections about how judgements were applied at key points of interventions. The analysis is structured around the specific episodes which leads to the identification of common thematic issues.   4.2 It is important to state from the outset that the principal reason for the initiation of this Serious Case Review was the significant harm that was experienced by Child H in relation to the Uveitis to the left eye and that through this Review it has been established that only one agency had knowledge of, and understood, the risk to Child H in this respect. The associated risk to Child H’s eyes was never brought to the attention of any other agency. The following paragraphs will explore the reasons why the reality of risks to Child H’s health were only discovered after the child’s health had deteriorated. This occurred because the referrals to Children’s Social Care did SLSCB SCR ‘H’     13  not reference that Child H had been found to have early signs of Uveitis following which no ophthalmology appointments had been attended, and this positon was exacerbated by the fact that Children’s Social Care did not initiate discussion with the Consultant Rheumatologist after either referral. Where an issue of practice or deficit in a system is identified, the relevant single agency recommendation is noted. The table of single agency recommendations is referenced at the end of the report.   4.3 Child H was diagnosed with a medical condition at the age of five years which required ongoing medical treatment and monitoring. It is a condition that causes discomfort and pain to varying degree and needs constant medical oversight to adjust or change treatment to respond to changing diagnoses. More positively, with the right treatment children can live relatively unaffected lives. MH told this Review that she had little understanding of the condition, and had little more than a leaflet to read to help her, medical professionals have disputed this to be true.  In the early days of Child H’s diagnosis, it is apparent that MH did understand that Child H needed treatment from a range of medical specialists as the child was taken to appointments for Rheumatology, Ophthalmology and Physiotherapy.  Inconsistent attendance has been a feature of Child H’s medical experience from the beginning of the diagnosis.   4.4 Child H was not taken for the first three ophthalmic outpatient’s appointments over a period of three months when Child H was five years old and recently diagnosed. It was eleven months from the first scheduled appointment that Child H was seen by a Consultant Ophthalmologist. The Consultant Ophthalmologist advised the GP at this point that Child H had no signs of Uveitis and had only attended after three missed appointments. Child H was then not taken for two follow up appointments at six month intervals. The next two scheduled appointment, again six months apart were not attended and on the second occasion the Consultant Ophthalmologist wrote to the Consultant Rheumatologist with a copy to the GP which stated  ‘There seems little point in making routine appointments. Would you be able to discuss this with the parents the next time you see [gender reference}, as it seems [gender reference] does need some screening to continue’ Child H attended the next appointment scheduled six months later where no signs of Uveitis was found with a review appointment made for nine months later. The next scheduled appointment was not attended, but Child H was seen four months later with no problems reported.   4.5 Child H was taken to the next scheduled appointment four months later. Child H almost ten years old and this was the last Ophthalmology that was attended.  Child H was seen by a Specialist Registrar, examination showed the presence of ‘mild to moderate activity with the left eye showing the presence of keratic precipitates.   Child H was prescribed eye drops for a six-SLSCB SCR ‘H’     14  week period and required a follow up appointment four to six weeks later. This information was relayed to the GP in a letter. As MH and Child H left the consultation, MH was given a form by the clinician which needed to be handed in to a receptionist situated at the entrance of the clinic. An appointment is then issued in accordance with the clinicians instructions, either immediately or to be received by letter.  No further appointment occurred for Child H. The GP received no further notification about Child H and it would be reasonably assumed therefore that no further medical treatment was required. At that time, a ‘Did Not Attend Pathway’ had been recently introduced into STHFT following a Serious Case Review. However the pathway only related to non -attendances at Paediatric appointments, and was not extended to other specialist areas which also see children such as Ophthalmic and Rheumatology.  See   HSTNHS CCG recommendation 2  4.6 The above system for screening children with complex eye problems is not a system designed around the needs of a child. The letter from the Consultant Ophthalmologist to the Consultant Rheumatologist illuminates that the appointments system implied that Child H was making informed choices about not attending for medical review when in fact the parents non-adherence to the child’s medical needs was a firm indicator of neglect of Child H’s medical condition many months before this possibility was highlighted under multi-agency child safeguarding procedures. It is noted that the detection of keratic precipitates was shared in a letter to the GP but was not shared with the Consultant Rheumatologist. Whilst this Review cannot determine whether MH passed the form for a further appointment to the medical secretary we can be confident that MH understood that further appointments were necessary to monitor Child H’s eyes particularly after the screening detected a problem that required treatment. At this time, FH remained living with the family also and has stated that he could have taken greater responsibility but medical matters were tended to by  MH.   4.7 As a consequence of the findings from this Review, the procedure for children who do not attend appointments will be reviewed within the South Tees Hospital Foundation Trust as a part of a range of measures to ensure that children do not miss vital medical treatment. Whilst the current Safeguarding Children Policy contains a procedure in relation to ‘Children who fail to attend for Hospital appointments’, it is evident that not all Departments who treat children within the Trust have an understanding of the welfare issues relating to children who are not brought for medical appointments, and that this should be treated very differently to patients who do not attend. The hospital state that Child H became ‘lost to follow up’ and that the Trust needs to improve appointment systems for children so that a new appointment is always made and given to the parent or carer for the child. This will establish that the appointment has been securely made and can be followed up if not attended through the revised procedure to address the needs of children who are not taken to medical appointments. SLSCB SCR ‘H’     15  See STHFT Recommendation 1 &2   and HSTNHS CCG recommendation 1  4.8 At this time, Child H’s medical care was not overseen by a Paediatric Consultant. The Consultant Rheumatologist worked primarily with adults and provided an outpatient service to children.  The Consultant clearly recognised a need to refer to Children’s Social Care however hospital policy also required that at the same time the information should be reported to the Safeguarding Children Team at STHFT and this did not occur. The role of the Safeguarding Children Team is to offer advice and support to hospital staff when considering safeguarding issues and to assist with achieving a clear referral pathway and subsequent challenge if the outcomes of a referral is not considered robust. In short, this team would have been ideally placed to co-ordinate a complete chronology of engagement and progress discussion directly with Children’s Social Care to safeguard Child H. It is likely that had a complete chorology of Child H’s medical history been produced at the point of the first referral, then the lapse of ophthalmology treatments and screening would have been identified at a much earlier point.  See STHFT Recommendation 3 &4  4.9 It is clear that Child H’s parents did not ensure that Child H had consistent medical care following the diagnosis, what is less clear is why. This Review has identified that there were no functional limitations on either parent’s ability to parent.  Child H was an only child  during the first five years of diagnosis and the family were able to access financial support to cope with the additional demands on the family resources arising out of Child H’s medical condition. Both MH and FH have indicated that their partnership was unhappy for some time before their separation, and both have stated that responsibility for Child H’s medical needs remained with MH. There are ‘low level’ concerns about hygiene and cleanliness for Child H throughout childhood and from the three last schools attended.  The School Nursing records provided relevant historical information that indicate concerns emerged about Child H’s school attendance and aspects of care from the age of six years when living in Middlesbrough, which prompted the involvement of an Education Social Worker. Child H was educated in a mainstream school with provision for special needs for a period, but was transferred into mainstream school aged seven. At this time, there were concerns expressed that Child H’s hands were always dirty, that the child smelt of smoke. Bed wetting was also an issue of concern. When Child H was nine years old, it was noted that three appointments were missed with the Consultant Rheumatologist and the Safeguarding Team at STHFT initiated contact with the then primary school who indicated that Child H was unclean.  A home visit was made to the home by an Attendance Welfare Officer and a School Nurse where the home conditions were described as ‘very poor’ and school attendance was 76%. A referral was made to Children’s Social Care in Middlesbrough and an Initial Assessment was completed. The Initial Assessment does not reflect that the intervention of the Attendance Officer and School Nurse was initiated by a concern from the hospital that SLSCB SCR ‘H’     16  Child H had missed three Rheumatology appointments, on the contrary, the Initial Assessment accepted the parents self-reported account that they are well supported in attending hospital appointments by family members.  The referral which prompted the Initial Assessment was made by the Attendance Officer who it is stated persuaded FH to let her into the house after refusing access to a School Nurse. The Attendance Officer reported concerns about the state of the house and did not reflect the history of why the two professionals were attempting to engage the family. The Initial Assessment relied heavily on self-reported information from FH and MH and did not appear to consult directly with any professional other than the Attendance Officer who made the referral. The closure to Children’s Social Care was based on an acceptance that the lapses in care to Child H had been temporary and related to factors beyond the control of the parents which had been resolved through improved housing conditions.  This Initial Assessment failed to identify the history and pattern of similar concerns with regard to Child H and the risks that substandard parenting was posing to the child’s health and development.   4.10 Twelve months after the Initial Assessment, Attendance meetings were initiated again for Child H in primary school and two meetings occurred right up to the point that the family moved home and Child H was admitted to the final primary school in Stockton-On-Tees.   4.11 When Child H transferred primary school, the school was aware of the history of attendance problems, however, it would seem that much less emphasis was placed on the history of concerns in relation to hygiene. Child H’s school attendance became exemplary following the move and whilst the school records record occasional instances of Child H attending in a ‘grubby state’, MH’s response was seen as swift and appropriate. Whilst this may be true with regard what were perceived to be isolated incidents of lapses in care, the wider picture shows a long standing pattern of compromised parenting of Child H, particularly given the additional needs arising from the medical condition.   4.12 The questions arises therefore, why this pattern was not recognised and this is likely to have many contributory factors which could include: • An over empathy with parents having to cope with the demands of a child with additional needs  • A lack of focus on the day to day experiences of Child H and what it meant to be smelly, dirty  • The impact of several moves of school and loss of continuity, as well as the impact of moving schools across geographical boundaries • A lack of clarity about the role of the school nurse and missed opportunity to make better connections between hospital and community health services to co-ordinate knowledge of Child H with school SLSCB SCR ‘H’     17   4.13 It would appear that throughout Child H’s school life, the parents and later MH alone complied just enough to show a level of compliance that satisfied professionals as to the renewed intentions to prioritise Child H’s care needs. This cycle is very familiar in serious case reviews, and there are two important features of engagement apparent. Firstly, disguised compliance, which is what happens when a parent gives the impression of engagement which will only ever be superficial whilst their true lack of commitment subversively undermines any real progress being made; and secondly, a start again syndrome, which is what happens when transitions occur and the impact of historical information becomes lost. Practitioners are constantly encouraged to maintain a state of healthy scepticism, to dig deeper for facts to support analysis rather than too readily accept ‘plausible’ explanations.   4.14 Significant to the early history of the case is the absence of any sustained multi-agency approach to supporting Child H as a child in need. The opportunity for co-ordinated early intervention was presented on more than one occasion, but the tendency to work to a single agency focus created the conditions within which the whole picture of Child H‘s day to day experiences and compromised health care became lost to the multi-agency professionals.   4.15 Child H had moved school and area some five months before the first referral was made to Children’s Social Care. When the referral was received in the First Contact Team and initial contact was made with the school they indicated no concerns about Child H’s welfare. Child H had attended that school for a half term prior to the summer holiday and was four weeks into a second term when the call was received. Had such a call been made to the previous school it is likely that the concerns about Child H’s hygiene would have been shared along with the history of trying to achieve improvements. Essentially, Children’s Social Care received a snapshot of Child H from a school that had only recent contact with Child H without an understanding that concerns from a previous school would have concurred with the view of the Consultant Rheumatologist with regard to Child H’s hygiene and MH’s ability to remain committed to meeting all of her child’s needs.  4.16 Within Children’s Social Care, the two Team Managers with responsibility for screening and allocating referrals did not have a common threshold for intervention, so with the same information, the First Contact Team Manager considered the referral should result in an Initial Assessment but the RAT Team Manager did not agree with this assessment and did not allocate. The Team Manager for First Contact considered the source of the referral to be extremely significant, and recognised the expertise of a Consultant in being best placed to form a judgement about the likelihood of comprised health for a child if current conditions prevailed.  Within this Review, Children’s Social Care have unequivocally stated that this referral should SLSCB SCR ‘H’     18  have resulted in an Initial Assessment being undertaken in respect of Child H and the decision not to do so was an error of judgement on the part of the RAT Team Manager. Whilst the First Contact Team Manager recognised that this referral identified a link between Child H’s medical condition and overall welfare, the Team Manager of the RAT Team interpreted this referral to be simply about poor hygiene of Child H and accepted re-assurance on the simplest level that there were no indicators of concern from the school.  It is important to note that this error of judgement occurred within a Team where more general concerns about performance were emerging through management systems including supervision and audits and as a consequence the Team Manager was removed from operational management prior to this Review. The decision not to initiate an Initial Assessment was not communicated to the Consultant Rheumatologist as would be expected in the case of a professional source of referral.  See Social Care Recommendation 1  4.17 The first referral to Children’s Social Care resulted in very limited activity and had no impact on Child H’s welfare. The contributory factors to this are as follows: • The referral did not fully reflect the true extent of MH’s noncompliance with medical appointments for Child H  • The high risk to Child H’s eyesight was not documented in the referral • Children’s Social Care did not respond in an appropriately robust manner to the referral • The information from the school did not indicate the limited context from which it was formulated • There was no outcome of the referral provided to the Consultant Rheumatologist and the Consultant Rheumatologist did not pursue the outcome to establish whether a point of satisfaction was achieved until five months later • The Safeguarding Children Team at the hospital was unaware of the referral and therefore could offer no assistance or challenge.   4.18 The birth of S1 was a significant change to the family and provided an opportunity for additional professional contacts with the family. S1 was born four months after the first referral to Children’s Social Care whilst Child H was in the last school year of primary school.  The two visits conducted by the Health Visitor nineteen months prior to the children being removed did invoke some comment about the home conditions and provided a further opportunity to raise the profile of this family amongst fellow professionals and multi-agency partners. The conditions of the home whilst worthy of note to record, were not addressed with the family nor was there any follow up work to establish whether the situation was temporary or constant. The Primary Health Care visit is carried out between day 10 and 14 after the birth of a baby, and it is part of the SLSCB SCR ‘H’     19  universal offer from the health visiting service. This visit should take place in the home and as part of early intervention and prevention should focus on family wellbeing, stability and good physical health.  Despite the observations of the Health Visitor and the knowledge of Child H’s medical condition there was no communication from the Health Visitor to the School Nurse to share the observations and therefore the concerns about the home conditions were committed to single agency records only. S1 subsequently failed to attend an appointment with the health visiting service for a 9 month – 1 year developmental review, and although to accord with local procedure this should have prompted a second appointment to take place in the family home, this was not followed and no further home visit were made by the health visiting service. The only other visit by a professional to the family home prior to the day the children were removed by the Social Worker who conducted the Initial Assessment following the second referral. In the intervening time, the family had moved home so the Social Worker and Health Visitor did not visit the same property.   4.19 It is very difficult for this Review to find out the facts about the conditions in the family home over the period of time covered by this Review. The Health Visitor made two home visits in late 2011 and early 2012, and the Social Worker made two visits later in 2012 and four months before the removal of the children in 2013.  The records of Children’s Social Care simply record the home conditions as an acceptable standard noting that only the downstairs communal areas had been observed. The Independent Reviewers debated with the practitioners when it was reasonable to request to see a child’s bedroom, should this be every initial assessment, should it be whenever concerns are expressed about potential neglect or do practitioners find it too intrusive? It was noted that the Health Visitor had not seen where the baby S1 was sleeping although this provides an important context to advice about sudden infant death. The Social Worker advised that they had not asked to see the bedroom as this is not a feature of general practice. The practitioners were reminded that as far back as the Maria Colwell Inquiry, now forty years ago, the significance of what can be revealed from a child’s bedroom has been important learning from many serious incidents. It was apparent to the Lead Reviewers that practitioners felt a need for agency guidance, to assume organisational permission and approach such a request with confidence.   4.20 After the first referral, Child H attended only one of four scheduled appointments before the second referral was made.  Two of the missed appointments were prior to the family house move and one was subsequent.  The Initial Assessment was a flawed assessment on many different levels. The Initial Assessment should have taken seven days to complete and this took eight months. The analysis of the assessment was undermined by the fact that different aspects of information had been gathered at significantly different points in time.  When the school was contacted, Child H had been in that school for four weeks, a second contact towards the end of SLSCB SCR ‘H’     20  the assessment period would have revealed more information about standards of hygiene and the fact that the school had occasion to talk to MH. Closer examination of the facts at the start would also have revealed that two of the missed appointments were prior to the move of address and this would have made MH’s explanation much less ‘plausible’. This was further compounded when the Social Worker undertook a second home visit six months after the first and MH had not taken action to ensure Child H attended Rheumatology appointments. Whether MH had advised the GP of a change of address was an insignificant question when that parent knows well that the child needed to attend for Rheumatology and it was the parent who should have ensured this occurred.  No contact was made by the Social Worker with the Consultant Rheumatologist, and this missed an important opportunity to get a better understanding of the treatment regime for Child H and potentially uncover the risk to the eye. During the extended period of the Initial Assessment therefore, MH showed a blatant disregard for Child H’s medical needs. In these circumstances, the closure of the Initial Assessment, albeit unintentionally, created the circumstances within which MH could continue to neglect the needs of Child H.  Although it was known that FH had regular contact with Child H, FH was neither informed nor consulted about the Initial Assessment because he did not live in the family home. If FH had been involved, this would have enabled the Social Worker to assess whether he could provide an additional protective factor for Child H and encouraged the child’s second parent to take additional responsibility for ensuring the child’s health needs were met.  See Social Care Recommendation 2  4.21 The second referral to Children’s Social Care also resulted in limited multi-agency activity or communication and did not further enhance Child H’s welfare. The contributory factors to this are as follows: • The referral did not fully reflect either the very long standing nature of MH’s noncompliance with medical appointments for Child H • The high risk to Child H’s eyesight was not documented in the referral • The Initial Assessment by Children’s Social Care was  disjointed and did not gather the facts pertinent to the reason for referral  • The information from the school was based on knowing Child H for four weeks, and was six months old and inaccurate by the time the Initial Assessment was completed • The Information provided by the School Nurse that similar concerns had existed at an earlier point was given insufficient weight in the assessment when it should have altered professionals to the ongoing pattern of behaviour • MH was able to misdirect the Social Worker by providing a reason for nonattendance at medical appointments that would not have stood up to the facts if the facts had been established SLSCB SCR ‘H’     21  • That MH was given the benefit of any doubt as to whether she had tried to change her address at the GP surgery as a reason for no further contact with the hospital when the more pressing issue was she had not secured medical appointments for Child H • There was no outcome of the referral provided to the Consultant Rheumatologist and the Consultant Rheumatologist did not pursue the outcome to establish whether a point if satisfaction was achieved • The Safeguarding Children Team at the hospital was unaware of the referral and therefore were unable to offer assistance or challenge.   4.22 The Initial Assessment indicated that MH reported experiencing no particular difficulties parenting Child H. This is in contrast to what MH has stated as part of this Review whereby she has stated that Child H could be wild, lashed out and was difficult to handle. The current knowledge of the family would suggest that Child H was very much left to their own devices, the child’s bedroom was in a shocking condition and MH and PMH stated that they did not go into the room. The fact that a Social Worker not known to Child H recognised that urgent medical treatment was needed to the eye is a tragic indictment of the care the child received.   4.23 Although the Consultant Rheumatologist remained concerned and unsure about the actions of Children’s Social Care, no further direct contact was made to establish what had occurred in response to the referral. It was eight months after the second referral that the Consultant Rheumatologist wrote a letter to the GP containing the advice from a Paediatrician to refer Child H to a Consultant Paediatrician. The Consultant Rheumatologist was particularly concerned that because the care of children with JIA was transferring to a Paediatric regional centre, Child H could be further lost to follow up if pro-active action was not taken.  The letter suggested that the GP referred Child H to a Paediatrician at either the North or South Tees hospital as Child H was not being treated for the JIA or screened for uveitis.   The fact that when Child H was last seen in Ophthalmology with the presence of keratic precipitates without subsequent follow up was not referenced. The GP responded to this letter by attempting to engage MH in a forward plan for Child H’s medical care, and this included canvassing parental choice about which Paediatrician Child H was referred to. Child H was referred to Children’s Social Care by the GP seven weeks after receiving the letter and after two attempts by letter to get MH to come into the surgery. At this stage it is clear that concentrated efforts were being made to ensure that Child H was not lost to medical follow up, but somehow, the passage of time of missed appointments lost a sense of urgency because the ‘problem’ of getting Child H to medical appointments was being passed around the various agencies without any resolution. The GP considered it appropriate to make efforts to engage MH in the process of meeting Child H’s medical needs but what the GP didn’t appreciate, no more than any other agency, was that MH’s pattern of failing to present SLSCB SCR ‘H’     22  Child H for medical appointments or taking a proactive stance to ensuring the medical needs were met was an endemic pattern established over seven years and that one more effort from one more professional was unlikely to effect any change. The Review Panel spent some discussing the reasonableness of  a seven week gap between the letter to the GP from the Consultant Rheumatologist to the GP referring Child H for a third time to Children’s Social Care. It is fair to say that this was not a gap without activity as two attempts were made to meet with MH, and it is understood that the GP believed that Children’s Social Care were already aware of Child H’s circumstances because the surgery had an information request from the surgery only weeks before the Consultants letter arrived. It is important to note on this matter that the GP knew that Child H needed medical follow up, not that there was an eye condition that was critical.   4.24 At the end of the first Secondary School year, Child H was believed to be fit and well by the teaching staff.  There was no observation of any problem to the eye. The medical advice to this Review is that the uveitis can appear within a very short space of time and feasibly this could have developed shortly before the Social Worker discovered the problem. Once identified, the Social Worker acted quickly and engaged police colleagues to get urgent medical attention for Child H and to place Child H and S1 into a safe environment.   4.25 During the practitioners meeting it became apparent that even amongst medical professionals there was varying knowledge about the additional complications of JIA beyond the obvious presenting symptoms, and the schools staff had no knowledge of the associated risk to Child H’s eyesight. This prompted Practitioners meetings to discuss the role of the School Nurse in identifying children in school with additional vulnerabilities and ensuring that staff have an understanding of the medical condition and any associated risk through contact with children’s Consultants if necessity. During the time period of this Review, the school nursing service was operating to a corporate caseload system which meant that individual school nurses were not attached to specific schools. As a result of this, relationships with partner agencies especially education were not well developed and opportunities to identify need and intervene early were reduced. The School nursing has since been reviewed and this has resulted in a locality model of working with a skill mixed team led by a specialist public health practitioner who has responsibility for a cluster of schools – one school nurse per comprehensive school with identified primary schools. The schools reporter that this model provided much greater support to schools and pupils and better channels for communication. See Education, Early Years and Complex Needs Service Recommendation 3  4.26 Child H is now described as a happy and settled child living within the family. Child H has friends and hobbies, is keen to learn and making remarkable progress in school.  SLSCB SCR ‘H’     23   4.27 The prognosis for Child H’s vision is that it will improve over a long period of time but it is thought it will never fully repair.    5 Learning Outcomes  5.1 Professionals who work with children should consider at an early stage of help how multi-agency rather than single agency interventions can maximise the welfare of the child.   In circumstances where more than one agency is involved in the life of a child, better outcomes and more effective working practices will be achieved if the work of each agency is co-ordinated through a multi-agency process. The review of this case shows how, when information is not shared both within and across agencies, critical risk factors can remain hidden amongst the barriers and system flaws to good communication.     The Early Help services in Stockton-On-Tees provide integrated support to children and families. Early Help services are designed to intervene early both in terms of the age of a child and also in terms of an issue arising in the life of a child. There is an intention in Stockton-on-Tees for the Early Help Strategy to be re-launched to provide a strong focus to the pathways for multi-agency working and to develop a common understanding and application of threshold for intervention at each stage of the pathway.   5.2 Children with medical needs that necessitate a range of specialist inputs require a nominated lead professional to maintain co-ordination of services and oversight of the outcomes for children.   In particular, the role of the school nurse needs to be developed to engage with children, parents and assist schools in understanding the impact of specific conditions on children.   From the point of diagnosis until after the critical incident, although Child H received a range of specialist medical services, there was no one lead professional that had an oversight of the child’s medical care. This had a range of impacts from the continuation of missed medical appointments without challenge, the lack of awareness of the potential impacts of Child H’s medical condition and an absence of multi-agency communication that made it easier for MH to disguise compliance.    Since the period of time covered by this Review, all children with JIA are treated under the care of Consultant Paediatric Specialist. The medical issues for a child with additional medical needs are often complex and this case highlights the need for professionals around that child to understand the issues associated with the condition in order to support the child well.  The Review Panel considered that the role of the school nurse in such instances should be explored SLSCB SCR ‘H’     24  and addressed within the commissioning arrangements with a view to outlining service specifications to be in respect of children with additional health needs.   5.3 Robust communication between safeguarding agencies requires clarity of information, clear and factual data and shared knowledge of chronologies   Referrals should contain all factually relevant data and those responding to referrals from professional sources should always instigate direct consultation particularly when no further action is determined.    Since the timeframe for this Review, a Safer Referral system has been introduced across the Tees area. However, the examination of this case highlights a number of difficulties that arose from the referral process, this included the quality of the contextual information provided, the judgements deployed in decision making and the responses without consultation with the Consultant who had specialist knowledge about the particular impact of the indicators of neglect on Child H. Using the Review to illustrate the critical pathway of referrals and responses, a multi-agency audit should be completed and reported to the Board to assess the impact of the Safer Referral system and whether this case is indicative of a wider need for improvement.  The quality of referrals is absolutely pertinent to the robustness of any consequent action and therefore must be considered as very significant safeguarding milestone.   5.4 Assessments of potential neglect of children should always take a multi –agency approach to determine how the indicators of neglect impact upon the child and take into account any specific risk factors. Both Initial and deeper assessment of neglect must take into account a longitudinal understanding of the family history as well as the parental capacity to meet the immediate and ongoing needs of the child.   The review of this case demonstrates that at each point of statutory intervention, the historical indicators of neglect were lost either because of the impact of transitions or because the professionals were insufficiently probing.  The use of a simple assessment tool such as a chronology would have mitigated against the risk of losing information through transitions and focus practitioners understanding of repeated patterns of parental negligence. A significant feature from this review is the illustration that problems and risks that existed for Child H as young as six years, were replicated time and time again. This case should be used in local safeguarding training to illustrate the need for chronologies beyond the presenting issue and to focus upon parental patterns of behaviour and what this tells agencies about the potential for change.   5.5 Safeguarding agencies should be alert to the risks that transitions pose to a consistent understanding of the needs of children, this includes transitions across Local Authorities boundaries, agency services, and changes in key professionals which support conditions within SLSCB SCR ‘H’     25  which disguised compliance of parents can flourish.  Where transitions are evident, practitioners should be mindful to the potential pitfalls to protecting children.   The review of this case provides several examples of the impact of transitions on the agency responses to Child H.  The family move between Local Authority areas and Child H’s moves of schools resulted in significant information becoming lost to transition, and this meant that the outcomes of assessments were adversely affected by insufficient knowledge to factor into the analysis. Perhaps the most common pitfall in working with parents who disguise compliance is the tendency to place an over reliance on self-reported information when other sources of information not readily, but easily available.  The direction to maintain ‘healthy scepticism’ is all around practitioners working with children and families, but little time is taken to help practitioners to think about what this means for day to day practice. There are a range of approaches to practice such as always accessing source information, creating a chronology of facts and seeking to validate information from more than one source that will assist practitioners in the quest to maintain a healthy scepticism. Developing and sharing a sceptical mind-set is an important part of becoming a safe practitioner. Time spent with practitioners reflecting on how this can be achieved and supported through organisational culture is time directly invested in keeping children safe.   5.6 Home conditions that could potentially impact upon the welfare of children negatively should be viewed and acted upon at the earliest possible stage.    Throughout Child H’s contact with welfare services, there are several occasions where concerns about the home conditions are noted as is the presentation of Child H. On these occasion, practitioners often record in generalised terms without adequate description to convey a clear understanding of the conditions of the home and the potential consequences for the child.  This approach to recording does not assist professionals to identify patterns or indeed collate evidence where necessary. A failure to recognise or act upon early indicators of neglect supports the continuation and often deterioration of neglected outcomes for children.  5.7 Multi-agency challenge is necessary to maintain the safest standards in multi-agency working and all safeguarding practitioners must take a determined approach to challenge and escalation where it is considered necessary to protect a child from harm or potential harm.  Challenge is an important feature of any safe system.  Whilst this case highlights difficulties in relation to the referrals and responses, it is also apparent that the responses were not subject to challenge or escalation when professionals were dis-satisfied.  The SLSCB has an Escalation Procedure, and practitioners should be advised and reminded of the need and process for challenge and escalation at all opportunities.   SLSCB SCR ‘H’     26  5.8 A multi-agency action plan 1 will be formulated following the learning form this case. Each participating agency has demonstrated a commitment to learning and development through contributing to this Review in a vigorous and diligent manner. The Review Panel has brought challenge and debate which has strengthened the Review and demonstrated a strong multi-agency strategic partnership.                                                    1 The Multi Agency Action Plan for SCR ‘H’ is a separate document  - SCR ‘H’ Part 2     Serious Case Review  Child H  (Part 2) Multi Agency Action Plan With progress notes.       This report will be published in line with statutory guidance. In order to preserve the anonymity for the children in this family, the author has: • used initials to represent people • made no reference to the gender  children • avoided the use of exact dates • not used any details about local services which could lead to  recognition of the children and family     SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15)    1 Introduction 1.1 This multi-agency action plan for Serious Case Review ‘H’ has been formulated following the learning from the case and should be read alongside the Serious Case Review Report Part 1. Each participating agency has demonstrated a commitment to learning and development through contributing to this Review in a vigorous and diligent manner. The Review Panel has brought challenge and debate which has strengthened the Review and demonstrated a strong multi-agency strategic partnership.    2.  Monitoring of Action Plans 2.1 Subsequent monitoring and auditing of the action plan, multi agency and individual, stemming from this serious case review will be monitored by the SLSCB to ensure the actions and learning outcomes are met. Regular monitoring reports will be presented to the SLSCB. Monitoring of the action plans in respect of the NHS Foundation Trusts will also be undertaken by the Clinical Commissioning Group.  3. Feedback to Staff 3.1 Individual agencies will ensure that key relevant members of staff are made aware of the lessons learned and issues arising from this Serious Case Review.  3.2 In addition, the lessons learned and key issues will be fed into the SLSCB safeguarding training, events and seminars and included in LSCB briefings, which will be widely disseminated across all agencies including schools.  SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 1  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status SLSCB 1 Professionals who work with children should consider at an early stage of help how multi-agency rather than single agency interventions can maximise the welfare of the child.   All agencies to reaffirm with staff: i) Tees LSCBs Information Sharing Protocol ii) National Information Sharing Guidance March 2015 iii) Early Help interventions iv) Relevant Threshold Document June 2015 LSCB Members Professionals working with children can evidence that they have considered the needs of the child at the earliest opportunity, shared information and identified who can offer support. Multi agency case file audits to review the appropriateness of information shared and the time frame was acceptable.  Complete  i, ii, & iv  Included in SLSCB E-Mail Bulletin 28th March 10th April  2015 No. 01 (2015/16) which is cascaded to staff. iii) 29.05.15 Board Members requested to ensure all staff are aware of the Early Help Strategy. SLSCB 2 a  Children with medical needs that necessitate a range of specialist inputs require a nominated lead professional, usually their GP to maintain co-ordination of services and oversight of the outcomes for children.   This recommendation has been discussed with the Assistant Medical Director NHS England CaNE. It is not an action that can be taken forward easily in Primary Care as GPs are neither mandated via the NHS Contract nor recompensed financially at this moment. TBC NHS England. If a child’s medical needs are not being met by parents/. carers this is identified and addressed promptly Protocol in place for monitoring medical needs of children with complex needs. and that an appropriate audit tool is developed to measure performance 3/6/15 This is still under discussion with Primary Care Commissioning Team to see if action is feasible within the current NHS Standard GP Contract 2b  In particular, the role of the school nurse needs to be developed to engage with children, parents and assist schools in understanding the impact of specific conditions on children.  N.B.  EEYCN 3 which is a similar action. SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 2  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status SLSCB 3 Robust communication between safeguarding agencies requires clarity of information, clear and factual data and shared knowledge of chronologies.  Referrals should contain all factually relevant data and those responding to referrals from professional sources should always instigate direct consultation particularly when no further action is determined.  Multi agency audits  take place checking: i. The referral against information held in the originating agencies records  ii. A record of feedback / request for feedback is held in case file. October 2015 LSCB Partners When submitted referrals are robust, accurate and provide all relevant details required   Referrals received enable appropriate action to be taken without delay.  SLSCB  4 Assessments of potential neglect of children should always take a multi –agency approach to determine how the indicators of neglect impact upon the child and take into account any specific risk factors. Both Initial and deeper assessment of neglect must take into account a longitudinal understanding of the family history as well as the parental capacity to meet the immediate and ongoing needs of the child.   Neglect multi agency training and awareness sessions are promoted that  reinforce the need for assessments to be multi agency taking into account historical information patterns of behaviour, home conditions and how to use appropriate assessment tools . April 2015 Chair Joint SLSCB & HLSCB Multi Agency Training Group Professionals are able to identify neglect at the earliest opportunity using appropriate assessment tools. Increase in earlier identification and support provided to families. Completed SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 3  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status SLSCB 5 Safeguarding agencies should be alert to the risks that transitions pose to a consistent understanding of the needs of children, this includes transitions across Local Authorities boundaries, agency services, and changes in key professionals which support conditions within which disguised compliance of parents can flourish.  Where transitions are evident, practitioners should be mindful to the potential pitfalls to protecting children.   N.B. Actions EEYCN 1 & NTHFT 2 which are also similar to this action Raise awareness of Tees LSCBs Cross Boundary Procedure  (3.4.1 & 3.11.9) May 2015 All LSCB Members Historical information is shared, understood and is taken into account when a move takes place both by the referring and receiving authority / agency. Complete reliable information is shared at transition point to inform the child’s plan. Complete  Included in SLSCB E-Mail Bulletin 28th March 10th April  2015 No. 01 (2015/16) which is cascaded to staff. SLSCB 6 Home conditions that could potentially impact upon the welfare of children negatively should be viewed and acted upon at the earliest possible stage.    This action has been combined with SLSCB 4 SLSCB 7 Multi-agency challenge is necessary to maintain the safest standards in multi-agency working and all safeguarding practitioners must take a determined approach to challenge and escalation where it is considered necessary to Board to determine methods and opportunities to raise awareness to increase professional challenge to take place. June 2015 SLSCB 0BTees LSCBs Professional Challenge and resolution of professional disagreement procedure (3.6.8) to be consistently applied.   1BDifferences of opinion All professional concerns and dissenting opinions are noted and commented upon. Complete  Included in SLSCB E-Mail Bulletin 28th March 10th April  2015 No. 01 (2015/16) which is cascaded to staff.  IRO’s are making SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 4  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status protect a child from harm or potential harm.  between professionals are discussed in a co-operative appropriate manner and timeframe.  reference to challenge and dissent at the start of each ICP Conference and RCP Conference.   Procedures have been amended and shared with staff to reinforce the need to record instances of challenge and dissent.          CAFCASS 1 The main learning in this case is the issue of compliance with the Cafcass Standard Operating Principles; in respect of obtaining relevant safeguarding information.   Practice Direction 12b (CAP 2014) issued on 22 April 2014 is the updated version of procedures used by CIT/EIT to progress work up to and at the first court hearing. The updated version of procedures were implemented on 22 April 2014. Cafcass To ensure compliance with procedures and good outcomes for the children and families we work with. A range of local and national auditing and monitoring is built into the Cafcass Operating Framework. The internal Cafcass improvement service completed a national audit in December 2014 that demonstrated a good level of compliance with procedures. Cafcass received good overall in the March 2014 national Ofsted inspection.  These and other measures provide internal and external verification of improved compliance Completed SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 5  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status with the updated procedures.          CSC 1 Referral to be made to Health and Care Professions Council (HCPC) in respect of the response by the former Team Manager, RAT to the first referral.  1. Referral to be made to HCPC.  2. Supporting information to be provided to HCPC. December 2014 Head of Children and Young People’s Services Registrant’s status is considered in light of concerns emerging from practice on this case. Audit trail that referral has been made. Completed  CSC 2 Identified practice issues to be addressed with Social Worker according to Stockton-on-Tees Borough Council’s policies and procedures.  1. Meeting to be held.  2. Decision to be made regarding appropriate action. February 2015 Head of Children and Young People’s Services Appropriate sanction /advice / support is offered. Audit trail that issues have been addressed.  Ongoing auditing to be determined. Completed. CSC 3 Dissemination of, and reflection on, wider learning points arising via Operational Development Group (ODG) and Team Meetings.  1. Discussion to take place at ODG.  2. Learning points to be cascaded via Team Meetings. July 2015 Head of Children and Young People’s Services Wider learning takes place. Minutes of meeting.  Ongoing auditing via monthly case file audits. Outstanding         EEYCN 1 To embed current good practice in relation to information sharing between schools/academies at transfer and transition points in clear procedures and protocols Include checklist in procedures currently being revised in relation to in year transfers and managed moves to ensure that all relevant information is received from schools and local authorities at transfer   April 2015 Education, Early Years and Complex Needs Service, Stockton-on-Tees Borough Council Consistent and complete information shared at transition and transfer to ensure medical conditions and needs are known to schools File Audits Complete  Processes are in place to ensure that all relevant information is received from schools and local authorities on transfer through revised protocols. SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 6  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status Ensure that current work underway in relation to primary/secondary transition includes sharing of information relating to medical conditions/SENCO information.    Include reference to these expectations at Safeguarding Forums and SENCO Briefings  A package of documents and protocols are in place to support transition of pupils to schools.  These materials are called ‘Moving Forward’ and contain specific reference to SEN and medical conditions information.  Training has been delivered to reinforce this issue for Headteachers, DSL and SENCOs.  EEYCN 2 To continue work with schools currently underway relating to record keeping, to ensure that all formal and informal contact with partners and other agencies are recorded.  To include all appropriate references to CAF.  Continue work with schools and settings to ensure that record keeping is in consistent format and robust and that children with medical conditions are highlighted in training April 2015 Chief Adviser, Stockton-on-Tees Borough Council   File Audits Complete.  A programme of training highlights the need for robust record keeping including medical conditions.   EEYCN 3 To undertake work with Schools, Colleges and Academies (particularly SENCOS) and the School Nursing Service to ensure that information and expertise is shared and Establish protocol and put in place a procedure and expectation to ensure joint and shared working between school nursing service, schools, academies May 2015 Education, Early Years and Complex Needs Service, Stockton-on-Tees Borough Council and NT&HNHSFT Relevant and accurate information pertaining to medical conditions shared with schools so that staff can be vigilant and put appropriate interventions in place File Audits In progress  The Education Safeguarding Forum on 9th June had a presentation from Public Health and the clinical lead SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 7  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status disseminated and that an iterative process is in place so that all staff are aware of signs, symptoms and care needs of children with medical conditions.    and colleges.   where appropriate. Iterative process in place between school nurse and school so that information sharing supports children.    from school nursing.         STHFT 1 South Tees Hospitals Foundation Trust to ensure the procedure for ‘Children who fail to attend for Hospital Appointments’ is reviewed and rolled out within all relevant Trust areas.  1 Review the systems and procedure currently in place regarding ‘Children who fail to attend Hospital Appointments’.  1 June 2015       Named Nurse STHFT  To ensure all relevant STHFT staff are aware and are adhering to the procedure for ‘Children who fail to attend for Hospital Appointments’   Audit of the DNA pathway within the hospital records to ensure children are attending for appointments to undertake when system embedded -March 2016..  Complete  The systems / procedures have been reviewed. 2 Roll out the reviewed protocol to all staff working in the Trust. October 2015.  STHFT 2 South Tees Hospitals Foundation Trust to ensure that a robust process exists to ensure all second and subsequent outpatient appointments for children are made.  A robust Trust-wide action plan to be devised to ensure that a process is developed specifically around children’s appointments being made.  October 2015  Named Nurse STHFT  Where children have identified health needs requiring secondary heath care appointments they are seen and followed up in a timely manner. Audit of the pathway to ensure that children are brought to all second and subsequent follow-up  STHFT 3 All relevant South Tees Hospitals Foundation Trust staff are aware of the process of how to escalate concerns when they are not satisfied with the outcome of their referral to children’s 1. Current training programmes to ensure all staff are aware of the Safeguarding Children Policy for South Tees Hospitals Foundation Trust. July 2015.          Named Nurse STHFT  All relevant staff are aware and understand to appropriately escalate concerns. 1. Audit of referrals to CSC to ensure staff are aware of how to escalate a concern and know the process of challenge if Complete  Audit completed 15th July 2015   SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 8  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status social care.    required.  2 A risk alert will be cascaded to all departments regarding escalation of a safeguarding concern and any subsequent challenge that may be required.   May 2015  Training presentations will evidence sharing good practice throughout the Trust. 2.Completed  STHFT 4 When a referral is made to Children’s Social Care regarding a child, all relevant medical information needs to be shared and how this may impact on the child if not addressed.  A risk alert will be cascaded to all departments to ensure all relevant medical information is shared during the referral process. February 2015 Named Nurse STHFT  To ensure all relevant medical information is communicated and as a result any potential risk to the child is addressed. Audit of referrals to CSC to ensure any relevant medical information has been shared to take place in July 2015 Completed STHFT 5 To ensure all STHFT relevant/clinical staff are made aware of the recommendations from this agency reflection and learning report.   1. A briefing paper to all departments within the Trust to emphasise the learning from good practice.   1. March 2015       Named Nurse STHFT  To ensure this good practice example is shared with health staff. 1 Evidence that briefing paper has been issued.   Completed 2 All staff directly involved to receive 1:1 feedback. June 2015 2 Evidence of 1:1 feedback meeting.          SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 9  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status NHSE 1 The good practice demonstrated by the General Practitioner in this case regarding follow up of  failure to attend health appointments and the outcome for the children will be disseminated to all General Practice Staff across Tees     1 This example of good practice will be used in Primary Care Safeguarding Children across Tees        1 January 2015            Deputy Director of Nursing NHS England Area Team (Durham Darlington and Tees) By sharing good practice professionals will be aware of the how good practice can have a direct impact on outcomes for children and this learning  will transfer into their everyday practice   Training presentations will evidence sharing good practice        Completed   3/6/2015 Letter from Assistant Medical Director to all GP practices reinforcing the need to have processes in place in the practice to follow up when informed about children’s non-attendance at appointments with other care providers. 2 A briefing paper to all General Practices across Tees will highlight learning from this SCR including learning from good practice. 2 February 2015 Briefing paper will be available to evidence action  NHSE 2 Representatives from NHS England and Primary Care will meet with colleagues in South Tees Hospitals Foundation Trust to scope the possibility of extending the existing Did Not Attend Pathway to include all Secondary Care appointments.       NHS England and Primary Care will work with South Tees Hospitals Foundation Trust to review and develop the existing DNA Pathway to include children and young people who fail to attend all secondary care appointments March 2015      October 2015  Deputy Director of Nursing NHS England Area Team (Durham Darlington and Tees) and representatives for Primary Care (to be identified)/ Designated Nurse Safeguarding Children (Tees)  When a child or young person fails to attend secondary care appointments relevant colleagues in Primary Care will be made aware and a clear pathway will be available to guide management. This will ensure any issues arising from such failed appointments are swiftly addressed resulting in better health outcomes for children  Introduction of an agreed revised pathway    An audit cycle will demonstrate effective implementation of the revised pathway    SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 10  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status         NT&H FT 1 When a child or young person fails to attend any Paediatric, medical or secondary care appointments in North Tees and Hartlepool NHS Foundation Trust a clear pathway will be followed to guide future management   North Tees and Hartlepool NHS Foundation Trust (in conjunction with relevant colleagues from Primary Care) to review and update the existing DNA Pathway to include children and young people who fail to attend all secondary care appointments.  The updated pathway will be incorporated into the Trusts Safeguarding Children Policy   December 2015       Director of Integrated Care Services  NT&H NHS FT  When a child or young person fails to attend secondary care appointments relevant practitioners will be made aware and a clear pathway will be available to guide management. This will ensure any issues arising from such failed appointments are swiftly addressed resulting in better health outcomes for children and young people   Introduction of an agreed revised pathway    An audit cycle will demonstrate effective implementation of the revised pathway   NT&H FT 2 When a school aged child or young person moves in or out of the North Tees and Hartlepool NHS Foundation Trust area a procedure will be followed to ensure information relevant to the continuing care of the child/ young person is communicated to the recipient caseload holder and contact with the child / parent/ carer is timely to ensure provision of care / assessment of need    North Tees and Hartlepool NHS Foundation Trust will ensure a Standard Operating Procedure is in place for the management of records when children transfer in or out of the Trust area  March 2015        October 2015  Director of Integrated Care Services  NT&H NHS FT  When a child or young person moves in or out of the Trust area there is a clear pathway to follow and this will include a review of records by a school nurse, letter of introduction to parents, a health questionnaire this will enable them to have  the opportunity to have their health needs assessed and any un- met health needs addressed in order that a health care plan can be implemented resulting in better The introduction of a standard operating procedure across the school nursing service in NT&H NHS FT    An audit cycle will demonstrate effective implementation of the procedure  SLSCB SCR ‘H’ Part 2 Action Plan (Updated 17.07.15) 11  Ref No. Recommendation Actions Date for completion of action Lead Agency or Chief Officer Intended Outcome How Will success be measured / evidenced? Progress / Status outcomes for children.  When a child moves out of the area relevant information will be communicated to the new area   NT&H FT 3 The school nursing service in NT&H NHS FT will have information leaflets to support them in the promotion of their role and responsibilities to school aged children and young people, this will be available to school aged children, parents/ carers and teachers    North Tees and Hartlepool NHS Foundation Trust will develop an information leaflet to be available to school aged children , young people, their parents/ carers and teachers identifying who their school nurse is, how and where to contact them and outline what the school nurse offer is , what health advice and early intervention is available to support them   September 2015   Director of Integrated Care Services  NT&H NHS FT When a child or young person attends a school in the NT&H NHS FT area parents / carers and teachers will know who their school nurse is and, how and where to contact the school nurse, they will be aware of the school nurse offer and what other advice, support and health promotion that is available for children and young people aged 4 to 18.   An information leaflet will be developed and circulated to parents/ carers when children commence school or move into a school in the NT&H NHS FT area   Schools in the NT&H NHSFT area will have information on the school nurse offer    