Death of a 6-7-week-old-girl in May 2012. Subject child was found by mother with her face pressed up against the back of the settee at home where she had earlier fallen asleep. Mother had just woken from sleep after having drunk alcohol earlier in the day. Subject child was living with mother and half-brother at the time of the incident. History of domestic abuse, alcohol misuse and referrals to children's services concerning the care of half-brother. Mother was arrested in 2011 for being drunk in charge of a child, leading to half-brother being placed in foster care. Half-brother was returned to mother's care following assessments that recommended that there was no role for a social worker. Mother has a chronic abdominal condition, requiring abstinence from alcohol use to avoid the condition worsening and leading to hospitalisation. Identifies lessons learned, including: assessment of the impact of chronic alcohol misuse usually takes place when the parent is no longer intoxicated, leading to insufficient understanding of potential risks to the child; lack of professional knowledge of parents' persistent or long term medical conditions compromising understanding of the impact on parenting capacity; and professional response to incidents without consideration of previous concerns, leading to missed patterns and possibility of continued ineffective responses. Makes various multi-agency recommendations.
      
   Serious Case Review No:  2015-C5641  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     Serious Case Review  OVERVIEW REPORT (Redacted)                  Independent Overview Author:  Ron Lock  December 31st  2012 Re Subject Child  Born February 12 Died May 12 1   Contents  Introduction      1.1 – 1.6   Page 3 Serious Case Review Process    2.1 – 2.8   Page 4 Summary of The Facts     3.1 – 3.17   Page 10 Analysis: The Identification of Risk Factors   4.1 – 4.18   Page 13 Assessment Practice     5.1– 5.10   Page 18 Decision Making/Missed Opportunities   6.1 – 6.20   Page 21 Policies and Procedures    7.1 – 7.3   Page 25 Communication and Information Sharing  8.1 – 8.20   Page 26 The Views, Wishes and Feelings of the Children     9.1 – 9.9   Page 31 Race and Culture       10.1 – 10.2   Page 34 Organisational Factors       11.1 – 11.6   Page 34 Immediate or Long Term Changes     12.1 – 12.4   Page 35 Actions following the Death      13.1 – 13.3   Page 36 Summary        14.1 – 14.6   Page 37 Lessons Learned      15.1 – 15.10   Page 38 Recommendations       16.1 – 16.7   Page 39        2  1. Introduction  1.1 This Serious Case Review (SCR) was undertaken following the death of a baby, whom for the purposes of this report will be referred to simply as the Subject Child.   At the time of the death, this child lived with her Mother and an older brother.   He was of school age at the time of his sibling’s death and he will be referred to as the Half-Brother in this report.   For the vast majority of the time, the Mother cared for the children as a single parent.  1.2 The circumstances of the Subject Child’s death during one evening in the Spring of 2012 was that the baby was found by her Mother to be lifeless, with the baby’s face pressed up against the back of the settee in their home.  This was where the baby had earlier gone to sleep.  The Mother had herself just woken from sleep after having drunk alcohol earlier in the day.      1.3 If “abuse or neglect is known or suspected to be a factor in the death” of a child, this requires that the Local Safeguarding Children Board (LSCB) should “always conduct a SCR into the involvement of organisations and professionals in the lives of the child and the family”1, and therefore in response to this guidance, and because the Subject Child’s death was potentially due to neglectful care, then The area LSCB commissioned this SCR.   At the time of completion of this SCR the Coroner gave a verdict regarding the cause of death as “unascertained” and that it occurred “in an unsafe sleeping environment”.  1.4 The purposes of this SCR reflect the relevant government guidance to: -  - Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; - Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and - Improve intra and inter-agency working to better safeguard and promote the welfare of children.2   1.5 Each agency that had some direct involvement with the children and their family was required to undertake an Individual Management Review (IMR) to look openly and critically at its practice in relation to their involvement with them.   In undertaking this, each agency was also required to produce a chronology of its contact with the family. The managers/officers conducting the IMRs did not at the time immediately line-manage the practitioners involved and were not directly concerned with the services provided for the children or their family.   1.6 Senior representatives from relevant agencies in the area were brought together to form a SCR Panel in order to review and analyse the material from the IMRs.   The Independent Chair of The area LSCB, undertook the role of Independent Chair of the SCR Panel and Ron Lock, a safeguarding consultant who was independent of all agencies in the area and with extensive 1 Paragraph 8.9 – Working Together to Safeguard Children – A guide to inter agency working to safeguard and promote the welfare of children – Dept. for Children, Schools and Families – March 2010 2 Paragraph 8.5, Working Together to Safeguard Children – Dept. for Children, Schools and Families, March 2010 3                                                             experience in safeguarding children and young people, was commissioned to write the Overview Report.    2. The Serious Case Review Process  2.1 The period to be covered by this SCR is from 19th January 2006 (which was the date that the mother presented with her first pregnancy with the Half Brother) up until the 29th May 2012, which was the date of the Initial Child Protection Conference following the death of the Subject Child just over three weeks earlier.   Although it was the death of the Subject Child as a baby which led to this SCR being initiated, because the time frame for analysis covers a period of more than six years, then the major focus has inevitably been upon the care which the older Half Brother received and of the services delivered to him and his Mother during that time.   The SCR Panel considered that the eventual death of the Subject Child needed to be viewed and understood within the context of this background.   2.2 The following agencies were commissioned to complete Individual Management Reviews: • Family Services – Social Care (to include information from Preventative and Enhanced Services (Localities) • Family Services – Education (including Schools and Early Years) re Half Brother • The Constabulary • GP  • The area Community Services: Health Visiting and School Nursing  • The Hospital– to include Midwifery service, and any department that the mother may have been referred to or received services from during the period under review.   • Additionally, the Ambulance Service and the Probation Trust were contacted and asked to provide relevant information in respect of any involvement they had with the family, including the extended family.   A brief report was received from Probation.   The limited extent of the involvement of both agencies did not warrant the completion of an IMR.  2.3 The SCR Panel members were:      - Head of Early Years and Childcare, Family Services  - Head of Safeguarding and Standards, Family Services  - Designated Doctor, CP  - Head of Community Services Law, CD  - Head of Safeguarding, CCS  - Public Protection Department, Constabulary  - Associate Director for Safeguarding Children and Vulnerable Adults, NHS  - Named Nurse Safeguarding Children, Hospital  Also in attendance:  - The area LSCB Business Manager - Overview Report Author Administrative staff of the LSCB  2.4 Specific Issues for the SCR to consider 4   a. To identify any risk factors and indicators of potential abuse and neglect in the family history known from point of pregnancy onwards with the half-brother (eldest child), including in the wider family network. and establish whether these risk factors were appropriately identified and taken account of in any work with the mother, the subject child and the half-brother  b. To establish if appropriate assessments were undertaken, and the quality of these assessments and of the recording of work with the children and the family.  c. To establish if decisions, plans and interventions made for the subject child and the half-brother were appropriate to the identified risk factors.   d. To establish if there was appropriate communication and information sharing within and between agencies and, if not, why not.  e. To establish how well individual agency and multi-agency policies and procedures to effectively protect the children, including those concerned with parental alcohol misuse and domestic violence, were understood and implemented by those working in all agencies  f. To establish how well issues of parental alcohol misuse were communicated, assessed, evaluated, and managed and in the planning for the children within and between agencies  g. To establish how well issues of domestic/ family violence were communicated, assessed, evaluated, and managed by agencies working with the mother and in the planning for the children.  h. To establish how well issues of parental mental health were communicated, assessed, evaluated, and managed and in the planning for the children.  i. To establish how effectively agencies sought and took in to account the views of the children, and the extent to which services took these into account in the provision of services.   j. To establish if any racial, cultural, linguistic and religious diversity needs of and economic and social disadvantages to the children and family were identified, taken into account, and responded to.  k. To establish if there were any difficulties with housing and accommodation and the impact of this upon the family.   l. To establish if services for the family were limited or enhanced by any organisational factors within or between agencies, e.g. workforce capacity, re-organisation.  m. To establish if staff involved were appropriately trained to achieve the level of competency required for their role.   5  n. To establish if supervisors and managers at all levels were appropriately involved in supervision and were accountable for decision-making.   o. To establish how well agencies were able to engage with parenting figures and other adults living with or close to the family and how any barriers to effective engagement were dealt with.   p. To establish if there were any missed opportunities to protect the children and what, if any, the identifiable contributory factors were to this.  q. To identify any immediate or long term changes that must take place as to how agencies work to safeguard children and whether they have implemented.  2.5 Methodology/SCR Process    2.5.1 The decision to undertake the SCR was made on the 12th June 2012 when the draft Terms of Reference were drawn up and the panel members were agreed.   The arrangements were also confirmed for the SCR in term of who would be the Independent Chair, followed by the appointment of the independent Overview Report author.  2.5.2 There were five SCR Panel meetings in all, from 3rd July 2012 through until 4th December 2012, following which the SCR Overview Report was presented to the area LSCB on the 11th December 2012.    The IMRs were presented to the SCR Panel on 17th September and to varying degrees each required some changes or additions to be made, and to complete a second version of their reports.   These were received during the period mid to late October 2012.  2.5.3 The first draft of the Overview Report was presented to the SCR Panel on the 16th October with a second draft completed for discussion at the 6th November meeting.   Because the Health Overview Report’s first draft was completed for the same deadline, further changes needed to be incorporated into the main Overview Report, with a final draft completed by the 28th November 2012.   This was ratified by the LCSB on the 4th December with some minor changes requested for the final versions, all of which were completed by 31st December 2012.  2.5.4 It was decided from the outset of the SCR process that there would be an opportunity for the practitioners and first line managers directly involved in the case to be able to contribute to the collation of factual information and to the analysis of the professional practice in the case.   A half day meeting took place on the 10th October 2012, led by the Overview Report author, when the practitioners were presented with a summary of the key incidents and events in the case, for which they were asked to add or confirm their agreement to these.  There was representation in the meeting from all the agencies who were involved with the family.   Overall there was no disagreement with the main details which had been provided to the SCR process via the integrated multi-agency chronology.   By this stage of the SCR process, some key themes for analysis had been identified and these were summarised as: -  • The response and management of parental alcohol misuse/domestic abuse • The impact of a chaotic lifestyle on the children • Challenging parents – showing respectful uncertainty 6  • Identifying patterns of events/lifestyle – undertaking holistic assessments  • Understanding and working with cultural and extended family influences • Professional communication - And the group were asked to use their direct experience of the case to consider each theme and identify:   o How significant was this particular theme in the case? o Were there any challenges or issues about how this was able to be addressed in the case? o What was the context of professional interventions at the time – e.g.; Organisational issues, workload, support systems  2.5.5 The outcome from this practitioner workshop has been used throughout the case to inform the analysis of professional practice and is included within the body of the report.  2.6 Parallel Processes  2.6.1 As the death of the Subject Child did not lead to any criminal convictions and the Half Brother was not made subject to Care Proceedings.   Therefore there were no parallel proceedings to consider alongside the SCR process.   2.7 Contributions by the Family  2.7.1 The Mother was visited by the Overview Author and the LSCB Business Manager for her to make a contribution to the SCR which she was able to do.  Her comments and contributions have been identified and included in the body of the report at relevant stages.    2.8 Individual Management Reviews FAMILY SERVICES   2.8.1 This is a comprehensive review of social work practice with this family and highlights relevant practice issues in respect of the assessment work undertaken with the family, and identifies that even when some intuitive assessment practice was undertaken, these were not used to inform any later assessments or follow up work with the family.   The IMR identifies a lack of challenge to the Mother’s disguised compliance and her denial of alcohol misuse as key areas of learning.   The IMR helpfully provides useful contextual information to explain the significant pressures which family services staff were under during the period of this SCR and additionally how new major organisational changes are already beginning to have a positive impact to improving services 2.8.2 The IMR’s recommendations appropriately reflect the learning from the case and focus on the need to utilise chronologies and to strengthen assessment practice, although much of this should be integral to the expected level of practice in assessment activity.  It was helpful to make particular reference in one recommendation to the area of parental alcohol misuse.  Family Services – Education (including Schools and Early Years)  7   2.8.3 This IMR not only covers the work of the Primary School and Nursery which the Half Brother attended, but also that of the Children’s Centre which provided a range of early services to the Mother and Half Brother.   It gives a good explanation and analysis of the work undertaken with the Half Brother and his Mother, but recognises that these services were generally unaware of any on-going domestic abuse or maternal alcohol misuse problems.   Whilst the IMR specifically raises issues of concern about the apparent lack of notification to their services of domestic abuse incidents, in reality these incidents primarily occurred prior to their direct involvement. 2.8.4 The recommendations appropriately address the findings which the IMR made and raises the issue of the need for training for staff in terms of parental strategies of disguised compliance and how to address issues of absent fathers in their work with families.  The Constabulary  2.8.5 This is a very detailed IMR which provides concise and objective analysis of Police practice in this case, identifying specific occasions when practice was very good, but also when alternative actions could or should have been undertaken to address the safeguarding needs of the Half Brother.   He was the only child who was present at the time of Police involvement in addressing domestic abuse incidents or those relating to maternal alcohol misuse.   The IMR is very clear in terms of lessons learned and how these can be transposed into current practice.     2.8.6 The IMR also helpfully identifies how current changes in multi-agency practice arrangements will assist and support the Police in their operational work with families and improve communication between key professionals.   The recommendations are not very specific in nature and some relate to multi-agency initiatives rather than the sole responsibility of the Police.   The IMR however overall reflects a very thorough understanding of the case from a Police perspective and of the learning it has generated. The GP Practice   2.8.7 This IMR explains how the GP Surgery in this situation had a pivotal role in its work with the family and clearly sets out what took place and the analysis of the interventions undertaken.   Whilst it highlights the extent to which the Surgery appropriately raised concerns with family services about the Mother’s alcohol misuse when caring for the Half Brother, it recognises that communication systems did not work well in respect of identification of risks to the Subject Child.  The IMR, like other health IMRs raises the question about the need to improve communication processes and for the need for more effective shared computer systems to achieve this.  There is one main recommendation made which attempts to address the many factors involved in information sharing and how to ensure it is more effective and efficient in the future.   Whilst the recommendation is appropriately made for the GP service to address, it will inevitably require input and cooperation from other agencies in order to achieve its outcomes.     The Community Services: Health Visiting and School Nursing   8  2.8.8 This IMR recognises that the health visitor was in a key position in working with this family and that concerns about the Mother’s alcohol misuse were raised with family services when appropriate, but that there was never any clear understanding of the extent of the alcohol use and so no effective assessment followed.   Good practice by the health visitor is identified when appropriate and there is some helpful analysis of practice overall.  This IMR also identifies communication problems between the health visitors, community and hospital midwives and gives a useful insight into the complexities of working with the database recording process and how the case recording by community health practitioners was sometimes inadequate.  The IMR also identifies how the Mother’s overall positive presentation generated an over optimistic view of her parenting and that there was evidence of disguised compliance.  2.8.9 The recommendations appropriately reflect the findings identified in the analysis from the IMR, which have a particular focus on improving communication, recording and the development of a team ethic among health visitors.  Hospital  2.8.10  This IMR reflects the work that was undertaken in the hospital which had extensive involvement with the Mother in terms of her having a chronic abdominal condition and in respect of the ante and post natal periods in respect of both children.   The IMR recognises that there was not a consistent response to potential incidents of alcohol misuse by the mother, in terms of recognising the possible impact on parenting ability.  Information sharing and record keeping are identified as areas which need concerted improvements.  2.8.11 Recommendations are therefore made to try to improve record keeping processes as well as information sharing both within the hospital via Safeguarding Management meetings to discuss cases, and externally with the community midwives.  Health Overview Report   2.8.12  This report succinctly draws together the learning from the community and hospital based health IMRs, recognising some of the difficulties of ensuring effective internal and external communication systems for sharing safeguarding information between health practitioners.  Some other concerns in relation to insufficient understanding of the implications of parental alcohol misuse are also highlighted.  It highlights that some lapses in practice could be attributed to organisational changes and capacity issues.  2.8.13 It is considered that the learning from the Rapid Response process was very useful and that these could have been more widely circulated - in this respect an additional recommendation has been made to reflect this issue in this Overview Report. 9  The Facts  Prior to the birth of the first child (Half Brother)  3.1 It was recognised by health professionals, that prior to the birth of the Half Brother, that the Mother had a complex medical history in terms of a chronic abdominal condition which had required surgery on more than one occasion.  This type of condition meant that the Mother needed to abstain from alcohol use, and if not that her condition could worsen and require hospitalisation.  Three year period from birth of Half Brother   3.2 When the Half Brother was born in 2006, there were no concerns about his care or his weight and he was discharged home with his Mother the following day.  His six-eight week developmental check was later recorded as satisfactory.   The Half Brother’s father was not part of the family home and although there was a male partner in evidence for the first year of this three year period, the Mother primarily cared for this child as a single parent.  3.3 During this three year period, there were five reported domestic abuse incidents involving the Mother, some of which led the Police to make child protection referrals to family services.   In fact in total, there were six separate incidents of concern about the care of the Half Brother referred to family services.    Additionally, there were nine occasions when the Mother needed some form of hospital attention, some including stays of two – four days.  All of these were related to flare ups of her chronic abdominal problems.     3.4 Apart from the involvement of the Police and family services at particular times of crisis, there was support provided by the health visitor, the GP surgery and for the year from the summer of 2008, regular involvement and support provided by the local Children’s Centre.   Whilst in 2007 when most of the domestic violence occurred, there had been an offer of support from a domestic violence advocate, the Mother said that she did not want this help.    The next 18 months  3.5 The Half Brother commenced at Nursery and at this three-year development assessment at about the same time, he was initially reported to have appropriate behaviour and play.   However he was later placed on the Special Education Needs register and later designated as “School Action Plus”3 and was given an Individual Education Plan.    3 School Action Plus ("SA+") is used where SA has not been able to help the child make adequate progress. At SA+ the school will seek external advice from the Educational support services, the local Health Authority or from Children’s Social Care. For example, this may be advice from a Speech and Language Therapist, an Occupational Therapist or Specialist Advisory Services dealing with autism, Behavioural Needs etc. SA+ may also include one-to-one support and the involvement of an Educational Psychologist.  As well as the use of external services, SA+ requires more detailed planning of interventions for children whose progress has been limited. A child's progress at SA+ stage should also be reviewed regularly (i.e. at least twice a year) and an IEP should also be written to assist the child.  – www.specialeducationalneeds.co.uk  10                                                              3.6 Overall, during this further period of time, it was apparent that the Mother’s alcohol use was continuing despite her often claiming she had ceased drinking.  It remained difficult however on all occasions to make the direct link between some continued hospital attendances because of her abdominal problems and alcohol misuse.  In mid-2010 the Mother was seen by a specialist in substance misuse when she said that she had not drank alcohol for the past 5 months.  The assessment considered that the Mother had no mental illness and no arrangements were made for the specialist to see the Mother again.  In late 2010, on one occasions when the Mother was found to be intoxicated at a friend’s house, both the Mother and the Half Brother were asleep on the settee and the Half Brother had turned his face to be pressed up against the back of the settee.  He was 4 years 4 months old at this time.  3.7 The domestic abuse incidents decreased which was no doubt due to the fact that there was no male partner living in the household although it was clear that there was the propensity for violence from within the Mother’s extended family, in which the Mother had become the victim on at least one occasion.     2011   3.8 In early 2011 the Mother was arrested for being drunk in charge of a child.   As a result, the Half Brother was taken into Police Protection and family services placed him in foster care.   Following an Initial Assessment and Strategy Meeting, the Half Brother was returned to his Mother and a Core Assessment followed which recommended that although the incident had been high risk, its recurrence was low because the Mother had explained that her reaction was related to a family tragedy.   The assessment recommended that there was no role for a social worker and the case was closed by family services.   3.9 There were further reported concerns about the Mother’s drinking over the following twelve months.  These were: - - A physical assault occurred between adult members of the extended family in the presence of the Half Brother – the Mother had been drinking alcohol at the time. - The Mother was intoxicated and reported that the Half Brother had been left in a taxi and had driven off.  He was later found safe where the Mother had left him.  - A member of the public reported to family services that the Mother was in the street drinking three bottles of wine whilst the Half Brother was running around  3.10 Of the above incidents, the concerns reported in Spring 2011 led to family services undertaking an Initial Assessment and a Core assessment which eventually led to the setting up of Child in Need (CIN) meetings, the first of which took place in the  Summer of 2011.   This meeting identified that the Mother was pregnant but understood that she had stopped drinking.  Some of the plans from the meeting included for the Mother to attend a parenting course and to have counselling via the GP.   There was an arrangement for a further CIN  11                                                                                                                                                                                       meeting in September 2011 which was attended by family services and school staff.  The case was closed by family services two months later.   3.11 The Probation Service made a referral to family services when they stated that the Half Brother was on occasions in a household with a person who had offences, which meant that he could pose a risk to a child.  The Mother told the social worker over the phone that she was aware of the individual and that he did not have any unsupervised access to the Half Brother.    3.12 In summary, during 2011, despite being pregnant for half of the year, the Mother had not managed to completely cease drinking.   There were however no hospital attendances during this year although she sometimes attended the GP with abdominal pains.   There was just one domestic abuse incident, this time again involving the extended family rather than part of any one to one relationship of her own.    3.13 During this period of time, there was some evidence of the Half Brother’s behaviour deteriorating within the school environment.  He was seen by a community paediatrician in the Summer of 2011, following a very delayed referral from the GP, although the paediatric assessment did not identify any concerns, and as a consequence no follow up was planned.  This was at a similar time to concerns being expressed within the CIN meetings about his behaviours.   There were also some occasions when the Half Brother was noted to have some physical injuries, although none of these appeared to raise professional concerns as to their cause.  2012 3.14 Early in 2012, it was reported to family services that the Mother had smelt of alcohol during a particular week, although at this time she was in the late stages of the pregnancy in respect of the Subject Child.  This had been told to the school.   Family services made telephone contact with the Mother who said she had not drunk alcohol through her current pregnancy.   Family services advised the school to report any further concerns immediately. 3.15  A day after the birth of the Subject Child when the Mother left the ward for a cigarette, the ward staff reported that she returned smelling strongly of alcohol.   Contact was made with the community midwife and the health visitor to enquire if there were any concerns about previous parenting that would prevent the Mother being sent home with the Subject Child.   Both community health practitioners were new to the family and knew nothing of the background and the response back to the hospital was that they had no concerns within the community.  The Subject Child was therefore discharged home.  3.16  The primary birth visit was undertaken although this health visitor knew nothing of the family background.   At the visit, the Mother reported having no concerns.   The father of the baby was reported by the Mother to live more than 50 miles away and that he had regular contact with his child.    A little later, the Subject Child failed to attend her 6 week check up with the GP and it was approximately a week later that the Mother called the ambulance to the home because the Subject Child was lifeless after apparently having fallen asleep with 12  her face pressed up against the back of the settee.   The Mother acknowledged that she had been drinking alcohol earlier in the day following an argument and domestic violence incident with the Subject Child’s father who had visited earlier that day. She did not however contact the Police in respect of this.  The Subject Child was taken to hospital where she was pronounced dead.  3.17  The Rapid Response process to deal with unexpected child death4 took place and the Mother was interviewed by the Rapid Response team and relevant information collected about the circumstances of the death.  A joint Sec 47 child protection investigation began and this eventually led to an Initial Child Protection Conference being held when there was a unanimous decision to make the Half Brother subject to a Child Protection Plan under the category of Neglect.   By this time, he was still living elsewhere under a voluntary care arrangement which had been instigated immediately following the death of the Subject Child. _________________________________________________________________________________  Analysis  4. The Identification of Risk Factors  4.1 Throughout the 6 years that this SCR covers, there were a range of risk factors in relation to the care and safety of the children which were identified by professionals at different times, although the level of concern associated with the risk was reflected in the responses which were made to address them.   4.2 Overall there were fourteen occasions when the Police were called to the home to respond to domestic abuse instances or of the Mother being intoxicated.   Many of these were passed to family services and in total over the 6 year period there were eighteen referrals or expressions of concern made known to family services.    These clearly represented formal identifications of risk factors although their frequency and the concerns behind the particular incidents tended to change over time, for example with regular early incidents of domestic abuse, but with concerns about the Mother’s alcohol misuse assuming  prominence as the Half Brother grew older.  4.3 It was good practice that the maternity services identified, based on the number of worrying factors from the Mother’s background, and her circumstances at that time of being homeless, that her first pregnancy constituted a risk factor.   The resultant referral to family services led to the appropriate action of an Initial Assessment being undertaken prior to the birth of the child.   It was similarly good practice when the health visitor made a referral to the local Children’s Centre in 2008 in recognition that the Mother may be socially isolated 4 The responsibilities of a  Rapid Response Team are to make enquiries into and evaluate the reasons for and circumstances of the death as well as to collect relevant information and to provide support to the bereaved family – summary from Para 7.50 Working Together to safeguard Children – DSF – March 2010 13                                                             and that she was in need of support as a parent (the Half Brother was approximately 20 months old at this time).  Both of these examples represented risk factors being recognised at early stages so as some support could be provided prior to difficulties escalating.   Certainly it appeared as though the Children’s Centre, who became involved following the risks being identified, provided some effective and consistent support for the Mother in her early care of the Half Brother.  4.4 It was significant that later on, the Children’s Centre, the Nursery School and the Primary School did not individually identify any risk factors, despite them having the greatest day to day contact with the family during the time period of the SCR.   In fact it was not until early 2012 that the school formally expressed some concern and identified the Mother’s possible alcohol misuse as a risk factor, and informed family services.   Therefore, whilst there were numerous earlier concerns about domestic abuse and of the Mother’s alcohol misuse for much of this time, little of it was evident by any presenting behaviours or incidents witnessed by the Children’s Centre and schools.  With the benefit of hindsight, some of the behaviour difficulties presented by the Half Brother were likely to have been linked with these family experiences.  The Mother presented as being a caring mother to the Children’s Centre and the schools, and showed evidence of her commitment to the Half Brother, for example by her attendances at play sessions and then by her attendance at meetings at the Nursery or the School to improve the Half Brother’s education and behaviour.   Additionally it was quite a long journey from her home to the Children’s Centre although she was committed to this sufficiently to attend regularly.   Although the GP practice recognised risk factors in relation to the alcohol misuse, it was noted that whenever she was actually seen at the GP surgery, the Mother presented well and did not appear to be suffering from the effects of alcohol and so it was not immediately evident that she had any current alcohol related problems.  4.5 The risks which were identified to the Police and family services were either in relation to domestic abuse or alcohol misuse.   In the majority of the domestic abuse incidents, the Police recognised the risk factors and consequently notified family services of these.   Although the initial incidents related to the Mother’s partner at the time, once he left, the incidents related to the wider family.   Although during these incidents, the Half Brother was also usually present and alcohol was a feature of the incident, these were not so readily identified as risk factors and an onward referral accordingly made to family services.  In this way, because the incidents featured the extended family rather than the immediate family relationships, then it might have been that the risks to the Half Brother were not viewed as so clear cut.  His presence however on these occasions should have meant that the risks were just as significant.   The Police IMR does not give this as a reason for the lack of identification of risk to the child on these occasions, but more related to workload and likely human error.   The IMR nevertheless is clear that under arrangements now, appropriate referrals to family services would be made even if the incident related to the extended family only.  4.6 There were five domestic abuse incidents reported during the Half Brother’s first year, although this only led to one Initial Assessment being undertaken by family services during 14  that time, which decided that there was no need for further action.   What was missing here in terms of identifying the overall risk factors was the need to view these incidents more holistically in that a pattern of recurring domestic abuse was likely to provide greater risk to a child than a one-off event.   4.7 More generally, family services’ response to the domestic abuse incidents as well as those related to expressions of concern about maternal alcohol misuse, were incident focussed and failed to create a coherent pattern of family life and how its chaotic nature was likely to generate increasing risks to the Half Brother and to the Subject Child if the concerns went unaddressed.  4.8 The health visitor, GP and the hospital were aware of some of the particular incidents and concerns in relation to alcohol misuse.   Certainly the Mother’s history of alcohol misuse was known and then links made with her hospital admissions which were thought to reflect a return to alcohol use by the mother.  There were numerous examples of the Mother down playing her alcohol use or denying it, even in the face of evidence to the contrary, and this no doubt delayed recognition by the professionals that her behaviours were potentially presenting accumulated risk factors to the children.  4.9 The Mother was very well known to the Hospital as she had been a frequent attender there from the age of 16 years.  Her difficult background as a child and young person was well known, as well as her recurring problem with alcohol as she got older and then became a parent.   When there was direct concern for the care of the Half Brother from the Mother’s alcohol misuse, appropriate referrals were made, but these did not happen on every occasion of her needing hospital treatment for her medical problems.   One difficulty was actually making the link between the flare up of her chronic condition with excessive alcohol use.   On occasions there was evidence of a clear link, but the Mother would sometimes say that the episode was caused by eating spicy food, and in fact in her contribution to the SCR, stated that this was often the reason for her condition needing hospital attention.  Specific concerns may not therefore have been obvious on each occasion in the hospital, but it might have been the case that the fact that she was so well known, led to some complacency about her situation in that she was not presenting with anything differently.  Taking a more inquisitive approach to understanding the degree to which alcohol was involved could have helped confirm or otherwise the direct cause of the recurrence of her condition and challenged the Mother accordingly about the dangers of continued alcohol use.  It was not apparent that the Hospital staff had a sufficient understanding of the social consequences and the effect that alcohol abuse would have in everyday living, particularly in respect of the impact on the children.  4.10 The health visitor alongside the nursery nurse provided support and advice to the Mother and were able to monitor the development of the Half Brother.   It was clear that there were some positive views held about the Mother’s parenting and they, like other professionals, were often reassured by the Mother that she was not drinking.  However as early as May 2007, the health visitor told the duty social worker of family services that whilst the Half Brother was thriving, she was concerned about the vulnerability of the Mother and the 15  impact of her drinking upon his care.   Also in June 2008 the health visitor discussed the dangers of drinking with the Mother in relation to her own health and parenting, and by the summer of 2009, with the Half Brother approaching 3 years old, the health visitor expressed concern to family services about their decision not to allocate a social worker to the case despite the Mother’s continued drinking at that time, and in the health visitor’s view, the Mother’s corresponding inability to be protective towards the Half Brother.  4.11 Whilst the GP practice was similarly often reassured by the Mother on several occasions that she had stopped or was managing her alcohol intake, the GP practice generally recognised the risk factors and spoke to the Mother about them, although these were primarily related to the Mother’s own health which was being seriously affected by her apparent continued alcohol use.   A referral to the counsellor within the GP Practice was evidence of their concerns.   The link with her parenting ability and the associated risks to the Half Brother was not as evident although it was when he was approximately 2 ½ years old that the GP made a referral to family services in this respect.   By this time it was apparent that the GP practice recognised that the Mother’s behaviours were not changing and required the input of family services to address the needs of the child.  In effect however the Mother reassured the social worker that she had stopped drinking and once again no further action was taken.  4.12 Therefore both the health visiting service and the GP surgery recognised the accumulation of concerns in relation to the Mother’s alcohol misuse which in turn heightened the risk factors and then led to those concerns being expressed to family services.    The Police similarly identified this when at the time of the incident in mid-2011 the Mother left the Half Brother alone in a taxi and then claimed he was missing; the assessing officer reported that the Mother “does not appear to be learning from her mistakes”.   In effect however, the Police response could only warn the Mother or continue to advise her about the need to get help from other support agencies, and on occasions she would reassure them that she would do so.   Overall it was the family services who were in the best position to act upon accumulating concerns, and the Police recognised this by advising family services on this occasion to “take a more robust approach” with the Mother.  This could have been done by providing longer term and more focussed interventions, with the support and involvement of the health practitioners, although in reality, family services’ involvement did not progress pass the assessment stage.    4.13 What was apparent with this family was that if they were not seen in the middle of a crisis such as a domestic abuse incident or when the Mother was intoxicated and unable to care for her child, then it was difficult to identify risk factors and to respond in effective ways.   It was clear that the Mother could be plausible and reassuring to professionals in normal everyday situations and could reassure them that any crisis was over and would not recur.   One example of this was when following a particularly worrying occasion when the Mother had been drinking all day and was arrested by the Police, the eventual Core Assessment by family services rightly identified the incident as high risk but that the chance of its recurrence was low, as she had convinced the worker that a family tragedy had led to her excessive alcohol intake.   However, this was too readily seen as an acceptable reason for the Mother’s behaviour.  Whilst reaction to grief can take many forms, the Mother’s high 16  level of alcohol use and intoxication at this time led to her being unable to care for her child.   This should not have been minimised or explained away as a one-off occurrence as it reflected the way in which the Mother responded to stressful circumstances.  4.14 This particular incident was a missed opportunity for more robust interventions by family services particularly as the incident itself led to the Police placing the Half Brother in Police Protection.   The Police’s response was appropriate to a very worrying situation and reflected their recognition of a high risk situation, which FAMILY SERVICES could then have built on by providing social work input to enable the Mother to recognise the chronicity of events and why professionals were concerned about the accumulation of risks to the Half Brother.   In effect the Core Assessment and case closure which followed, and the acceptance of the Mother’s explanation for her behaviour, meant that the risk factors went unaddressed.   This was evidenced by two further episodes of the Mother’s alcohol misuse reported to family services via the Police occurring just three months since the completion of the assessment.   On both occasions she had the care of the Half Brother.  4.15 There was potentially another occasion when Police Protection could have been used and this took place just a month earlier in late 2010 when the Mother was found to be drunk in charge of the Half Brother and of concern at this time was the description of the Half Brother as being unwell and as expressionless and distressed.  The police officer however considered that the Half Brother was not in any immediate danger or likely to suffer significant harm.   The Police IMR considered that on this particular occasion there was another woman on the premises who was also intoxicated and that she may have been the focus of Police activity, as she was arrested regarding an unrelated offence.   Even if the Police did not take immediate protective action in respect of the Half Brother, potentially family services could have been asked to make an urgent visit to the home to assess the risk to the child although it was not until the following day before the incident was reported to family services.  4.16 Prior to the death of the Subject Child, only one Strategy Meeting was held in response to incidents of concern, when in reality the continuation of worrying incidents of the Mother’s alcohol misuse placing the Half Brother at risk, as occurred during a concentrated time between late 2010 and Spring of 2011, should have led to a further Strategy Meeting at that time and a Sec. 47 child protection investigation being undertaken.   In fact during the Half Brother’s first year (up to the summer of 2007) there were sufficient incidents of domestic abuse, some linked to alcohol misuse, to warrant Sec 47 child protection enquiries being conducted.   This was an early example of the continuing tendency of family services to separately focus on single incidents and fail to recognise when a pattern of risk factors required them to raise their response to the child protection threshold.     4.17 The pregnancy and the eventual birth of the Subject Child was in itself a risk factor and this vulnerability should have been recognised and the family circumstances re-assessed as a result.   Although there was a Child in Need meeting in September 2011, and it was known at that time that the Mother was  pregnant, this was not considered as an additional risk factor, with the focus at that time still on the Half Brother at which time the concerns were 17  not high.   Local procedures state that where there is “knowledge of parental risk factors including substance misuse, mental illness, domestic violence” that a referral to family services should be “considered” and that all pre-birth referrals should be subject to a Common Assessment Framework.5  However there was no record of any agency considering a pre-birth assessment referral to family services at this time.  Whether the fact that family services were undertaking a Core Assessment at this time in relation to earlier concerns led to a referral not being taken, is not known, but even though the Mother informed the social worker that she was pregnant, this was still not given any attention within the assessment.  There was also an opportunity to arrange for a follow on CIN meeting for the latter period of the pregnancy to reassess the situation at that time although again this option was not taken up.   The reasons for this would appear to be that the main focus remained on the Half Brother and there was no high level of concern about the Mother’s alcohol use from a multi-agency perspective, believing that she had ceased drinking, which then led to family services closing the case.  4.18 When the school passed on concerns to family services of the Mother smelling of alcohol, this was just a month before the Subject Child was born, and considering the background, needed to have elicited a response from family services, and in fact whilst contact was made with the midwife the family services IMR stated that “it was not followed through”.  In fact on the last occasion when family services were involved, they had closed the case because they had accepted that the Mother was not drinking because of her pregnancy – from the school’s information, this was however apparently not the case.  According to family services, information was gained from the Mother at this time who said that after contact with the midwife the previous day, all was well – (there was no corresponding record of midwifery contact at this time).   The Mother said that she had not drunk alcohol during this pregnancy and that she had regular blood tests and transfusions due to her chronic medical condition, although this was not checked and no contact made with the midwife.   Additionally the Mother said that the Half Brother’s behaviour was deteriorating.  It was therefore of concern that the decision was made by a senior social worker that the circumstances did not meet their thresholds for intervention and the school were asked to monitor.      5. The Appropriateness and Quality of Assessment Practice 5.1 Overall, during the 6 year period of involvement covered by this SCR, there were nine occasions when formal assessments were undertaken by family services and yet there was no continuation of intervention in terms of a social worker being allocated to the case as a result of any of the assessments.   Whilst the assessments were fairly spread out, with none occurring during 2008, in contrast there were two Initial and two Core Assessments over an eight month period during 2011.   Overall, to have so many assessments in itself should suggest that there were continuing concerns which were not being addressed.   It was not apparent that sufficient learning from one assessment was fully considered in the context of the next assessment in order to give a more informed understanding of the pattern of family life and of any resultant or build-up of risks to the Half Brother and then to the Subject Child. 5 Chapter 2.29 Pre Birth Multi Agency Procedures and Practice Guidance – The area LSCB – July 2011 18                                                             5.2 On occasions the assessments gained useful historical information and occasionally the assessments identified the vulnerabilities of the Mother in terms of her alcohol misuse and of the impact on the Half Brother.   However, for example, despite this being highlighted at the time of the second assessment in July 2007, the Initial Assessment still led to “no further action”.  Some of the assessments as individual pieces of work appropriately identified the risks and need for future support for the Mother, but none of them ultimately led to any coordinated or focussed interventions to address potential safeguarding concerns for the Half Brother.   The fact that the Half Brother needed an Individual Education Plan during his pre-school experience meant that he clearly had some behavioural and learning issues identified at an early stage which was then taken through into his Primary School.   There should have been some links made between these issues and some of the incidents and concerns which led to assessment activity.   In this way there was an insufficient connection between the incidents of concern and the Mother’s alcohol misuse, with some of the Half Brother’s presenting behaviours and to what extent these may have reflected any impact upon him in respect of his developmental progress. 5.3 In general some of the shortcomings of the assessment practice by family services were that information given by the Mother was generally accepted at face value without any objective information being sought to support or challenge what the Mother had said.  In this way it was clear that she was quite plausible in her explanations to social workers.   The social workers no doubt encountered difficulty in establishing with the Mother the existence or extent of any alcohol misuse, but her denial of any such problem was often accepted without much question or challenge.  This issue warranted greater exploration within the relevant assessments. “On an emotional level, for those who have experienced long histories of using substances or where the use has provided significant emotional support, facing the possibility of examining their pattern of substance misuse can be particularly stressful”6.   It was clearly therefore going to require a level of persistence and a greater opportunity to build a trusting relationship with the Mother before there was likely to be any acknowledgement of any alcohol problem by her.   The short term assessment activities were not however the means by which this could be realistically achieved. 5.4 None of the assessments led to any identification that the child protection threshold had been reached although if incidents and concerns had been linked and a focus maintained on the potential impact upon the Half Brother of this lifestyle, then in reality it could be argued that such a threshold had been reached.   This was particularly so at the end of 2009 after a number of reported incidents and concerns over the previous eight months, and again in the Spring of 2011 after a similar pattern of concerns re alcohol misuse over the preceding five months.    5.5 Another shortcoming of the assessments was the failure to clearly identify to what extent the Half Brother’s care had been shared with members of the extended family or friends.   At the time of the death of the Subject Child, it was apparent that much of the care of the Half Brother, and then the Subject Child, had been shared with another couple who were family friends.   The details of this family should have been collected and any information in respect 6 Parental Substance Misuse and Child Welfare -  Kroll, B and Taylor, A – Jessica Kingsley 2003 19                                                             of them sought at earlier stages.   Similarly the extended family were often referred to as providing support or care for the Half Brother and yet their details were never clarified or information sought in sufficient detail in respect of them.   This was particularly important as two members of the extended family had offences recorded against them which could have posed risk to a child in their care.   Additionally, on some occasions the extended family were the source of tension and conflict.   In this way the paucity of the knowledge of extended family compromised the quality of any assessment undertaken. 5.6 In essence therefore, whilst the family services assessments occasionally collected useful information and were able to identify risks to the Half Brother, they collectively had little impact on the family lifestyle or in getting the Mother to change her behaviours and to consider the impact on her child care abilities. 5.7 The ante natal and post natal assessments in respect of the Half Brother were however thoroughly undertaken by the health visitors, and information was gained upon which to base later interventions by the health visitor and nursery nurse, who was involved for a three month period during 2008.   Assessments and follow up interventions tended however to be based on information given by the mother and she did not generally divulge information that may have been seen as concerning in terms of her parenting and for example only spoke of her wider family when they had been supportive.   Whilst some useful work was undertaken by the nursery nurse to support the Mother with parenting issues associated with diet (presumably of the Half Brother) and behaviour, there was no record of how it was assessed that the Mother needed this type of support. 5.8 The Half Brother’s developmental review was carried out when he was just over 3 years old with the outcome that his development was age appropriate and nothing of concern was noted.   Once again however this was based on the Mother reporting this. 5.9 It was when the Half Brother was just over 4 years old that the school informed the GP of some of the Half Brother’s behavioural difficulties and requested an assessment.   After first seeing the Mother and the Half Brother at the surgery, the GP made a referral to the community paediatric service.  Unfortunately this referral, according to the GP IMR “went astray” and was not resurrected for another four months, when the referral was re-made.  It then took a further four months for the Half Brother to be seen for a paediatric assessment.    These delays reflected inefficient practice without any real understanding of why the delays occurred.   Also as the time between the referral and the appointment was eight months, there was likely to be a change in the presenting concerns in respect of the Half Brother.   In event the assessment appointment did not generate any new initiatives, with the Mother claiming that there were no problems, and no further appointments being offered.  Whilst the original referral had referred to the Mother’s health problems, there was no specific mention of the Mother’s alcohol issues, or any instability in the family, meaning that unless the Mother mentioned these, any assessment was likely to be compromised by the lack of this knowledge.  It would however have been reasonable to expect the assessment to have explored the family background by asking pertinent questions of any past or recent problems in an attempt to understand the behavioural problems that the Half Brother was said to be presenting.  In effect the assessment did not add anything to the professional 20  understanding of the Half Brother’s circumstances or in terms of his behaviours or to what extent they may have been linked to the Mother’s possible drinking and the overall family lifestyle.   The assessment in fact took place just over a week after the incident in which the Mother had left the Half Brother in the taxi so it was most unfortunate that the assessment was not able to consider this context.  Overall, this reflected a missed opportunity to gain a greater understanding of the family circumstances and of the potential impact upon the Half Brother. 5.10 In terms of assessments undertaken by the Police in their contact with the family, the respective IMR identified that there was a general improvement in the quality of the Police assessments from April 2011 based on the use of staff expertise in the Multi-Agency Referral Unit (MARU) which had been established from that time.   These latter assessments were therefore more multi-agency based and had the potential for generating appropriate actions by the most relevant agency as a result.  As part of many of the Police contacts, relevant assessments, especially prior to 2011, were hampered by the Mother’s lack of co-operation and corresponding limited information available to share with other agencies. 6. Decision Making, Plans and Interventions – Identification of Missed Opportunities 6.1 Whilst the Hospital had regular contact with the Mother in relation to admissions and attendances at the A&E Dept., particularly in the earlier periods of time, there was just one occasion when a referral was made to family services as a result.    This was in the summer of 2009 when the Mother had a laceration to her hand following a fight in the home, and when it was identified by the doctor that the Half Brother was present; an immediate referral was made to family services.   This was good practice by the Hospital. 6.2 The Police were unaware of the incident and it would have been useful for either the hospital or family services to have informed them as they could have assisted with enquiries about what actually transpired during the incident – potentially there were criminal acts involved.  At the Practitioner Workshop, there was disagreement about whether it was expected practice or appropriate for the Hospital to have informed the Police of this incident, with the Police view that they should have been informed, whilst the Hospital view was that to report every injury which they see at A&E that might have had some criminal act involved, was unworkable in terms of the numbers that it would represent.  In this instance the Mother was not claiming that she had been assaulted and it is not clear what difference, if any, Police involvement at this time would have, as it would presumably have been in respect of the two men involved in the fight. 6.3 However, whilst the referral to family services was entirely appropriate, in effect their response was slow and out of timescale in respect of the Initial Assessment which followed and used the opportunity to meet with the Mother and to observe the half Brother in his home circumstances and no concerns were noted about the parent/child interaction. The social worker accepted from the Mother that the Half Brother had been asleep during the altercation and that she had stopped drinking since then.  Contact was made with the health visitor who said that she was not concerned about the day to day care of the Half Brother but nevertheless remained concerned about the Mother’s vulnerability and her use of alcohol.  No action was taken by the social worker to establish the names of the other 21  people involved in the incident or checks made in respect of them.  Police involvement would have helped in this respect.   In summary, regarding this incident, whilst the Hospital had made a prompt referral, the delay and limited response by family services meant that the opportunity had been lost to respond effectively to this worrying incident and in particular to put them into the context of the previous incidents of concerns that had been raised.  6.4 For other hospital attendances by the Mother, generally these were responded to as medical problems, which whilst understandable in the context of the role of the Hospital, generally they accepted at face value that the Mother had now ceased drinking alcohol and therefore did not address any associated social problems by onward referral to other agencies.   Similarly, potential risks were not identified in respect of the care of the Half Brother.   Whilst it could not have been said with complete confidence that alcohol misuse was the cause of every hospital admission for the Mother’s chronic condition, these could have been explored more robustly by the hospital.   This could also have been said of the consultation that the Mother had with the specialist in substance misuse, in that the background evidence of alcohol misuse should have led to greater challenge that it had now ceased. 6.5 To some extent, decision making based on background knowledge was compromised with the services provided in the Hospital, by the fact that the Mother had six volumes of medical notes, and most of the relevant risk factors were contained in volume two, when generally only the final volume was accessed to aid decision making. 6.6 With regard to the domestic abuse incidents, the lack of engagement by the Mother with the Police meant that this had an impact on decision making in respect of her as a victim.   Despite some repeat episodes, her refusal to cooperate with attending police officers to take action against the perpetrators meant that she was not able to be offered any protection via the prosecution of offenders.  In the Mother’s contribution to this SCR and to the Rapid Response team immediately following the Subject Child’s death, she spoke of a period of domestic abuse from the Subject Child’s father following the child’s birth and during the pregnancy, but more particularly on the day that the Subject Child died, which she claimed led her to consume alcohol.   Overall the Mother said that she did not feel able to report any concerns to the Police or any other agency of any specific incident in relation to the Subject Child’s father.  In this way the Mother again did not receive any service to help protect her or the children.   She also described that when asked by the midwife about domestic abuse at this time that she replied that there was none. 6.7 The decision to provide Police Protection to the Half Brother at the time of the Mother being found drunk in charge of him in early 2011 was a sound decision and this intervention at the time showed relevant concern for the care and safety of the Half Brother.  A strategy Meeting which was then held and there was a quick response to this referral and actions taken to ensure that the Mother and the Half Brother were seen separately and together in order to inform the assessment.  However, the completed Core Assessment did not generate any further intervention when a different approach by family services could have been to provide a more in-depth intervention to consider her parenting capacity, and to address the 22  reasons for the Half Brother’s behaviour difficulties which she acknowledged at this time were of concern to her 6.8 In other respects, decision making following incidents or concerns reported to family services either generated a letter being sent to offer support, and then more regularly to either Initial or Core Assessments being undertaken.   The lack of urgency attached to family services’ response to the  referral from the Hospital about the Mother cutting her hand in 2011 in an altercation with knives in her home, was concerning and in fact the Mother was not contacted until five weeks after the incident.  By this time the crisis had passed and the delay in family services making contact would no doubt have given the Mother the view that the incident was not considered as being serious by family services.   In general where a decision was reached for family services to undertake a single agency response to a particular concern, there was no process for this to be reported back to any agency, particularly the Police who may have been involved in the decision in the first place.  In this way there was no monitoring if intended actions were completed. 6.9 The only time when a pattern of interventions was decided upon following a family services assessment was when a CIN process was set up in the summer of 2011, with subsequent CIN meetings being held in July and September.  The Core Assessment at this time had concluded that the Mother had ceased drinking but that she would need parenting support and that this would be accessed through the School and Children’s Centre.   Whilst the assessment had identified that the Mother was again pregnant, no specific interventions or follow up appeared to be have been decided upon as a result.  This should have been identified as a new risk factor which would need monitoring and more robust interventions with the Mother to support her at a time when alcohol use could have significant impact on her unborn child.   By the time that the social worker shared the outcome of the Core Assessment with the Mother, a further anonymous referral had been received about her drinking, but her explanation that she had been drinking lemonade rather than wine was again accepted and so no further interventions were arranged and the case was closed.  Although the case was held with the family services intake team, the need for a Team Around the Child meeting was identified to take place in November 2011, although there was no record of this happening. 6.10 In terms of health visiting practice, there were follow up contacts made with either the Mother or family services after notifications of hospital admissions and domestic abuse incidents.  The health visitor made her concerns known to the Mother about the impact of alcohol misuse and domestic abuse on the care of her child, although generally the Mother denied or explained away such incidents as not reflecting concerns.  The health visitor nevertheless was sufficiently experienced to recognise that the problems existed despite the maternal explanations, and carried out announced and unannounced visits to the home but did not ever witness the Mother’s drinking.   To some extent this must have taken away the strength by which the Mother could be challenged.   The health visitor nevertheless appropriately made her concerns known to family services. 6.11 There was an incident when the Half Brother had a physical injury to his nose, said to be the result of a fall against the wooden leg of a settee.  The GP referred the matter to the hospital 23  and although the referral letter identified the child as previously being at risk, it was not suggestive that the cause of the injury was in itself suspicious.  However in the circumstances it would have been prudent for the attending doctor in the hospital to have checked with the Safeguarding Children Team to ascertain any other relevant information.   6.12 Although the family services IMR refers to another occasion when the Half Brother had a bruise on his head, this is not mentioned in the records of other agencies so it is unclear when this occurred and where the information came from.  What is concerning however is that the Half Brother apparently gave two versions of how he got the injury, one being that his mother hit him, so it would have required some form of follow up.   However, there was no further information in respect of this and there is no reference to this in any other IMR. 6.13 In terms of the pregnancy and birth of the Subject Child, as explained previously, there were no interventions established to work with the Mother at this time to address any potential issues of risk.   When the Mother presented with the pregnancy in respect of the Subject Child, the hospital records held scant information about the father and when she was questioned in a routine fashion about domestic abuse, she maintained that there was none. 6.14 As the pregnancy continued, the Hospital addressed medical issues in respect of the Mother, supported by information and concerns being presented by the GP at the time, but did not make specific links with past or recent alcohol misuse to inform any assessment of risks to the unborn child.   Again there appeared to be a view at the Hospital that the Mother had ceased drinking. 6.15 Following the birth of the Subject Child, when the Mother smelt of alcohol on the ward, it was appropriate that the ward to sought advice from the Named Midwife.  It was not however apparent that the Hospital medical records were accessed as these would surely have provided ample information to suggest that there were potential risk factors here, and lead to a referral to family services.  Unfortunately the community midwife was new and knew nothing of the background and so no intervention followed.   This was a missed opportunity at the beginning of the Mother’s care of the Subject Child to have addressed alcohol misuse in connection with the care of a new born baby and of all the concomitant risks that this could generate. Engagement with parents and other adult figures 6.16 Because of the amount of involvement that the Mother’s extended family and friends had in her life and their occasional care of the Half-Brother, then it should have been important to have gained information about them.  As already stated, the family services assessments failed to do this in any consistent way, and often information about the details of family members was confusing.   When concerns were expressed to family services by Probation in late 2011 about a member of the extended family, family service’s response was to ask the Mother about this over the telephone and accepted her response that there was no unsupervised contact with this individual, without any further checks being taken.   Whilst this relative’s previous offence did not automatically place a child at risk in his presence, Probation were clearly sufficiently concerned to make the information known to family services.   Contact by family services  with the Half-Brother’s father would have been 24  appropriate in the circumstances in order to better understand the circumstances of the contact arrangements and to more clearly identify whether there were in fact any risks to the Half Brother, attached to these arrangements. Whilst family services did not make direct contact, Probation may well have further emphasised this concern to the relevant member of the extended family. 6.17 It was not until after the Subject Child’s death that there was any assessment of the involvement of the particular family friends who periodically cared for the Half Brother.  At that time they were considered to be appropriate carers for the Half Brother which was sanctioned by family services. 6.18 The Police had background knowledge of some of the other adults in the extended family and in fact needed to deal with them in some of the incidents that took place, although there was little reference to the sharing of information in respect of them with other agencies.    6.19 The school experienced similar confusion in that when on one occasion the Half Brother mentioned his “Dad” at home, this was the only time he had made such a reference and the school had always understood that the Mother was a single parent.   Overall the school did not have an accurate understanding of any of the extended family and were incorrect in considering that a family friend was the Mother’s step-father. 6.20 Overall there was a consistent lack of knowledge as well as a degree of confusion about members of the extended family and of friends who provided support or generated conflict within the family.   In this way, no single agency had a clear understanding of the status or role of other adults, as none were specifically engaged by any professional to gain a greater understanding of their role and of any potential risks that they may have generated.  It is not recorded, apart from the Police contact with the male in the hone at times of domestic abuse incidents, that any professional had direct contact with the fathers of the Half Brother or the Subject Child, although it was not apparent that they were resident in the home at any time.   However they were occasionally visitors and there was contact between the Half Brother and his father and of the Subject Child’s father, so it was prudent for practitioners to have strived to gain information in respect of them. 7. The Implementation of Individual and Multi Agency Policies and Procedures  7.1 Whilst policies and procedures were generally followed by the respective agencies, for example with regard to domestic abuse notifications, it is apparent that no agencies made use of any definitive guidance or procedure for working with parental alcohol misuse.   In this way there was no agreed understanding about what actually constituted alcohol misuse and consequently on the actual impact on the children involved.   Whilst the concerns about parenting abilities were no doubt fairly obvious to practitioners in this case who directly witnessed the mother intoxicated, it was much less clear how risks could be assessed when there was no direct experience of alcohol misuse.  Whilst it could be identified that “Misuse is taken to mean that the level of dependency or consumption is significant enough to 25  impact on family life and potentially the care of children”7, there was no policy or guidance used to support how practitioners could work to such a definition.   The “Framework for Assessment” set of materials does however provide a questionnaire that could have been used to help understand the part that alcohol played in the Mother’s life and of the impact on parenting.  7.2 Some research undertaken with social workers working with parental alcohol abuse, identified how difficult it was to assess the impact on parenting capacity, especially when the carers are binge drinkers; “They recognised that carers could provide good enough parenting in between periods of binge drinking and found it all too easy to minimise the impact of this binge drinking on the children in the family”8.   It could be argued that this was the sort of challenge which the practitioners who worked with this Mother faced, in that when not drinking she appeared to present as a capable and caring mother.  7.3 The policy context is addressed within a very recent report by the Children’s Commissioner9 which expresses the view that “The current family-focussed agenda does not address parental alcohol misuse at a strategic level.   There is a lack of an alcohol specific focus.   Similarly there is less recognition, and response, to alcohol abuse compared to drug misuse”.   Unlike drug use, alcohol use is not illegal and this might go some way to explain why some studies have highlighted that “children living with parental alcohol misuse tend to come to the attention of care services much later than do those living with parental drug misuse”10.  Similarly there is research evidence that children who experience parental drug use are much more likely to be subject to care proceedings or made subject to child protection plans than those children who live with parental alcohol misuse11.  8. Communication and Information sharing Re Domestic Abuse 8.1 Generally the Police appropriately shared information with family services and the health visitor about domestic abuse incidents, although as mentioned previously, there were some inconsistencies in this respect.   It was also apparent that the GP surgery was given information about some incidents although not all, as they only seemed to hold information in respect of two incidents in early 2007.   Their knowledge may well have come via the health visitor, but generally it was not clear that community health practitioners received all information about the domestic abuse incidents where the Half Brother was present.  7 “Parental Substance Misuse and Implications for Children” in “Child Neglect – Practice issues for Health and Social Care” – Taylor, J and Daniel, B – 2005 – Jessica Kingsley 8 “Child Neglect – Identification and Assessment” – Jan Howarth – 2007 – Palgrave Macmillan 9 “Silent Voices – Supporting children and young people affected by parental alcohol abuse” – The Children’s Commissioner – Adamson, J and Templeton, L – September 2012. 10 “Silent Voices – Supporting children and young people affected by parental alcohol abuse” – The Children’s Commissioner – Adamson, J and Templeton, L – September 2012. 11 “Parental substance misuse and child care work – findings from the first stage of a study of 100 families” – Child and Family Social Work 11:325-335 2006. 26                                                             8.2 On the occasion in early 2007 when the Mother’s partner at that time was arrested of an assault committed against the Mother, it appeared as though there was no onward referral to the domestic violence advocate although the Police IMR identifies that such a referral would be much more likely under the current arrangements (MARU) in view of the co-location of advocacy workers.  Other potential referrals to advocacy for the Mother were presumably not made because she would not engage with the Police in trying to resolve the problems she was encountering in an abusive relationship.  8.3 Generally therefore, there was key communication on most occasions between the Police and family services re domestic abuse concerns although the extent to which professionals from other agencies were informed, is unclear.  Also the assessments which family services undertook at the time when there were domestic abuse concerns ,(Summer 2007 and Summer 2009) were primarily focussed on maternal alcohol misuse rather than domestic abuse, although it was agreed between the health visitor and social worker on the latter occasion that the Nursery would be a protective factor for the Half Brother.  It was not apparent however that they were informed of the earlier domestic abuse incident prior to the Half Brother commencing at Nursery.    Although it was also usual practice for the Children’s Centre to be notified of domestic abuse incidents, those which occurred in mid-2009 and early 2010 were not in relation to incidents involving the Mother’s partner at the time, which appeared to mean that they were not treated in the same way as intra-familial domestic abuse incidents.  As there were no child protection conferences or CIN meetings within the time that domestic abuse was occurring, there were no obvious or formal means by which information could be shared.  Re Alcohol Misuse  8.4 Whilst it was apparent that suspicions of alcohol misuse by the Mother was an on-going concern, unlike domestic abuse there was no process by which information would be formally shared between agencies.  Because of the generally positive way that the Mother and the Half Brother presented at the Children’s Centre and the Primary School, then parental alcohol misuse was not an identified problem.   However, if information had been shared more routinely at times of Initial or Core Assessments, then this could have been redressed.  8.5 The Police response to specific incidents when the Mother was found drunk in charge of the Half Brother were dealt with speedily and family services quickly informed.  Generally however the way in which the Mother’s explanations for her behaviour were accepted without robust challenge, meant that her behaviours were not further addressed.   In some ways the fact that she had a chronic condition affected by alcohol meant that there was greater likelihood that social workers would accept the Mother’s assertions that she had stopped drinking.  For example she talked of how the GP had told her that she would die if she continued drinking, and so this was given as strong reasoning for her not drinking.   Also one of the later family services assessments identified that the GP had said that if the Mother did consume any alcohol, that she would be in considerable pain.  In this way there was a somewhat naïve belief that the Mother would not therefore drink. 27   8.6 It was apparent from the Practitioner’s Workshop held, that a number of practitioners who worked with the family did not know of the clear links between the Mother’s chronic abdominal condition and past and current alcohol misuse.   This was not surprising as the links had never been formally made for those who worked in the Nursery, Primary School or Children’s Centre.   To some extent there was an assumption by health practitioners that other non-medical professionals would nevertheless understand the links.  8.7 Whilst the GP knew of the Mother’s numerous hospital attendances, and made the link with continued alcohol use, the Hospital did not necessary make these links and make any external referrals as a result.   In truth it would have been difficult to always make a definitive link between each Hospital admission and excessive alcohol use.  The Mother in fact often talked of how eating spicy food led her to have flare ups of her condition.   As part of the SCR process, clarification was sought from a consultant surgeon who had operated on the Mother, who explained that even if the Mother had completely ceased drinking alcohol, there could still be episodes or flare ups and that in this way “It would not be possible to say that the repeated A&E attendances were evidence of a resumption of alcoholic intake”.  8.8 The Hospital did not apparently always enquire with the Mother whether she had been drinking to cause the flare up of her condition, and so making links to any irresponsibility on her part in terms of her parenting was not made.   There was of course other evidence of the Mother’s alcohol use and sometimes she admitted to drinking alcohol to the Hospital and the GP, although this did not lead the Hospital to make any referrals in respect of this.   There was however a lack of clarity about the exact level of drinking which was reported on those occasions.  For example the Mother’s descriptions of her drinking habits to professionals on three separate occasions, were unclear in terms of detail or of their frequency.   If greater attention had been given to collecting the detail of the Mother’s drinking behaviours at that time, it would have improved chances of monitoring this or giving better detail as part of any referral onwards of concern.    In fact at an A&E admission in early 2008 when the Mother described a high level of drinking, this was a clear opportunity to refer her to substance misuse services.  8.9 The GP was alert to the concern about alcohol misuse even though the Mother never actually presented as intoxicated at the surgery.  However the GP Surgery appropriately made contact with family services and referred concerns at various times.   In fact the respective IMR for the Surgery claimed that family services were “contacted repeatedly regarding the Mother’s alcohol problem” and on one occasion in the summer of 2009 the GP expressed the view to the social worker undertaking an assessment at that time that “the Mother needed to know that professionals were concerned about her drinking”.   This was at the same time that the health visitor also made her concerns known that the alcohol misuse was not being addressed.   The GP’s IMR also states how the GP had become frustrated by the lack of a robust response to alcohol misuse when a significant problem linked to care of the Half Brother had been identified.   This situation met the criteria for an escalation of the concerns to a manager within family services, although there was no reason given why the GP surgery did not take this initiative.   Alternatively there was the 28  option for the GP to discuss the case with the community consultant paediatrician and raise the concerns further in this way and potentially gain this level of specialist support for their concerns.  The respective IMR has identified this as a learning point for the Surgery.   8.10 Although counselling had been offered and provided via the GP surgery, in reality the Mother failed to engage with this service, but when family services were informed of this, it was not considered overall to have been an indicator of the Mother failing to acknowledge or address her problems.   Family services on several occasions recommended that the Mother attend a specialist service for substance misuse but left this to her to make contact.  It was very unrealistic in the circumstances to expect that the Mother would have the necessary motivation to attend, particularly as her response was often to deny that any problem existed.   For this strategy to have been successful, it would have needed much greater support and encouragement from the social worker and/or any other professional.   It was apparent that the Mother was very plausible in her explanations of her circumstances to professionals and for example one of the reasons given for the substance misuse consultant not to request any follow up, was because the Mother said she was attending classes in building self-confidence.   However, there was no other information in any IMR that such classes were provided or known about.  Similarly in January 2012, the Mother reassured the Primary School that she was working with the health visitor on parenting issues.   Again there was no evidence that this was in fact taking place.  8.11 Although the alcohol misuse concerns had the potential at an earlier stage to have raised the concerns to the child protection threshold, at least when a CIN process was established, this was an opportunity for the first time to share information and to try to tackle the problems from a multi-agency basis.  However, there was no evidence that the CIN process progressed the work in any new way, not helped by the GP being unaware that this process had begun.   The CIN meetings did identify that there had been concerns about maternal alcohol misuse and so the School were at least made aware of this as a potential concern  8.12 When the Primary School became directly concerned in early 2012 about the Mother’s alcohol use, they quickly informed family services, but to then leave it to the School to monitor was an insufficient response by family services at this time when a more proactive response was needed.  What was particularly concerning was that at this time the Mother was eight months pregnant and the Half Brother’s behaviour was said to be deteriorating.  8.13 In fact there was only a limited link between the alcohol use and the pregnancy with the Subject Child in latter 2011 and early 2012, when in effect, with the benefit of hindsight this should have been a critical time to intervene with the Mother and address any concerns before the birth of the new baby.  8.14 Significantly, there was a change of community midwife at this time which meant that the Mother was not seen until she was seventeen weeks pregnant.   Because the midwives do not have access to the hospital records when away from the Hospital, then it was clear that the new midwife, who did not seek out information, did not know of the concerns about alcohol misuse.  Therefore the community midwife was reliant on the Mother who 29  outwardly presented with no concerns.  It is difficult to understand in the circumstances that with so much information already known to a range of health professionals about the Mother’s background, that none of this became known to the new midwife.   Even when the midwife was told of the Mother possibly drinking at the hospital a day after the Subject Child’s birth, this did not elicit a greater enquiry of background information.   Instead the Mother’s assertions that there were no difficulties were accepted.     8.15 Although there were attempts made, there was no communication between the midwife and the health visitor about the pregnancy.  It was most unfortunate that not only was the midwife new to the family, but the health visitor similarly had not had contact with the family previously and in fact when she did her “new birth” visit, did not even know the Mother’s name as she had been unable to speak to her colleagues before the visit.  8.16 Concerns however should have been raised during the pregnancy and before the direct involvement of the new midwife and health visitor, and the first opportunity to do so was at the CIN meetings in July and September 2011.   Although it was reported that the CIN meeting was made aware of the new pregnancy, neither the original health visitor nor the nursery nurse was there to give their background concerns, as the Half Brother was now attending school.   Also, his paper record was not handed over to the school nurse until a week after the first CIN meeting.    8.17 The GP was however concerned about the pregnancy and in particular about the Mother’s health and of her potential alcohol use, and so in the referral letter to the hospital, the GP asked for the antenatal clinic to “keep a close eye” on the Mother and referred for hospital based care, adding that the pregnancy was “high risk”.   There was reference in the letter made to the Mother’s chronic medical condition and alcohol problems.   The letter was not copied to the community midwife but she had access to the GP notes – however the GP did not know that this midwife would not be looking after this new pregnancy and would be replaced by a new midwife.  8.18 Therefore with the failure of the CIN process to identify the need for agencies to work closely during the pregnancy and in the post natal stages, alongside family services’ decision to close the case in October 2011, meant that there was no monitoring of the family circumstances during this period.  Also, the unfortunate coincidences that left the Mother with a new midwife and a new health visitor who knew nothing of the family background, meant that the pregnancy went by without the necessary level of assessment, intervention and support that was required at this crucial time.   Even when incidents of concern arose such as the school referral about the Mother smelling of alcohol just before the birth, and then the similar concerns of ward staff a day after the Subject Child’s birth, these still did not raise sufficient concerns to warrant purposeful interventions being undertaken by either family services or community health staff.  The previous midwife and health visitor, who knew the family, should have provided the family background information to the new midwife and health visitor to enable them to have given an accurate response to the hospital and clarified that there had been previous maternal alcohol misuse problems.   It was concerning that the new community midwife and health visitor embarked on providing 30  services to the family in complete naivety about the background.   In fact, within the Hospital at this time, there were substantial medical records which could have been accessed prior to discharge, which would have clearly given evidence of past alcohol misuse by the Mother.   8.19 Communication would clearly have been more effective if the shared health recording software (known as Database) was more effective, but there were examples where not all information was held on this and there were historical anomalies.   For example during the pregnancy with the Subject Child, the GP practice was using a computer system that did not communicate with Database, although full access to their records was given to the health visiting team.   However the fact that there was a new health visitor at this time who did not access the records, and did not have any information that would alert her of the need to do so, meant that although the practice was under the impression that they had alerted the health visitor to this as a high risk pregnancy, in fact this had not happened.  The same situation appeared to apply to the new community midwife.   Also there were no other means by which routine communication would take place between the GP and the health visitor and community midwife.   Furthermore for each unit of service which uses the database, they have to decide who can access their component of the record.    Therefore all records were not accessible to all professionals who could access the database, such as the Children’s Centre.      Community health services staff were trained in the use of the database as it was rolled out during the spring of 2011, with school nurses embarking on this more than a year later.   Inevitably the introduction of new recording systems need time to bed in and for staff to understand how to use them, but there also needs to be recognition that  this will always create the potential for poor or limited communication to take place during the interim.  Mental Health  8.20 There was no assessment of the Mother’s alcohol use which informed the practitioners who were working with her.   There was the one occasion when the Mother had an appointment with a specialist in this field, but because the finding on this occasion was that she drank “intermittently”, and that it was no longer a significant problem, then no link was made to any mental health concerns or whether there were any mental health issues associated with alcohol misuse.   This was a missed opportunity to have linked occasions of the Mother misusing alcohol at times of stress or as a source of emotional support with potential mental health problems.   There was one occasion when the Mother referred to being depressed following a family tragedy in early 2011, and she claimed that she would follow this up with the GP.   In fact she did so and sought bereavement counselling via the GP, although she did not maintain any meaningful contact with the service.   9. The extent to which the views, wishes and feelings of the Children were sought and taken into account  9.1 It was apparent that during some of the assessments carried out by family services, that the Half Brother was separately spoken to, and the Mother recalled in her contribution to this 31  SCR that on two occasions the social worker requested to speak with him and seek his views. This was done in the company of the Mother.   On the occasion when he was subject to Police Protection, it was appropriate the he was spoken to alone by the social worker.  At least in these instances the Half Brother’s individual needs were considered and this was an important principle, but because of the generally short and focussed nature of the assessments, no rapport could realistically be built up that would enable him to feel free to talk openly about his wishes, feelings and experiences.  9.2 Within Nursery school, Children’s Centre and his Primary School, where he was well known, the Half Brother did not ever mention concerns about his home life, and with these professionals not being aware of much of the on-going concerns about maternal alcohol misuse, there was no apparent reason to engage him over and above that which would happen with any child. When he did however mention his “dad”, the School did ensure that they followed up what this meant.   In respect of children’s experiences of parental alcohol misuse it is suggested that “Children draw upon a range of personal and other resources to cope and this changes over time.   However coping does not equal resilience…”12  9.3 It may have been such coping strategies which meant that, possibly apart from the behaviour difficulties that the Half Brother presented, he was able to present a positive image in school.  For example, “From a child’s point of view, a “don’t talk” rule is imposed and children are encouraged from an early age, not to tell”13.   This therefore suggests that there would have to be some recognition of the problem of alcohol abuse by a professional and then for that professional to reach out to a child and gain their confidence to enable them to share their feelings about their home life.  At no time in this case however was any practitioner at such a stage, and so there was no consistent or purposeful attempts to engage the Half Brother in this way.  In fact on one occasion the social worker noted a good attachment between the Mother and the Half Brother, and no doubt this was the case as there was evidence at various times of them having a positive relationship.   However in terms of parental alcohol misuse, an understanding of attachment would have to take other factors into consideration in that there may be an element of role reversal in that a child may take a protective or caring role with their parent.  9.4 Overall there was minimal attention paid to the potential of risk of significant harm to which the Half Brother may have been exposed to or more significantly to the Subject Child.  When there were behavioural concerns however in respect of the Half Brother, the school did attend to these and worked with the Mother to address these by putting an Individual Educational Plan together and regularly reviewing this with the Mother.   This was good practice.   The Half Brother was however placed on an Action Plan at his Nursery School, which was a quite rare and reflected his additional needs.   However when he moved from the Nursery School to Primary School, the Half Brother was in fact assessed at the being just above the band for Action Plans.   12 “Silent Voices – Supporting children and young people affected by parental alcohol abuse” – The Children’s Commissioner – Adamson, J and Templeton, L – September 2012.  13 Parental Substance Misuse and Child Welfare -  Kroll, B and Taylor, A – Jessica Kingsley 2003 32                                                              9.5 “Parental domestic abuse and alcohol misuse are strongly correlated.   Research suggests that with either family problem, it is often the disruptive behaviour and associated worrying for the child that causes the most upset”14.   This could have accounted for some of the Half Brother’s presenting difficulties although it needs to be acknowledged that incidents of domestic abuse were not common occurrences from 2009.   However, it was apparent that some went unreported during the Mother’s pregnancy with the Subject Child and following her birth.    9.6 During the Mother’s attendances at the Hospital for her chronic medical condition, questions were sometimes asked by staff about the care of the half Brother, although arrangements were not questioned or challenged.   Overall however there was no consistency about whether the Half Brother’s situation or needs were asked about, although in these circumstances of a background of a somewhat chaotic family lifestyle, then these enquiries should have been routinely made.  9.7 In terms of Police involvement, generally this took place when the Half Brother was too young to express his wishes and feelings, although at such times referrals were made to family services so as his needs could be addressed.   However it could be argued that during later interventions in early 2011, greater opportunity should have been given to the Half Brother to express his views and form the Police to gain a greater understanding of the mother/child relationship.     9.8 Following the death of the Subject Child, the Half Brother was interviewed and his views were sought regarding his placement with carers.  This was good practice at a very traumatic time.  9.9 The developmental needs of the Subject Child as an unborn child needed greater attention than she was afforded by professionals, in that with no assessment or understanding of any level of maternal alcohol misuse, then the potential impact upon the unborn child was not addressed.   There is considerable research to suggest that alcohol use, depending on its frequency and severity, can have an adverse impact on the health and development of a growing baby.   Although it is generally agreed that the more alcohol is consumed, the greater is the impact on the unborn child, “regular moderate use of substances is often less harmful than “bingeing”, as the sudden arrival of the substance in the baby’s system, followed by the subsequent withdrawal, can place him or her at more risk”15.  During the pregnancy there were no occasions when the Mother attended hospital with her chronic medical problems, although there were two referrals made to family services, one from a member of the general public and one from the School passing on concerns about the Mother’s possible drinking.   The Mother’s medical issues which were consistently addressed during the pregnancy by the Hospital and the GP missed the need to give as much attention to the needs of the unborn baby. 14 “Domestic Abuse experienced by Young People living with Alcohol Problems” – Vellerman, R et al, Child Abuse Review Nov- Dec 2008 15 “Caring for the pregnant drug user” Ford, C and Hepburn, M - 1997 33                                                                   10. Racial, Cultural, Linguistic and Religious diversity needs 10.1 The family’s background or culture did not have any bearing on how the family were dealt with, as no enquiry was made in respect of this.  None of the assessment activity addressed this issue in any detail or considered it in a way of understanding the Mother’s lifestyle and her approach to parenting.  10.2 The involvement and role of the extended family was not assessed that would have helped to understand the Mother and her children’s experiences and lifestyle.   The Half Brother appeared to be cared for by extended family members or friends fairly regularly although whether this was a cultural factor was not at all clear.  In respect of alcohol use, it was not clarified to what extent this may have been a feature within the extended family. There could be a stereotypical view from a professional perspective about family alcohol use and the role of the extended family that “ can lead to either the realities of children’s lives being ignored or to assumptions being made about the way in which the extended family will swoop in and save them if need be”16.   Overall, in this way the role of alcohol in the family’s culture needed greater understanding by professionals involved with the family, even if it was to identify how this context would make it additionally difficult for the Mother to manage her alcohol use or cease drinking all together.  11. Organisational Factors 11.1 The two services which have identified that workload or organisational issues had a direct impact on the services provided to this family, were those in relation to health visiting and also for the family services social work teams where issues of pressure of workload, training and management support have been highlighted. 11.2 In respect of health visiting, the small team which were linked with the Mother’s surgery saw their caseloads grow with the establishment of new local social housing, which generated a level of social isolation for local families.   Additionally, from 2009 there were periods of long term sick and three periods of maternity leave.   Overall, this reduction in capacity led to progressive work or targeted work not able to be prioritised or simply being unallocated.   Whilst the reorganisation of some health visitor posts gave this Surgery an increase in establishment, the new health visitor had a phased return to work and did not reach full capacity until December 2011.   This was a critical time at the closing period of the Mother’s pregnancy with the Subject Child, and as referred to earlier, the newness and lack of background knowledge possessed by this health visitor, meant that the service to the Mother and her new baby was to some extent compromised. 11.3 There were significant organisation issues which impacted on the work of family services alongside mangers identifying the constant stress of managing high numbers of referrals and some criticism locally of thresholds being too high for family services intervention.  Alongside a high number of new or inexperienced social workers, there was pressure to 16 Parental Substance Misuse and Child Welfare -  Kroll, B and Taylor, A – Jessica Kingsley 2003 34                                                             achieve Initial and Core Assessments within time scales, which meant that Core Assessments were being undertaken within one visit.  Whilst it was apparent how the organisational and workload pressures created this scenario, it would not have been possible to have completed a good quality assessment within these circumstances.   As with other services, the introduction of the new recording system  (from May 2008) generated teething problems with the system felt by practitioners and managers to be unstable, unpredictable and time consuming.  An additional difficulty was the need to be simultaneously checking and collating both paper and computer files.    11.4 No doubt these factors had considerable impact on social workers and their managers to undertake effective child care practice, and in these circumstances it could be seen how the failure to link assessment activities and build up a more coherent and clearer picture of the pattern of family functioning, was significantly compromised.  Of significance was that workers were not encouraged to undertake chronologies and the pressure was such that once checks were undertaken and a visit made, the pressure was to close the case.   There were also tensions on what could be transferred to the long term team, as these cases had to have very clear social work tasks before a transfer could be made.   Because each apparent crisis or incident of concern in this family was time limited and the Mother was quick to reassure any social worker that all was now well, then it can be seen how so many assessments were undertaken without any of them leading to more long term purposeful social work intervention. 11.5 By 2008, unqualified social workers were undertaking duty work, and Initial Assessments in respect of Children in Need were being undertaken by them.  Alongside a high number of newly qualified staff, it can be seen that no matter how committed and well intentioned the workers, that there was a greater likelihood of risk issues being missed or misinterpreted.  11.6 Pressures were clearly experienced by family services managers and supervisors and so this would inevitably have compromised their ability to provide quality supervision, although they appropriately signed off completed work or assessments.  In a less pressurised atmosphere, they may well have been more questioning of some of the quality of assessments, particularly where analysis did not always reflect the facts, and less agreement to move so quickly to deciding “no further action”. 12. Immediate or Long Term Changes  12.1 As stated previously, the MARU arrangements have been implemented recently which will help to improve communication by more day to day face to face discussions between practitioners from Police, family services and Health as well as Probation who are about to join the new initiative.  In this way some of the reliance on formal systems such as CIN meetings or CP Conferences for communication to take place, will reduce and should assist with the ability to identify concerns at an early stage.  12.2 Family services has reorganised and implemented a different model of working through the development of a more systemic way of working which is intended to create better quality practice via increased professional autonomy, presumably in a move to emulate the 35  principles proposed by Munro17.  Alongside the considerable development of Integrated Assessment Teams, which has included the need to undertake “threshold assessments”, it is anticipated that this can support families with interventions at an early stage.   Such a service could have helped to address more effectively the needs of this family, as it was the failure to provide any consistent or purposeful input in the early stages of concerns about the Mother’s alcohol misuse, which meant that safeguarding issues were never fully addressed.   Furthermore, changes within family services now ensure that all Initial and Core Assessments are undertaken by qualified social workers.  12.3 There is now a requirement for a CIN meeting to be called within the second week of a Core Assessment being undertaken, and that all relevant agencies to be involved.  Certainly if such a process had been previously in place, it would have added significantly to information sharing.  Whilst there is also now good practice guidance in respect of composing chronologies, this may need greater emphasis by operational managers to ensure that it is a consistent feature of child care cases where there are accumulated incidents and concerns.  12.4 The IMRs in respect of the Education services, including the  involvement of the Children’s Centre and Nursery, and in respect of Community Services re health, have both identified the need for improvements in communication processes.  However, whilst Education identify that improvements are needed in communication with outside agencies, Community Health Services identify that changes are needed in improvements between health visiting and community midwives.   This has been further explored in the Health Overview Report.  13. The appropriateness of actions following the death of the Subject Child 13.1 Overall, the actions undertaken following the death of the Subject Child were efficient, effective and well-coordinated between the Hospital, Police and family services.  The circumstances of the death led to the Half Brother being appropriately safeguarded, with him being placed immediately with family friends, who were provided with financial support to do so.   Although this was not a local authority foster placement, this was a family whom the Half Brother knew well, and it was carefully considered as being appropriate to his needs in the circumstances, with contact arrangements being put in place for the Mother. 13.2 The Rapid Response process was undertaken appropriately with a visit made to the maternal grandmother’s home by health and Police personnel, which provided useful contextual information in respect of the circumstances of the death.   The Mother had not wanted to return directly to her home after the death.  The Police had attended the home address prior to the Rapid Response visit and information regarding the earlier visit had been shared. 13.3 The Strategy Meeting and Sec.47 investigations were undertaken in a timely manner, leading to a CP conference being convened in respect of the Half Brother within the required 15 days.   Overall therefore the response to the Subject Child’s death and to the protection of 17 The Munro Review of Child Protection – A Child-Centred System – Eileen Munro – Dept of Education  May 2011 36                                                             the Half Brother represented a timely and well-coordinated piece of inter-agency intervention. 14. Summary  14.1 Whilst the background of domestic abuse during the early period of this SCR and the apparent continuation of the Mother’s alcohol misuse throughout much of the period, could be viewed as representing a chaotic lifestyle, in contrast the Mother generally presented well to professionals who had regular contact with her and demonstrated that her attitude to the Half Brother was appropriately caring.  In this respect therefore the family did not present as being chaotic to those who were working with her on a day to day basis.    The majority of those professionals who attended the practitioner workshop certainly echoed this view.   The experience of the Police and family services however tended to reflect a contrasting picture where concerning incidents reflected a propensity for violence in relationships as well as the continuing feature of maternal alcohol misuse.   The only occasions when these apparent different experiences of the family would come together would be when the range of assessments by family services would seek and provide information to the professionals working within health and education who had daily contact with the family.   Such opportunities however were more focussed on seeking information rather than providing it, and so in this way the day to day services were to some extent compromised by retaining an overly positive view of the family.  The only agency that had regular contact with the family and raised formal concerns was the GP practice although they appeared to experience some frustration at what they considered were ineffective responses to their concerns about parenting.  14.2 Whether the tragic death of the Subject Child could have been predicted or prevented by a different form of agency intervention is difficult to assess.   If it is argued that the Mother’s alcohol use was a factor in the death, then potentially a more consistent service to addressing any alcohol problems or to challenging her more robustly on relevant occasions, could have had an impact on reducing her later alcohol use.   However at no time was any plan put into place to address any potential alcohol problem as its extent and the impact on parenting had never been clarified or fully assessed.  There was no step-down process following the CIN meetings or case closure by family services during the period of the pregnancy, and in this way the services tended to disperse at this point.   The recent national report by the Children’s Commissioner identifies that in order to be effective in addressing parental alcohol misuse that “the links between universal /specialist services, adult/children and family services and alcohol/drug treatment services are crucial”.  However, at no time in this case was there ever a coordinated response to the family’s presenting problems in respect of maternal alcohol misuse.  14.3 Parental alcohol misuse during pregnancy is a well-recognised risk factor, and if there had been a greater focus on this as part of interventions or assessments during the ante natal stages, then this potentially could have made a difference to the eventual outcome.   The Mother was able to deny alcohol misuse and was often unchallenged about this.  There was an incident when the Mother was intoxicated and the Half Brother had fallen asleep with her 37  on a settee, and whilst he was over 4 years old at the time and did not present the same level of risks as that for a baby, nevertheless this was not robustly challenged at the time in an attempt to get the Mother to learn the lesson that this was an inappropriate and potentially dangerous way to care for a child.     14.4 However, it could not realistically be said that the circumstances of the Subject Child’s death a predictable event.   As said previously, without any real understanding by professionals of the extent of any maternal alcohol misuse problems, then such a tragic outcome was not predictable.   Better ante-natal assessment prior to the Subject Child’s birth should however have identified it as a risk factor.   The fact that the health visitor and midwife were new to the family for the period of time at the end of the pregnancy was undoubtedly a factor in this and it was very concerning that they had no background information to support their initial work with the Mother and her new baby.  14.5 The missed opportunities in this case for more purposeful interventions also reflected how valuable resources were underused and to some extent wasteful.   The paediatric assessment of the Half Brother, the consultation with the substance misuse specialist and the limited involvement of the counsellor attached to the GP surgery, all reflected appropriate interventions at the time but which ultimately failed to add to any understanding of the maternal alcohol abuse or of the impact on the Half Brother or Subject Child at that time.  14.6 It was apparent that there were some committed and useful interventions however and that the Mother accessed some of these appropriately – these included the Children’s Centre, GP, Nursery and the support and advice offered by the Primary School.   Those providing direct input to the Half Brother no doubt provided some much needed compensatory and positive experiences for him.  15. Lessons Learned  15.1 There is evidence that parental alcohol misuse is often minimized by professionals as representing less of a concern about parenting capacity than parental drug use.  Research however identifies that the experiences of children living in such households have many similarities and can experience the same levels of significant harm18.  15.2 Assessment of the extent of chronic parental alcohol misuse usually takes place when the parent is no longer intoxicated.   If any such assessment does not capture the reality of what actually occurred at the time that the parent was intoxicated, there will be the unintended potential for concerns to be downgraded and therefore any understanding of potential risks to the child, to be compromised.  18 “Silent Voices – Supporting children and young people affected by parental alcohol abuse” – The Children’s Commissioner – Adamson, J and Templeton, L – September 2012.  38                                                             15.3 For any assessment of risk to primarily rely on accounts given by the parent, without any objective evidence being sought to confirm or challenge such accounts, is likely to miss identifying the potential safeguarding risks to the children.   Overall professionals need to have “respectful uncertainty” in dealing with parents, particularly where there is known to be parental alcohol misuse  15.4 Practitioners need to be alert to parents displaying disguised compliance, and be mindful that an over optimistic view of parenting will be formed if this is not challenged.  15.5 Lack of understanding or knowledge by professionals, about a parent’s persistent or long term medical condition, will compromise their ability to work effectively with the family and in particular about understanding the meaning of that condition in terms of any impact on parenting ability.  15.6 For incidents of concern to be separately and individually addressed without any consideration of previous incidents or concerns, will mean that any patterns of parenting will be missed and the professionals could continue to respond in ways which had previously proved ineffective. The routine use of significant event chronologies which are easily accessible to the practitioner would greatly help in this respect.  15.7 The combination of maternal alcohol misuse and pregnancy must be viewed as a high risk scenario, not only to the unborn child but also to the parenting in the first six months of the child’s life.  15.8 If a professional experiences a belief or frustration that actions in response to concerns raised are not being appropriately responded to by another agency, then if these concerns are not escalated upwards to senior managers or sideways to specialist practitioners, it is possible that continued risks to children will remain unaddressed.  15.9 It is often the child’s development, behaviours and relationships with others which give indicators of difficulties within the home.   If the sources of any such developmental delays or behaviour problems are not fully understood or assessed, it may mean that problems within family functioning are not identified and consequently that risks to the children are missed by practitioners.  15.10 It is important for practitioners to understand the lived experience of the child and to gear their interventions accordingly – without this it is not possible to form a true understanding of potential safeguarding risks.  16. Recommendations Note has been taken of the recommendations contained within the IMRs and within the Health Overview Report so as these recommendations reflect other findings from the overall analysis which are not otherwise identified.   The recommendations below relate to multi-agency practice. 39  16.1 That existing multi-agency guidance for professionals working with parental alcohol misuse should be reviewed and re-launched. 16.2 That the LSCB ensures that all LSCB partner agencies conduct a single agency audit to identify the extent to which historical information is accessed and utilised to inform current assessment and practice  16.3 The LSCB provides training that meets the needs of professionals in all agencies to be able to identify and intervene effectively where parental alcohol misuse presents a risk to children and young people. 16.4 That the LSCB uses the learning from this case to remind practitioners at all levels and their managers of the following concepts required for effective safeguarding in order to address the identified shortfalls in practice in this case: • ‘respectful uncertainty’ • Professional curiosity • Disguised compliance from service users • The ‘lived’ experience of the child • Behaviour as understood in the light of child development knowledge • The need to escalate cases to address difficulties when inter agency practice is ineffective.   16.5 The LSCB should conduct a themed multi-agency review of cases in to the effectiveness of practice where parental alcohol misuse is a risk to the children in the family  16.6 That the LSCB and CDOP panel ensure that the information gathered and learning arising from the Rapid Response process is shared with operational staff as a matter of due course and urgency after a child dies  16.7 That the LSCB will monitor the progress of all agencies against the recommendations in their individual action plans.  Ron Lock 31.12.12 40  