Life-threatening injuries to a boy in August 2020. Child N fell from a second-floor window and sustained serious injuries. Learning includes: work with families should demonstrate an understanding of the impact race, culture and religion can have on parents' behaviour; agencies should obtain contact details of a parent not living in the household and should engage them in important decisions regarding their child, unless there is a reason not to do so; practitioners require the knowledge and skills to promote engagement with families who are resistant to co-operating with services offered; for children experiencing neglect there can be a range of factors which mean that incidents have some element of forewarning; the category of harm should reflect the risks to the child, which should be articulated in the child protection plan; statements for family court proceedings should articulate all the risks of harm to a child. Recommendations include: consider how agencies can develop practitioners' knowledge and skills in working with resistant families; when a section 47 enquiry is initiated all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation; undertake a review of safeguarding training to ensure that cultural awareness and sensitivity is promoted; the child protection service should undertake an audit of the categories of harm identified for children who are subject to child protection plans to ascertain if the categories reflect the identified risks.
      
    Serious Case Review No: 2022/C9604  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   1       Local Child Safeguarding Practice Review Child N      SILP Lead Reviewer: Adrienne Plunkett A Local Authority Safeguarding Board Commission Approved by the Safeguarding Board 31.5.22   2    CONTENTS:        PAGE:   1. Statutory Framework       3     2. Significant Incident Learning Process    3  3. Process for LCSPR       3  4. Family Engagement       4  5. Background information      4  6. Scoping Period        4  7. Analysis: KLOE        11  8. Good Practice identified       27  9. Key Learning        28      10. Recent Developments       30  11. Conclusion         31  12. Recommendations       32   Appendix A: References       33   3  1. Statutory Framework:  1.1. This Local Child Safeguarding Practice Review (LCSPR) was commenced in 2021 and undertaken in accordance with the guidance contained in Working Together to Safeguard Children 2018 1 which outlines reviews should be completed in a way which: ▪ Reflects the child’s perspective and family context. ▪ Is proportionate to the case under review. ▪ Focuses on potential learning. ▪ Establishes and explains the reasons why events occurred. ▪ Invites families to contribute. ▪ Fully involves practitioners.  1.2. Working Together 2018 encourages Local Safeguarding Partnerships (LSPs) to use a variety of models for undertaking LCSPRs, including the systems approach.  The Significant Incident Learning Process (SILP) is one such model. 2. Significant Incident Learning Process (SILP):   2.1. The SILP methodology reflects on multi-agency work systemically and focuses on why those involved acted in a certain way at that time. The SILP methodology adheres to the principles of: • Involvement of families • Active engagement of practitioners and frontline managers • Systems methodology • Proportionality • Learning from good practice  2.2. SILPs are characterised by practitioners, managers and Agency Report Authors coming together for a Learning Event, where the perspectives of all those involved are discussed and valued. The same group considers the draft Overview Report at a Recall Event, ensuring practitioners contribute to the key learning. 3. Process for this LCSPR:    3.1. In 2020, the authority’s Safeguarding Children Board’s Independent Chair made the decision to undertake a LCSPR in respect of Child N.  Furthermore, a decision was taken that this would be undertaken using the SILP methodology.  The Terms of Reference were prepared, and the Agency Report Authors’ Briefing held in February 2021.   3.2. The Scoping Period for the Review covers the period from when Mother and Child N moved into the local area in 2015 to N’s serious, life threatening, injuries in 2020.  1 Working Together to Safeguard Children:  A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, HM Government July 2018. 4    3.3. Two SILP Learning Events were held, one for Practitioners and one for managers, in April 2021 and the Recall Event was held in September 2021. Events were attended by practitioners, managers and Agency Report Authors from Education, nurseries and schools, NHS Foundation Trusts, Clinical Commissioning Group (CCG), GP Practice and Children’s Social Care, 3.4. An application was made to the Family Court for the Reviewer to have access to court documents and a court hearing was arranged. This led to the timescale for the review being extended. 4. Family Engagement in the LCSPR: 4.1. Both parents were informed that the LCSPR was being undertaken and that they would be invited to participate in due course.   4.2. Advice was sought from practitioners working with the family about how best to engage with the parents and obtain their views about the services offered.  Despite this advice being followed, unfortunately it has not been possible to meet with the parents and incorporate their views into the review. 5. Background Information:  5.1. N’s Mother is of Black African heritage and grew up in countries experiencing civil war and genocide. Her parents are deceased; she was cared for by an aunt and received a good education.  N’s Father is white British. The parents have never shared a home together.  5.2. N is described by practitioners as a bright, happy and affectionate child, ’a little star’, who loves buses and trains.  N’s verbal communication skills are limited, but can understand non-verbal cues, and has the ability to learn, being fascinated by numbers and enjoying phonics and songs.  N responds well to the structure and routine at school.   5.3. The Scoping Period evidences long-term concerns regarding the neglect of N, but practitioners acknowledge Mother and N’s close relationship. 6. Scoping Period: 6.1. Mother and N moved to the local area in December 2015, to be nearer Father. At the age of two and a half years, N commenced at Nursery 1, where attendance was irregular for 10 months. Mother’s attitude towards the nursery staff was inconsistent; sometimes co-operative and at others irritable and hard to engage.  Some days she was happy to leave N but on other days found this difficult, which affected N’s behaviour.  N left the nursery as Mother chose to change provision.  6.2. The Health Visitor identified concerns about N’s development and behaviour early in 2016. N was referred to the Child Development Centre (CDC) and in November 2016, at the age of three years, was diagnosed with autism spectrum disorder (ASD) by the multi-disciplinary Team Around the Child (TAC), including the pre-school provision, Speech and Language Team (SALT) and the Community Paediatrician.  5  Mother and N attended the meeting, and it was noted that she had some difficulty accepting the diagnosis and was not receptive to the support services offered.  6.3. Follow up support was offered by the Community Paediatrician at CDC, SALT and the National Autistic Society, with a review planned after 6 months.  Mother and N sporadically attended the support sessions at the CDC and three SALT post diagnosis group meetings.  The Health Visitor was informed of the diagnosis. 6.4. The CDC 6 months review did not take place and, although there was considerable communication between professionals, a multi-agency plan was not put in place.   6.5. Mother’s lack of acceptance of the support services offered impacted significantly on N as a child with special needs, in the development of key skills, notably communication and language.  Agencies involved with the family are of the view that Mother was looking for a ‘cure’ for N and she was disappointed when practitioners could not offer this which affected her engagement. The family were isolated, without the support of family or friends 6.6. In March 2017 Mother contacted the GP surgery as she was having difficulty managing N’s behaviour.  An appointment was arranged with the GP, who suggested further input from Paediatrics may be helpful.   Mother became angry and left the consultation. Following further discussion, it was agreed Mother would follow up with N’s school. 6.7. In May 2017, N commenced at Nursery 2, with Mother hoping that the new provision would ‘cure’ him.  Mother’s approach towards the nursery staff was again inconsistent and she did not engage with professional advice. refusing to give agreement to SALT involvement.   N left 9 months later due to the non-payment of fees.  • Child in Need (CIN) Plan:  6.8. In June 2017, the family were evicted due to rent arrears and deemed to be intentionally homeless. There were reports from neighbours of N being left unattended, ‘hanging out’ of windows and running into the road. A single assessment was undertaken by Children’s Social Care and a CIN Plan recommended.  Mother did not engage, and the plan ceased in October 2017.  However, further concerns were raised by Housing, including N being locked in a room whilst Mother went shopping/into communal areas causing distress, N being disruptive throughout the night and several moves of B & B accommodation due to the complaints.  6.9. In October 2017, the Police and Fire Service received a report that Mother had forgotten her key and N was locked in their room.  The Fire Service assisted with unlocking the door.  The Police dispatched a unit one hour after the report but did not check on N’s welfare. Given the concern that such incidents were escalating, a Strategy Meeting was held between CSC and the Police.  The decision was that CSC should undertake single agency Section 47 enquiries; the outcome was that Mother agreed to engage with the CIN Plan. 6  6.10. Further unsuccessful attempts were made to engage Mother in the CIN Plan.  Using the Signs of Safety Scoring, the level of risk was assessed as 3 – 5. 2  The safety scale 0 indicates the child is highly likely to be harmed and 10 indicates there is sufficient safety to cease involvement. The CDC, SALT, OT and Health Visitor were not aware of the CIN Plan until informed by the Family Intervention Team in February 2018, neither were they informed the family had been evicted and were living in B & B accommodation.  • Child Protection Planning:  6.11. The CDC Manager referred the family to CSC in February 2018; concerns included the Education, Health and Care Plan (EHCP) not progressing, N not attending nursery or receiving SALT, N presenting as anxious and fretful and showing signs of developmental delay.  Mother was not engaging with the services offered, and concerns were expressed about her mental health, parenting capacity and lack of a support network. The family were experiencing frequent house moves and following another eviction, had been placed in a Travelodge. CSC took the view that the threshold of significant harm 3 to trigger child protection procedures was not met.   6.12. However, due to continuing concerns, following a CIN review in March 2018 when there was a ‘recalibration’ of approach to better reflect the level of need, a single agency Section 47 investigation was agreed. This was undertaken by a specialist Social Worker from children’s social care (CSC) who recommended an Initial Child Protection Conference (ICPC), held in April 2018.  Both parents attended the ICPC.  The unanimous decision was that N was at risk of significant harm and required a Child Protection Plan (CPP) in the category of neglect. Mother had not engaged with services (SALT, CDC, Nursery) and the family were experiencing frequent accommodation moves.  There was discussion as to whether the difficulties of engaging Mother were related to possible ASD.  The CPP included an assessment of Mother’s cognitive abilities, support with housing, an EHCP and assessment by SALT. The Pre-Proceedings Public Law Outline Process 4 was initiated, and the Local Authority commenced care proceedings. 6.13. In May 2018 Police reported to CSC that N had been found alone at a railway station, nearly one mile from home, having crossed a busy road and before Mother had reported N missing (after approx. 45 minutes).  N was found ‘by chance’ by a Police Officer leaving the Railway Station; the Officer reported to the Supervisor and discussed assuming Police Powers of Protection.  When Mother came to collect N, she  2 Signs of Safety: The Signs of Safety approach is a relationship-grounded, safety-organised approach to child protection practice, created by researching what works for professionals and families in building meaningful safety for vulnerable and at-risk children. https://www.signsofsafety.net/ 3 Significant Harm: “Harm” is the “ill treatment or the impairment of the health or development of the child”, Section 31, Children Act 1989 (England and Wales).  Harm can be determined “significant” by “comparing a child’s health and development with what might be reasonably expected of a similar child”. 4 The Pre-Proceedings Public Law Outline (PLO) process takes place when the S31 Children Act 1989 Threshold Criteria are met and the Local Authority is concerned about a child’s wellbeing and unless positive steps are taken to address and alleviate those concerns, the Local Authority may consider making an application to the Court. The PLO process is therefore the last opportunity for parents to make improvements to their parenting before care proceedings are issued. Family Law Group, July 2020. 7  explained she had left N in the living room whilst in the kitchen.  She denied any involvement with CSC and Police records were not checked, which would have provided the information that N was subject to a Child Protection Plan.  The Police Officer did not confirm the details or visit the family home to ascertain further information about N’s welfare and full details of the incident were not recorded. (Police: Single Agency Learning Point) 6.14. The Local Authority applied for an Interim Care Order; this was granted, and N and Mother were placed in an out of area foster placement.  The CPP ceased in June 2018 as N was a Child Looked After (CLA) and the reviewing process then became the planning mechanism.   • Child Looked After (CLA):  6.15. There were concerns at the first placement about the lack of routine and boundaries for N, as well as Mother’s mental health.  Her behaviour towards the foster carer became suspicious and threatening and the placement was considered no longer viable. Following an Emergency Planning Meeting in July 2018, when the legal advice to the Local Authority was that there was insufficient evidence to separate N and his Mother, they moved to a residential placement in London. 6.16. There were early concerns in the second placement about the lack of boundaries for N, road safety and Mother undoing the safety catches on the windows.  Mother appeared to ‘baby’ N and was dismissive of support. At the CLA Review in October 2018 new safety concerns from the placement were noted and a ‘danger statement’ was issued as Mother had again unlocked the window restrictors.  The CLA Review reinforced the need for close supervision. 6.17. In November 2018 N commenced at School 1 where he attended regularly for six months whist in the residential placement.  An EHCP was in place and support was provided by the SENCO and Headteacher.  N had 1:1 support and, though non-verbal, communicated using gestures. The Educational Psychologist visited the school on three occasions to complete an assessment, but each time N was not in school, so tried to complete the assessment without seeing the child. However, dissatisfied with this, returned for a fourth visit and was able to observe N.  Whilst regularly attending School 1, the Social Worker noted that N ‘blossomed’, reading, and playing with other children.  There were concerns for Mother’s mental wellbeing as she presented as suspicious and critical of the school.  6.18. Following a report of N being left unattended in the family’s room for thirty minutes, a Strategy Meeting was held in February 2019 and Section 47 enquiries were undertaken by the Local Authority in London.  There was a further incident when N ran out of the property and along the street before being stopped by Mother.  It was decided that the ICO negated the need for an ICPC.      8  • Return to the community: Placement of Child with Parents Regulations  6.19. At the court hearing in April 2019, the court did not agree that the test for the interim separation 5 of N was met and the family moved back to the Local Authority area into temporary accommodation under the Placement with Parent Regulations 6.  Extensive supervision was arranged by a local children’s home, the social worker and agency staff.  Mother did not consent to the involvement of SALT and OT for N.  6.20. N received tuition from the Virtual School and commenced at School 2 at the end of July 2019.  A large number of schools were considered by Mother before a decision was reached.  At School 2 N received 1:1 support and supervision. Mother was anxious about leaving N and worried about removal by the Local Authority. Despite continued attempts to gain consent for SALT, this was not given. Father was invited into school in September 2019 to support N in school, but N did not attend that day.   N did not attend School 2 for more than four consecutive days. 6.21. School 2 describe N as a happy child with ‘huge potential’.  At the age of 5 years, N’s language and communication skills were those of a much younger child but N understood non-verbal cues and used hand signals. Mother found N’s progress difficult to accept.  She did attend a local parenting course for children with autism. 6.22. N made progress with counting and phonics, evidencing his potential.  School staff were confident that with regular attendance N would meet milestones.  School continued to try and progress referrals to SALT and CDC, but Mother declined consent. • Final Family Court Hearing:  6.23. At the Final Hearing in August 2019, the Local Authority requested a Care Order and a Placement Order, with a plan to place N for adoption.  The Local Authority’s view was that Mother would be unable to support any other permanency arrangements, e.g., with contact. This plan was supported by the Independent Reviewing Officer (IRO) and the Children’s Guardian and had been supported by the Independent Social Worker until the day of the hearing.  It was opposed by the expert Psychologist who had been jointly instructed by the parties.  6.24. The threshold of significant harm was met, but the Local Authority’s application for Care and Placement Orders was dismissed by the Judge and no orders were granted.  The IRO recommended the Local Authority appeal and the CLA Nurse and SALT raised concerns about whether Mother could safely meet N’s long-term needs. The Care Plan did not have a contingency plan should the Local Authority’s recommendation not be accepted by the court. (Child Protection Conference Team Recommendation)   5 Interim removal of children from their parents: In approaching the issue of interim removal, the court must consider whether the risk to the child's safety demands immediate separation (per Thorpe LJ in Re H (A Child) (Interim Care Order) [2003] 1 FCR 35) and is such an action proportionate (Article 8, Human Rights Act). 6 Placement of children with Parents etc Regulations 1991 provide for the accommodation of children in the care of a local authority with a parent, person who is not a parent but has parental responsibility. The Children Act 1989.  Amended by Care Planning, Placement and Case Review Regulations 2010  9  6.25. The advice to the Local Authority was that there were no legal grounds to appeal the decision, as due process had been followed.  6.26. On the final day of the hearing N was seen to run into the road by a member of CSC staff. A Strategy Meeting was held, and the decision taken that there would be no further action in view of the outcome of the court proceedings.  6.27. In October 2019 CSC referred Mother to the Common Point of Entry, Mental Health Service, due to concerns about paranoid thoughts. The Crisis Team rated the referral red, and a joint visit was undertaken by the Social Worker and the Mental Health Worker. (Good practice) The assessment concluded there was no evidence of mental disorder or impairment, and she was discharged to the care of the GP. 6.28. In mid-October, a month after N commenced fulltime at School 2, after many attempts to engage Mother and improve N’s school attendance, a referral was made to the Education Welfare Service (EWS) due to poor school attendance (40%). This was followed, after 6 weeks of chronic school attendance, by a Child Missing Education (CME) 7 referral in December. School 2 were in frequent contact with the Education Welfare Officer and when necessary, made referrals to Children’s Social Care. 6.29. In October 2019, the duty to accommodation the family was accepted under the homelessness legislation, and they were offered a two-bedroom second floor flat which Mother initially refused.  The Housing Department sought advice from an organisation providing housing medical advice as to the flat’s suitability, which was also assessed by the Social Worker, Team Manager, Housing Officer and Occupational Therapist prior to Mother accepting the tenancy in November. Safety modifications were agreed, i.e., window restrictors, removal of bath glass panel, securing boiler cupboard and fuse box, and completed. The Contractor and Housing Department ensured that the window restrictors were securely in place.  6.30. Housing’s surveyor undertook an inspection of the property in November 2019.  He identified one of the window restrictors in the living room had become detached and returned a few days later with the contractor to refit this and check all the others.  In addition, a slide bolt was fitted to the front door, out of N’s reach.  There was concern about how the window restrictor had become detached, as this would be ‘virtually impossible’. Mother told the surveyor that the social worker had pulled it off. The surveyor was concerned about Mother’s lack of coherence and reported this to the Housing Department which triggered a ‘safeguarding concern’ to CSC.  The contractor was confident this would not recur.  • Child Protection Planning:  6.31. Following a Strategy Meeting in November 2019, an ICPC was held in December 2019 due to concerns about N’s poor school attendance (30%), the lack of consent to SALT and Mother’s mental health.  The decision was that N was at risk of significant harm and required a CPP in the category of emotional abuse.  The plan included: N to attend school, a health review by the School Nursing Team, Mother to seek help with her mental health needs and to engage with community resources.  There was  7 Child Missing Education: Statutory Guidance for local authorities: September 2016. DFE 2016.  10  also a decision to seek legal advice and consider initiating the Pre-Proceedings Public Law Outline Process for the second time.  The decision to use the category of harm of emotional abuse, rather than neglect, represented a shift in safeguarding priorities. N’s lack of boundaries and supervision and risks to his physical safety, which had consistently been previous concerns, were not referenced in the plan.  (Learning Point) 6.32. Mother contacted the GP Practice three times between December 2019 and June 2020 requesting support with N’s sleeping, eating, nocturnal enuresis. Onward referrals were made with her consent. 6.33. In the three months before the RCPC in March 2020 concerns continued about N’s safety and wellbeing.  Mother had not consented to the health review by the school nursing service, poor school attendance continued and, following 6 weeks of chronic non-attendance, a CME referral had been made and a Fixed Penalty Notice (FPN) issued. A home visit by the EWS to discuss the FPN ended due to Mother’s ‘intimidating verbal response’.  6.34. Social Worker 2 had seen N run across the windowsills and finger marks were noted on the windows.  Whilst the restrictor on the living room window had been repaired earlier in November, by mid-November another of the restrictors was observed by the social worker to be broken. This was reported to Housing, but there is no evidence that any action was taken in response. In January N was observed to run into the road, whilst in Mother’s care, causing a car to swerve. 6.35. Monitoring N’s safety at home and outside was not a part of the CPP.  Additionally, whilst there is an expectation that children’s bedrooms should be seen during child protection visits by the Social Worker, N’s bedroom was not seen as Mother denied access.  6.36. At the RCPC in March 2020 it was agreed that the CPP should continue; the category of harm was changed to neglect, but the CPP, i.e., actions and timescales, was unchanged. PLO had been initiated and, after three cancelled meetings, the Legal Planning Meeting had been held in mid-February. 6.37. Early in March EWS Officers made an unannounced home visit, they could hear N in a bedroom but did not see him.  (Recommendation for the Education Welfare Service) 6.38. When schools closed due to the Pandemic, due to being the subject of a CPP, N was offered a school place and attended occasionally. Mother explained that there was no requirement for N to attend.  School and EWO maintained contact and tried to encourage N’s attendance. CSC prioritised cases according to a traffic light system; N was given the highest priority and rated as red which meant home visits continued. The family were given the same priority by the Foundation Trust.  6.39. Early in June 2020, School 2’s Family Support Advisor (FSA) contacted Mother to encourage N’s attendance at school.  Mother did not want N to attend and was aware she would not face prosecution.  The same day Mother made a request for a change of school, stating that N was not happy. This request was accepted without 11  any communication with the Social Worker or members of the Core Group, and a place was allocated at School 3.   (Learning Point) 6.40. In July 2020 there was a further referral to Mental Health Service by the Social Worker.  Mother was presenting as paranoid, worried she was being watched by Eastern European men. The referral was rated amber; Mother was contacted by the Mental Health Service but did not respond and was discharged.  6.41. The EWO maintained weekly telephone contact with Mother, who shared that N had got into the bath twice fully dressed and turned on the taps. The EWO advised a lock should be fitted on the bathroom door and informed the Social Worker, but there is no evidence any action was taken to safeguard SC.  Further attempts to gain Mother’s consent to SALT, through the EWO, were unsuccessful. • Legal Proceedings:  6.42. As the Child Protection Plan was not progressing, the Local Authority again initiated care proceedings in June 2020, and applied for an ICO with interim separation and placement in foster care. Mother did not attend the Case Management Hearings in July and August or instruct a solicitor.  The Children’s Guardian and the Judge considered that the test for interim separation was not met, and the case was adjourned for assessments until October 2020.  • Incident August 2020:  6.43. Tragically, whilst unsupervised, N fell from a second-floor bedroom window and sustained serious, potentially life threatening, injuries. A passer-by called emergency services.  The Local Authority obtained an ICO, the test for interim separation was met and, following discharge from hospital, N was placed in foster care and has made good progress. A criminal investigation was commenced. Concerns have subsequently increased about mother’s mental health needs.   7. Key Lines of Enquiry (KLOE) 7.1. Is there evidence of consistent child-centred practice and consideration of the voice of the child within risk assessments and the crucial decision-making and planning processes, and was consideration given to promoting the welfare and safeguarding a child with a disability?    ‘This child centred approach is fundamental to safeguarding and promoting the welfare of every child. A child centred approach means keeping the child in focus when making decisions about their lives and working in partnership with them and their families.’ 8  7.1.1. The Agency Reports and discussions at the Practitioner and Manager SILP Learning Events evidence that practitioners kept N very much at the forefront of their thinking and interventions with the family. Practitioners from Early Years provision, Schools, SALT, Educational Psychology and CSC spoke of N with understanding,  8 Working Together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children.  HMG 2018. 12  knowledge, concern and warmth.  They were distressed by N’s fall and the injuries sustained, having felt that they had strived to prevent such a serious event.   7.1.2. Practitioners recognised that Mother and N had a close attachment and worked to maintain this relationship.  The concerns were that Mother was denying N access to schooling and the services essential to support the development of abilities and skills for a child with a disability.   7.1.3. There was a good understanding of N’s needs as a child with a disability and practitioners worked hard to offer the appropriate services to promote development and to support Mother in meeting these needs. The need for stimulation, play and supervision to promote N’s development and ensure safety were recognised. The services recommended by the Specialist Team (CSC), were appropriate for a child with special needs, e.g., play centre and support groups.   7.1.4. The CCG Agency Report Author notes that the GPs were child centred and recognised N’s individual needs in the context of the diagnosis.  Appointments were routinely offered and GP records evidence attention to N’s presentation, e.g., appearance, behaviour and interaction with Mother.     7.1.5. Nursery 1 promptly identified N’s developmental delay, raised this with the CDC and contributed to the multi-agency assessment. The Education Psychologist was persistent in attempts to see N whilst undertaking the assessment and at the fourth attempt was successful. The Special Educational Needs Service encouraged mother to visit a special school for N, as this provision may be most suitable. School 1 focussed on developing N’s life skills, e.g., toilet training. When N commenced at School 2, Mother was concerned that N did not want to attend and would be upset when she left. School staff worked hard to provide evidence that N was settled, and suggested Mother come to school and reassure herself, but she declined.   7.1.6. The SALT assessed N as having ‘limited functional language’ and wanted to support the development of N’s social and communication skills, with strategies and the utilisation of aids, which would also promote inclusion.  SALT was keen for sessions to be held in N’s home environment, but Mother wanted them outside the home.  She tended to focus on N’s speech development, did not recognise the wider need to promote communication skills and was dismissive of aids and strategies.  There appeared to be a change in Mother’s attitude towards speech therapy; prior to the move from the Local Authority area she wanted more speech therapy sessions but following their return would not consent to the service.    7.1.7. Health services encouraged sessions at educational settings to promote a co-ordinated approach to N’s needs, with workers present as well as Mother.  They were aware the impact of not having a secure home and not attending nursery/school regularly would have on N as a child with a disability, exacerbated by the family’s isolation and limited social support.    7.1.8. The Housing Provider paid considerable attention to N’s safety when a property was allocated to the family.  There was a joint assessment by Housing, CSC and OT as to the suitability of the property and Housing were advised by an independent medical organisation.  The property was surveyed carefully, and steps were taken to make it safe for N, e.g., window restrictors, lock on front door.  This was followed up by 13  the surveyor undertaking a property check in November 2019, which identified that a window restrictor had been damaged.    7.1.9. The CPP in April 2019 did not reference that N had a diagnosis of ASD and the long-term impact of neglect on a child with special needs. However, the CPP in December 2019 was more explicit, referring to N’s special needs and the concerns about Mother’s ability to understand and meet these needs. The Review and Planning Agency Report notes that N’s voice was heard through practitioners’ observations and interactions with N. The Social Worker’s descriptions of N were well observed; she was able to state N’s preferences and interests and recognised the affection shown towards mother. N’s special needs were an important factor in determining the level of risk as high and the decision that the CPP should continue.   7.1.10. In summary, there is good evidence of child-centred practice and practitioners demonstrated an understanding of the heightened risks posed by neglect for a child with a disability   7.2. What was practitioners’ understanding of the role of the father in family life and of his relationship with N and of what part he might play in promoting/securing N’s wellbeing?  Did managers and practitioners demonstrate an awareness of the concern nationally about agencies’ lack of engagement with fathers?  Has any training been provided for staff regarding this?  7.2.1. For some time, concern about agencies’ lack of engagement with children’s fathers and the focus on mothers has been highlighted in research and reviews of serious case reviews.  This equally applies to a parent with parental responsibility not living in the household with the child and to significant others, e.g., wider family members.  7.2.2. It is understood that N’s parents’ relationship was short-term, and they had never shared a home together.  The Health Visiting records note that when N and Mother moved into the area Father had a ‘significant role in N’s life’, with contact taking place every weekend.  However, it appears that this pattern did not continue, with contact becoming more sporadic. None of the practitioners observed N with Father.   7.2.3. Records indicate that Father’s view changed during the Scoping Period, initially believing that Mother should be supported to care for N, but in the second set of family court proceedings he did not consider she could safely parent N. On occasions Father expressed a wish to be considered as a carer but subsequently withdrew the offers.  7.2.4. The overall picture is that most of the Health and Education agencies, apart from School 2, had not requested or recorded Father’s details and made little or no attempt to involve him in their work with N and Mother.  They were not aware if he held parental responsibility. There is no evidence that he was involved in the development of the Education, Health and Care Plan or included in any meetings outside of those arranged by CSC.  (Learning Point)   7.2.5. Health agencies:  The Foundation Trust has little information regarding Father. No information has been provided as to whether he was invited to the Trust appointments, e.g., multi-disciplinary meeting to share the diagnosis of ASD, but he 14  did not attend any.  His involvement was not considered when there were difficulties with gaining consent to SALT/OT involvement. Could Father have given consent for this? The GP records did not contain details of N’s Father; these were not recorded in the ante or post-natal records.  (Single agency recommendation: Clinical Commissioning Group)   7.2.6. Education:  Records evidence there was little involvement with Father.  The exception being School 2 which contacted father when there were concerns about N’s attendance and difficulties engaging with Mother.  He was invited to the school and did so on one occasion but unfortunately N was not in school that day.  The School understood that whilst father wanted to be part of N’s life, this was difficult due to the nature of the parental relationship. Requests for school placements were made solely by Mother, notably the change from School 2 to School 3 which would have had a detrimental impact on N.  Despite the Education Welfare Service being very concerned about N’s school attendance, the Service did not contact Father. This suggests that consideration was not given as to whether Father or other members of the paternal family might be able to support N’s school attendance. Hence this was potentially a missed opportunity.  7.2.7. Children’s Social Care:  There is evidence that the Social Worker endeavoured to maintain contact with Father and keep him informed of developments. He was invited to participate in the Child Protection and CLA Planning and Review processes and attended some of these meetings.  Greater engagement by Father might have identified other family members who could have offered N support and protection.   7.2.8. In summary, agencies’ lack of involvement with Father, particularly in the early stages, indicates a lack of consideration of his role in N’s life and the support and protection he and his family, e.g., a paternal grandparent, may have been able to offer N.  Does this attitude devalue the role of fathers (and parents not living in the household)? What about his rights, given he had parent responsibility for N, e.g., did he have the right to know about the action being taken by the EWS?   7.2.9. The First Annual Report of The Child Safeguarding Practice Review Panel,9 highlighted the continued concern about the lack of information regarding fathers, noting that the ‘primary focus of health professionals and social workers continues to be on the need, circumstances and perspectives of the mother’. The Panel is concerned that ‘such a lack of curiosity in fathers and partners not only leaves women and children vulnerable, it can also leave fathers feeling alienated and forgotten and their role in bringing up the children dismissed’.  It argues that services need to find ways to become more male friendly to encourage the involvements of men in the lives of their children.  This finding has resonance for this LCSPR, as there were missed opportunities to engage Father in working alongside services in meeting N’s needs. This approach also applies to any parent with parental responsibility not living with the child and to significant others in the child’s life, e.g., grandparents, aunts and uncles.        9The Child Safeguarding Practice Review Panel Annual Report 2018 to 2019:  Patterns in practice, key messages and 2020 work programme.  15   7.3. What understanding was achieved of the reasons for mother’s rejection of professional opinion and of services to promote N’s wellbeing (including the impact of culture, ethnicity and her lived experience) and what action was taken to promote her engagement? Was this identified as a risk factor for N?  7.3.1. It is apparent from Agency Reports and discussions at the Practitioner and Manager SILP Learning Events that Mother was a complex personality, mistrustful of professionals, fearful of losing her son, and there were challenges for practitioners in engaging with her.  On occasions Mother would ask for help in managing N’s needs and behaviour but either decline services when offered, e.g., GP’s referral to Paediatric Dietitian, or only be prepared to accept services on certain conditions, e.g., SALT.   7.3.2. Mother’s behaviour towards professional staff was inconsistent and at times could be confrontational and intimidating. Social Worker 2 received a hostile response from Mother when she asked to see the bedrooms and similarly the Education Welfare Officer when she made a home visit to discuss the fixed penalty notice. Evidence would indicate that this resistance to professional engagement increased after the outcome of the first set of family court proceedings.  It is noted that local procedures do not contain guidance for Working with Resistant Families, as other Safeguarding Partnerships have, and this would be helpful for practitioners. (Recommendation 1)  7.3.3. Mother is Black African and was cared for by a relative after the deaths of her parents.  Despite growing up in a country experiencing a violent civil war, Mother has told practitioners that her childhood was happy, and her family were unaffected. The family are believed to be of some social standing and Mother received a good education. Mother has no family in UK. She is described by Health professionals as a ‘proud and private woman’. Despite attempts to do so, practitioners, including the Children’s Guardian, have been unable to explore Mother’s background in any depth, but it is known that for many people whose countries experienced genocide there has been a long-term impact with some experiencing mental health difficulties, including post-traumatic stress disorder.   7.3.4. Discussion at the Learning Events suggested that Mother had certain attitudes and values that presented challenges in securing services.  There are indications that she preferred to deal with people with some status, e.g., Headteacher at School 1, GP.  Also, that she did not treat practitioners of different ethnicities in the same way, e.g., not accepting services from Asian and Italian staff.  This created challenges in building working relationships, but the CSC Report Author suggested these were not explored.  7.3.5. It is evident that during the period under review, a number of practitioners were concerned about Mother’s mental health.  Two assessments were undertaken by mental health services, due to her paranoid thoughts.  These concluded that Mother did not have a diagnosable psychiatric condition, but there were indications that her mental health was fragile at times.  The Independent Reviewing Officer and Children’s Guardian recognised the need for a psychiatric assessment in the care proceedings.  This assessment similarly concluded that Mother was not suffering with a depressive or other mental illness, nor did she have a personality disorder.  16   7.3.6. Mother had difficulty understanding and accepting N’s diagnosis of ASD and practitioners are of the view that she hoped N would be ‘cured’.  It is evident that following the diagnosis, a considerable amount of support and specialist services were offered to N and Mother by the CDC, SALT, nurseries and CSC.  Some of this she engaged with, however, it was difficult to gain her sustained co-operation.  The underlying reason for this appears to be a reluctance to accept the diagnosis and it is not clear from the reports and discussions what actions were taken by practitioners to understand the reasons behind this reluctance and to encourage Mother’s understanding and acceptance.   7.3.7. There are two particular areas for reflection and learning.  Firstly, whilst there was a lot of professional activity and inter-agency communication, there is a question about whether this was effectively planned and co-ordinated.  It was planned to hold a review meeting six months after the diagnosis in October 2017, but this did not take place and there were no further multi-disciplinary meetings arranged by health agencies.  This would have provided the opportunity to co-ordinate the activities of the range of health professionals and to consider how best to engage with Mother and encourage her understanding.  Although the Paediatrician at the CDC was the lead professional, a ‘key worker’ was not identified who could have taken the lead in building a relationship with N and Mother.  It is understood that in similar circumstances the CDC would now convene multi-disciplinary meetings to discuss any difficulties in engaging with a family and what action could be taken.  (Learning Point)    7.3.8. Practitioners from health agencies and N’s nursery were not informed of or engaged in the Child in Need plan in 2017. Hence, this was another missed opportunity to coordinate the work of the large number of practitioners working with N and Mother, even if she had declined to engage in this. The lack of co-ordination of Child in Need plans for children with disabilities was identified in Ofsted’s Thematic Inspection, highlighting that many CIN plans were not detailed or focused on outcomes and reviews did not always include all professionals working with the children. 10  (Learning Point)  7.3.9. Secondly, there is limited evidence that Mother’s ethnicity and culture were considered in understanding her response to N’s ASD diagnosis, hence practice lacked cultural awareness and sensitivity. There is a lack of evidence that Mother’s background was considered in the support offered following diagnosis, which could be seen as a crucial time for the family. The Practice Guidance, Safeguarding Disabled Children, 11 highlights the potential for double discrimination and that children with a disability from Black and minority ethnic groups can receive services that are ‘not sensitive to their culture and language or relevant to their needs’. This lack of awareness was mirrored in the Agency Reports where, despite this aspect being included in the KLOE, it was not addressed.  The Education Report Author recommends that the impact of a family’s ethnicity and culture should be addressed in safeguarding training and clinical supervision. (Education Single Agency Recommendation)    10 Protecting disabled children: Thematic Inspection.  Ofsted 2012. 11 Safeguarding disabled children: Practice Guidance.  DCSF 2009. 17  7.3.10. It should be noted that The Children’s Specialist Support Team did recognise the impact of Mother’s ethnicity and culture and allocated an experienced, skilled, French speaking Social Worker to work with the family, evidencing an attempt to reach out to Mother and put her more at ease. A Black social work student also supported the work.  The Social Worker attempted to discuss the cultural aspects but had difficulty in establishing a dialogue with Mother.  There is a view that this may have been due to underlying psychological issues.  7.3.11. An acknowledgment of the need for a further specialist assessment to understand the barriers to Mother’s engagement and her dismissal of professional opinions was noted at the Child Protection Conferences. The Child Protection and Review Agency Report Author highlights the need for practitioners and managers to routinely consider the impact of culture and ethnicity within assessments and planning. (Recommendation 3)  7.3.12. There is a body of literature that references the challenges for parents of African origin in accepting the diagnosis of ASD and that their child has special needs. Involving African families in the education of their autistic children, published by The National Autistic Society (NAS), 12 highlights the need to be aware of cultural differences in working in partnership with parents.  The paper suggests that there remains a stigma attached to having a child with autism within African families, some may believe that autism is a result of adultery or witchcraft.  Parents can fear the label and family and friends knowing that their child has autism. The NAS recommends that if professionals show some understanding of the family’s culture, parents will respond positively and feel more comfortable to work in partnership.    7.3.13. Autism in Black, Asian and Minority Ethnic Communities, the Report on The First Autism Voice UK Symposium 13 highlights that culture plays an important role in how people view autism and recommends that service providers need to broaden the support menu currently available to include a culturally sensitive approach to diagnosis, family-specific care and support services. At the Learning Event the Foundation Trust’s Safeguarding Lead noted that there is no word for autism in many languages spoken within the BAME community and parents might well not understand the nature of autism.  (Learning Point and recommendation)  7.3.14. It is difficult to know whether a more co-ordinated approach to supporting the family and providing services to N, combined with increased cultural awareness, would have made a difference to Mother’s engagement with services, particularly in view of what appears to be her fragile mental health, but certainly there are important lessons here for working sensitively with BAME families from the point of diagnosis of a child’s special needs/a disability.    7.3.15. An additional factor to consider in respect of Mother’s engagement with agencies is the outcome of the family court proceedings in August 2019. No orders were made, and Mother had agreed to co-operate with a Child in Need Plan.  However, there is no evidence that she did so and by December 2019 N was again the subject of a Child Protection Plan.    12Bankole, Olatokunbo, Involving African families in the education of their autistic children, National Autistic Society, 4 April 2016. 13Autism in Black, Asian and Minority Ethnic Communities: A Report on The First Autism Voice UK Symposium. 2020.  18   7.3.16. Throughout agencies engagement with the family, there had been difficulties gaining Mother’s consistent co-operation and concerns had been escalated appropriately through Child in Need and Child Protection Plans to family court proceedings. Discussions at the Learning and Recall Events indicated that post-proceedings practitioners felt undermined, lacking in authority, and were at a loss as to how best to work effectively with the family to safeguard N.    7.4. What impact did Ms K’s lack of engagement have on practitioners and on the effectiveness of the safeguarding network?   7.4.1. Despite the challenges for practitioners working with the family, it is evident that many made real efforts to work together and engage with Mother, e.g., School 2, the Social Worker and Education Welfare Officer.  They recognised the adverse impact of her lack of engagement on N as a child with special needs and on his global development. There is a view that Mother’s non-engagement increased on the family’s return to the local area in 2019 and following the family court hearing.  This was recognised as a risk factor in the return to an ICPC in December 2019.    7.4.2. The Education and Children’s Support Services Report Author notes that there was a consistent theme across provisions of N’s Mother being ‘defensive and suspicious’ towards staff, of expressing the need for help, but refusing this when arrangements were made.  Mother appeared to be worried that professionals would take her son away and hence kept him away from professional sight.   7.4.3. SALT was persistent in attempts to gain mother’s consent to a service for N, sought advice from the Safeguarding Team and shared the information at the Strategy Meeting.    7.4.4. The nurseries and schools worked hard to find ways to engage with Mother. School 1 supported Mother to encourage N’s attendance, which led to good progress, e.g., with toilet training, widening diet, and academically with numbers and phonics. The school was confident that this good progress would have continued if N’s attendance had been regular. 7.4.5. The Educational Welfare Officer had weekly telephone contact during the pandemic to try and encourage N’s school attendance, as did School 2’s Family Support Worker. However, Mother was angered by this contact and as a result requested a change of school.  This was agreed with the Special Needs Officer without consultation with other agencies and without consideration of the impact of a further change, to a third school, on a young child diagnosed with ASD for whom this would be difficult and may well have hindered any progress made.    7.4.6. During the initial child protection proceedings and the care proceedings the allocated Social Worker specialised in working with children with disabilities and their families. The Social Worker was experienced in communicating with children and was French speaking.  There is evidence that the Social Worker persisted in trying to establish an effective relationship with Mother and support her in understanding and meeting N’s needs.  This was recognised in the Family Court Judgement, which noted the obvious commitment of the family’s Social Worker and that she had exhausted all her skills in trying to engage with Mother,  19   7.4.7. The CSC Report Author highlighted that Mother’s lack of engagement left workers feeling ‘frustrated and drained’ whilst trying to manage what was perceived as a high-risk case. Practitioners ‘knew something was going to happen’. This was particularly noticeable during the period when N was the subject of an Interim Care Order and placed with Mother under Placement with Parent Regulations with intensive supervision.  There is evidence that the impact on practitioners was recognised and the CSC put support processes in place with weekly Team Briefings to update the Team and ensure that both practical and moral support was available.  The Head of Service and Assistant Director were well informed.   7.4.8. This professional fatigue was recognised by the LCSPR Panel, highlighting the importance of regular, reflective, safeguarding supervision and the value of multi-agency group supervision in such cases. (Learning point)  7.4.9. The CAFCASS Children’s Guardian notes the significant efforts that practitioners made at various stages during the care proceedings to work collaboratively with mother, e.g., at the residential placement.  There would be ‘brief positive changes by mother’ and investment in care plans but these were short-lived.  7.4.10. There is also evidence that Mother’s hostility led workers to not pursue matters, including those relating to risk to N.  The EWO felt threatened on the visit to discuss the fixed penalty notice.  The social worker was refused access to the bedrooms, which meant they were unable to check the window restrictors. Therefore, Mother’s behaviour prevented the practitioner taking protective action.  7.4.11. Agencies recognised that Mother’s lack of engagement with services, which led to N’s lack of attendance at health appointments and inconsistent attendance at school, impacted adversely on N’s wellbeing and development, particularly social and intellectual development, which was magnified for a child with a disability.  The lack of access to SALT hindered the important development of N’s communication skills and must have increased any sense of isolation.  It was this inability to promote N’s welfare and safety that led to the Local Authority’s decision to initiate care proceedings twice.  7.4.12. In summary, Mother’s lack of engagement hindered agencies in providing services which would support N and promote his development, physically, socially and intellectually, and this position was exacerbated following the outcome of the family court proceedings in August 2019. It also prevented the social worker undertaking the necessary checks of safety in the home. Currently the Safeguarding Board does not have guidance for practitioners on working with resistant families and with disguised compliance.14  This would be an important addition to the Multi-Agency Safeguarding Arrangements Procedures.  (Recommendation 1)        14 Working with families who display disguised compliance: Guidance for Professionals. Wirral safeguarding Children Board, December 2017. 20  7.5. What assessments were undertaken of the protective factors and risks to N and did the categories of abuse identified in the Child Protection Plans fully address the risks to N?  Was sufficient consideration given to the risks of physical and emotional harm associated with long term neglect?    7.5.1. N was the subject of several Strategy Meetings and Section 47 enquiries.  The Police Agency Report Author raises the question of whether joint police & CSC enquiries, rather than single agency enquiries by CSC, could have been considered, as it would be with concerns about physical and sexual abuse.  When there are serious concerns about neglect, notably a history of children being left unattended, Police Officers can make house-to-house enquiries, identify witnesses and collect statements, e.g., from neighbours, which would provide evidence for child protection procedures as well as family court proceedings. Officers could also advise neighbours of the action to take when they have concerns, which would allow for protective action when appropriate.  7.5.2. The Agency Report Author suggests that there could have been greater consideration of whether there was a role for the Police to establish whether Mother should be held criminally responsible for her lack of care/neglect of N, i.e., a proactive role for the Police.  There were such significant concerns that the Local Authority was seeking removal, a criminal investigation may not have resulted in charges being brought, but it could have supported the court proceedings and demonstrated to the court the gravity with which Mother’s actions were viewed by the Police Force. (Learning Point & Recommendation 2) 7.5.3. The Police were not represented at any of the CPCs, including the ICPCs.  Due to insufficient staff to attend all ICPCs, attendance has to be prioritised.  An Internal Review in 2020 noted that attendance had fallen below the expectations of the Local Authorities (ICPCs 63% and RCPCs 5%)).  Steps are being taken to address this, with remote attendance and requests for officers involved with a criminal investigation relating to the family to attend.  MASH Police staff review the minutes of RCPCs  7.5.4. There were two periods when N was the subject of a Child Protection Plan.  The first short period being from April to May 2018, when an Interim Care Order was granted to the Local Authority and N became a child looked after (CLA), and the second being from December 2019 until September 2020 when N again became a CLA following the serious incident.      7.5.5. At the ICPC in April 2018, the decision was that N was at risk of significant harm and required a CPP in the category of neglect 15.  The danger statement noted that Mother’s sporadic engagement with professionals meant N was not receiving the support required to aid development.  Additionally, Mother’s difficulties in managing  15 Neglect: The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: a. provide adequate food, clothing and shelter (including exclusion from home or abandonment) b. protect a child from physical and emotional harm or danger c. ensure adequate supervision (including the use of inadequate caregivers) d. ensure access to appropriate medical care or treatment It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.  Working Together to Safeguard Children: A guide to interagency working to the safeguard and promote the welfare of children HMG, 2018.  21  her finances meant the family did not have a stable home and N was not attending nursery, The CPP included: parenting assessment and expert assessment of Mother’s functioning, N to attend school for further assessments, SALT and OT support for N and support for Mother in relation to housing.  The Local Authority were to take legal advice.  The risks to N were well recognised by agencies and the category of harm, i.e., neglect, was appropriate.    7.5.6. Following the final hearing in the family court in August 2019, when no orders were made, concerns about the risks continued.  N’s school attendance was poor, Mother did not give consent for SALT involvement and there were concerns about N’s safety, e.g., being left unattended, observed to be in danger on the roads, damaged window restrictors.  An ICPC was held in December 2019 and again it was agreed that N was at risk of significant harm and required a CPP, in the category of emotional abuse. 16  7.5.7. There have been discussions at the LCSPR Panel and the Managers’ Learning Event about the choice of category of harm and whether emotional abuse was appropriate.  Evidence would indicate that the wider definition of neglect fitted more closely with the risks to N and emotional abuse less so, The Named Professional for Safeguarding for the NHS Foundation Trust had suggested at the Conference that neglect would encompass the risks to N’s physical, social and emotional needs.    7.5.8. At the Learning Event, the Conference Chairs’ Manager suggested that this decision may have been made because parents can find the term ‘neglect’ difficult to accept so ‘emotional abuse’ was used as this may have been less distressing for Mother.  Additionally at the Panel, it was suggested that, given the outcome of the family court proceedings and the ongoing difficulties engaging with Mother, professionals were ‘bewildered’ and trying to find different ways to engage with her post the care proceedings, i.e., a sense of what else can we do?  7.5.9. Whilst it is perfectly understandable that professionals were looking for ways to engage with Mother, this thinking meant that the decision was based on Mother’s needs and not on the day-to day-experiences and risks to the child. Neglect is much closer to what N was experiencing, e.g., a failure to meet N’s physical and psychological needs, likely to result in impairment of the child’s health or development, to protect a child from physical and emotional harm or danger and to ensure adequate supervision.  (Learning Point)  7.5.10. The significance of the category of abuse is that it highlights the greatest risks to the child and sets the focus for the development of the CPP.  The danger statement  16 Emotional Harm:  The persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to a child that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or ‘making fun’ of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyber bullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone. Working Together to Safeguard Children: A guide to interagency working to the safeguard and promote the welfare of children HMG, 2018.  22  noted that N was not attending school and lacked structure and routine, which would impact on his learning and emotional development, and the impact of the Mother’s lack of a support network and isolation on her mental wellbeing.  There is no reference to the concerns about N’s lack of boundaries and supervision and risks to physical safety.  The actions in the CPP include an updating of Mother’s psychological assessment, N to attend school, Mother to access social and community resources and consistent arrangements for contact with Father.  However. there is no action in respect of the physical risks to N, e.g., promoting road safety and checking the door locks and window restrictors are functioning. (Learning Point)  7.5.11. The CPP was reviewed at the RCPC in March 2020; a decision was taken to continue with the plan but, appropriately, the category was changed to neglect. There had been a further incident of N running into the road with cars needing to swerve and concerns about N running on the flat windowsills.  However, there were no changes to the actions in the CPP or to the timescales for the completion of these. Therefore, there is a question about how effective this CPP was in providing a working tool for practitioners in protecting N.  (Learning Point)  7.5.12. The gap in the CPP relates to the lack of recognition of the risk of physical harm; there had been reports of N being left unattended, running into the road whilst in mother’s care and concerns about the window restrictors becoming detached. These serious risks should have been addressed in the plan, so that practitioners remained mindful of them. An appropriate action would have been that the Social Worker and a representation from Housing should undertake checks of the safety features in the family home every 4 weeks.  7.5.13. There were two incidents during this period of child protection planning which were not followed up sufficiently robustly.  Firstly, the Social Worker observed a broken window restrictor and secondly, the EWO was informed by Mother that N had got into the bath twice and turned the taps on.  The lack of focus on the physical risks may be the explanation for this, which highlights the importance of CPPs clearly identifying risks to children.    7.5.14. Each of the agencies represented at the CPC has responsibility for drawing together an effective CPP.  Questions for the Board are whether the fact that the CPP was not refreshed at the RCPC is common practice and whether attendees at CPCs see themselves as having an active role in the formation of the CPP. (Recommendation 4)  7.5.15. The research paper ‘The Role of Neglect in Child Fatality and Serious Injury’ 17 has relevance for this review.  It ‘offers ‘a re-analysis of neglect in serious case reviews’ from four consecutive government commissioned national two-yearly studies.  The study explored ‘how circumstances came together when neglect has a catastrophic impact on the child’ in six difference ways, one of which was ‘accidents with elements of forewarning’.  Accidents are sudden, unexpected, events without forewarning, but for these children there were a range of factors which meant that the incident, although not directly predictable, offered some element of forewarning. Similarly, the  17 Brandon, Bailey, Belderson and Lasson: The Role of Neglect in Child Fatality and Serious Injury. Child Abuse Review Vol 23: 235 – 245 (2014) Wiley Online Library.  23  NSPCC Briefing (2015)18 suggests that attention should be paid to frequent accidents and injuries as these may be an indicator of poor-quality parenting through the lack of supervision or of living in an unsafe home.   This was certainly true in respect of N’s fall from the window; there had been concern about N’s safety in the home and in the street and about the level of supervision N received for some years. The practitioners ‘knew something was going to happen.’  There was an ‘element of forewarning’. (Learning Point)  7.5.16. In respect of N, there is evidence that there was concern about immediate risk of harm and a sense of urgency in the work, hence the Local Authority initiating two sets of care proceedings.  However, there is evidence that the child protection planning from December 2019 to September 2020 was not effective and did not address the serious and enduring risk of physical harm to N.  7.5.17. In summary, it was recognised that N was at high risk, and it was appropriate that child protection procedures were initiated, and N was made the subject of a CPP.  However, there are questions about whether the category of harm in December 2019 reflected the nature of the risks and whether the plan was effective in protecting N, both in its actions and timescales.  Evidence would also suggest that the fact that physical ham was not referenced in the CPPs meant this was then not highlighted in the Local Authority’s evidence for the second set of proceedings, potentially undermining the case for immediate removal of N for his safety.   7.6. Were there barriers that prevented agencies taking timely measures to safeguard N and, if so, do these have an impact on partners’ ability to safeguard children with a disability more generally?   7.6.1. The additional vulnerability of children with disabilities and that neglect will have both a short-term and long-term impact on their development and wellbeing is understood. There were several factors which undermined agencies’ ability to promote N’s welfare and put safeguarding measures in place.  7.6.2. Firstly, the family moved frequently and were not always living in suitable accommodation, e.g., B & B, Travelodge.  Additionally, the two placements when N was a CLA were outside the Local Authority area, and it took time to trigger local services. These changes of accommodation and placements presented challenges for services in gaining access to and providing timely services for N.  The family were registered at three GPs, which the CCG’s Report Author considers affected continuity of care.   7.6.3. Secondly, Mother’s presentation was extremely changeable, at times appearing to want help but not accepting this when offered.  The Foundation Trust’s Report Author suggests that where there is a lack of parental consent to treat a child, despite strong evidence of the clinical need, consideration should be given to escalation to senior managers and discussion with CSC.  (Foundation Trust: Learning Point and Recommendation)   18 NSPCC learning: Neglect:  Briefing summarises the risk factors and learning for improved practice around neglect.  September 2015.  nspcc.org.uk/learning.   24  7.6.4. Thirdly, there appears to have been a delay in the progression of the second set of family court proceedings.  The Local Authority initiated care proceedings in June 2020, the case was adjourned at the Case Management hearings in July and August, and a hearing date was set for October 2020, four months later. This was a significant delay given there had been serious concerns about N’s welfare and safety since December 2019 when the CPP had not progressed and was not safeguarding N.   7.7. To what extent has the Covid-19 pandemic impacted either on the circumstances of the child or family or on the capacity of the services to respond to their needs?  7.7.1. Information presented to the LCSPR provides evidence that undoubtedly the restrictions imposed by the pandemic increased the family’s social isolation and vulnerability and presented additional challenges for agencies in providing services to safeguard and support N’s wellbeing and development. The Foundation Trust’s Author suggests that Mother’s lack of engagement with services to meet N’s needs was ‘masked by the pandemic’. However, the risks to N were such that his needs were prioritised by agencies during the pandemic.   7.7.2. CSC operated a traffic light system for evaluating cases and N was consistently rated as red, which meant that home visits continued.  A school place was available, although Mother took the decision not to access this. Both the school and the EWS maintained regular contact and endeavoured to encourage N’s attendance. The lack of attendance at school increased risks to N’s development as well as to physical safety, 7.7.3. Health agencies also rag rated N as red due to the significant risk, which was likely to increase due to more time spent at home during lockdown.  The GP continued to offer face to face appointments for more vulnerable patients, including N.   7.7.4. The one service area where there appears to have been an impact was in the family courts.  The Local Authority instigated care proceedings in June, at a hearing in July the court did not agree that the test for interim separation was meet.  There was a case management hearing in August and a date was set in October 2020 for an interim removal hearing, i.e., four months later.  It is understood that there were two reasons for this delay, firstly the difficulty with providing Covid safe courts and secondly, the shortage of judges.  7.8. Learning in respect of the family court proceedings: ‘Plans and interventions for disabled children suffering neglect should be time-limited, with a focus on measuring whether sufficient change has occurred to secure the safety and well-being of the child.’19 7.8.1. With the consent of the Judge, various court documents have been made available to the Lead Reviewer.  These include the reports of the expert Psychologist and the Judgement in the first set of proceedings which concluded in August 2019.  The Psychologist had been provided with documentation and met once with N and  19 Kennedy and Wonnacott: Neglect of Disabled Children.  Chapter 13: Child Neglect: Practice issues for health and social care. Jessica Kingsley Publishers, 2005. 25  Mother, once with N and Father and briefly with both parents prior to preparing the first report in May 2018.  He had met with them once more before preparing an update in May 2019.  Also made available to the Lead Reviewer were statements from the Mother, Local Authority and Children’s Guardian in the second set of proceedings, which commenced in July 2020,  7.8.2. First set of family court proceedings: There are a number of factors to take into account: • The Judgement noted that the decision of the Court was ‘finely balanced’.    • Within the proceedings an application had been made by the parties to jointly instruct an expert Psychologist.  This was found by the Court to be ‘necessary’ to resolve the proceedings.  • The Judge was highly complementary of the work undertaken by the Social Worker and acknowledged the commitment made to trying to find ways of engaging positively with Mother.  • The Local Authority and the Children’s Guardian, CAFCASS, did not concur with the assessment of the jointly instructed Psychologist.  • Within the proceedings there was robust challenge to the evidence of both the Psychologist and the Social Workers, to the extent that the Independent Social Worker, instructed by the Local Authority to undertake a parenting assessment, reconsidered and no longer supported the Local Authority’s plan for a Placement Order.  • The Court found that the threshold criteria for significant harm were met.   • When considering the welfare stage, the Judge did not find, when applying the welfare checklist 20, that the Local Authority’s Care Plan, which was to separate mother and child and place N for adoption, was in N’s best interests. The test for severing the parent/child relationship, where the care plan is adoption, is very strict and should only happen when there is no other option, when ‘nothing else will do’ (this is a welfare test).    7.8.3. The Psychologist’s position was that there was a positive attachment between N and Mother, and this should not be discarded lightly; separation would be psychologically damaging to N, more so for a child with autistic spectrum disorder. Mother could provide good enough care and the family required an appropriate education placement for N and suitable housing. The Psychologist recognised that Mother’s lack of autistic specific knowledge and skills were party due to not attending sessions rather than a psychological difficulty and she needed to learn autism specific management techniques and develop better ways of co-operating and negotiating with others.  Mother risked alienating the very people offering to help, but if she was given appropriate training, therapy and support she could manage to care for N long term.  Mother had stated a willingness to take part in the programmes recommended.   20 Welfare Checklist: Children Act 1989, Section 1 (3) and Adoption and Children Act 2002 Section 14. 26  7.8.4. No orders were made, and the Judge anticipated that, following the conclusion of the proceedings, N would become the subject of a Child in Need Plan and receive support and services through this route. 7.8.5. The findings and recommendations of the Report of the Public Law Working  Group, published in March 202121 may be relevant for this LCSPR.  The Report noted the increase in the number of experts being approved by the courts in public law proceedings. It highlighted that such applications should not be made unless the opinion of an expert is necessary and such an instruction can lead to delays in proceedings. This was judged to be ‘necessary’ in the case under review.  7.8.6. The report also highlighted that ‘Professionals who know the family and the child should feel confident about reporting to and advising the court’ and made the following recommendation regarding this. • Recommendation 33: There should be a shift in culture and practice away from early instruction within proceedings of experts. Social workers and Children’s Guardians are expected to have the expertise to make professional judgements and assessment both generally and particularly in respect of the assessment of siblings and parental relationships/bonds and commenting upon attachments.  7.8.7. It is interesting to note that this recommendation for the family justice system reflects discussions that have taken place in the course of this LCSPR, notably the value that courts place on the evidence of social workers, who may know a family well, and the Children’s Guardian, who is appointed by the court to represent the rights and interests of the child, to be the child’s voice. Recommendation 33 recognises the expertise that social workers and Children’s Guardians bring to the family court proceedings. 7.8.8 Since the conclusion of the proceedings, there has been a case in the appeal court which may also have relevance for the review, The N (Children: Refusal of Placement Orders) 22 where the Family Court Judge had refused the Local Authority’s application for care and placement orders despite ‘severe difficulties’ and the Local Authority appealed.  Lord Justice Peter Jackson concluded that ‘the Judge was entitled to decide that it might be possible to reunite the children with their mother’. However, • He should not have dismissed the local authority’s application without first ensuring that reunification was underpinned by clearly understood court approved arrangements.  • Accordingly, the appeal will be allowed to the limited extent that the local authority’s application is remitted to the Judge so that he can consider and endorse such arrangements or, if they cannot be devised, redetermine the application.   21 Public Law Working Group: Recommendations to achieve best practice in the child protection and family justice systems. Final Report (March 2021). 22Case no: b4/2021/1517:  N (children: refusal of placement orders):  In The Court of Appeal (Civil Division) on appeal from The Family Court at Liverpool 27  7.8.9. This Judgement indicates that there is now an expectation placed on Family  Court Judges to ensure that there are realistic plans in place to support a child’s rehabilitation and hence refuse a local authority’s application for a placement order. 7.8.10. Second set of family court proceedings:  These proceedings were initiated in July 2020 and the Local Authority made an application for an Interim Care Order with a plan for immediate separation and N’s placement in foster care.  The Judge and the Children’s Guardian considered that the Local Authority had not provided sufficient evidence to show that N was at immediate risk of harm requiring separation. The Judge refused the application, on the basis that the test for immediate separation was not met, and a hearing date was set in October 2020.  7.8.11. The statements of the Social Worker provided evidence of the impact of Mother’s continued lack of co-operation on N’s development, e.g., education, speech and language therapy, and highlighted the risks in the lack of road safety.  However, there is no reference to concerns about safety in the home.  The Local Authority and the Housing Provider had taken substantial steps to ensure that the flat was safe for N, e.g., fitting window restrictors, an additional lock on front door, but there had been concerns about the window restrictors becoming detached. 7.8.12. An explanation for the absence of this evidence in statements may be due to the lack of attention to the physical risks in the child protection planning, as referred to in 7.5.7/7.5.10.  As this risk had not been highlighted in the Child Protection Plan, it is not surprising that its significance was not brought to the attention of the court in the evidence presented.  If this information had been included. it would have provided more evidence in respect of the immediate risk of harm to N. 7.8.13. The review has highlighted the importance of practitioners from all agencies having sufficient time to prepare statements for court and for them to be provided with management oversight and reflective supervision when undertaking this important task. (Learning Point) 8. Good Practice Identified: • Evidence of child centred practice:  Many of the practitioners spoke very warmly of N, they knew him well and understood his needs.   • Practitioners demonstrated an understanding of the impact of long-term neglect on a young child with a disability and this informed the assessment of risk and escalation of concerns.  • The Social Worker showed commitment, understanding and tenacity in trying to establish a working relationship with Mother in order to support her in meeting N’s needs.  The Judge complimented the work of the social worker and commented that if there was any other means of engaging with the family, she would have tried this.   • CDC did not accept the response to concerns about Mother’s lack of engagement with the services offered, escalated this internally and contacted CSC to ensure the extent of the concerns were fully understood.   28  • Educational settings worked hard to engage with N’s mother and to promote N’s development, socially and academically.  School 2 engaged with Father to support N in school.  • SALT recognised the impact on N of not receiving therapy and were tenacious in seeking consent.  • The Educational Psychologist showed determination to see N to undertake the assessment and did so on the fourth attempt.  • The EWO maintained weekly contact with mother during the pandemic to try and encourage N’s attendance at school.  • Housing ensured that the necessary safety modifications were made to the family’s flat prior to them moving into the property.  • The Children’s Specialist Services Team held weekly team briefings to ensure that all workers in the team were kept up to date with developments, intervention with the family was well co-ordinated. and practical and moral support was offered to the practitioners.  • GPs records flagged CPP, CLA and diagnosis of ASD.   Routinely offered Mother a face-to-face appointment at the surgery following telephone consultations.  9. Key Learning: 1. Multi-disciplinary working: Following the diagnosis of a child’s disability by the Child Development Centre, support for the family should be co-ordinated through multi-disciplinary team meetings and plans that are reviewed regularly.   2. Cultural awareness and sensitivity:  Work with families should demonstrate cultural awareness and sensitivity and an understanding of the impact that race, culture and religion can have on parents’ behaviour and reactions and how best to offer support and encourage engagement with a view to promoting the child’s best interests.  (Recommendation 3)  3. Engagement with the Father/a parent not living in the household: All agencies should obtain the names and contact details of a child’s father/parent not living in the household, importantly those with parental responsibility, and as a matter of course inform and engage them directly in important decisions and discussions regarding their child, e.g., formulation of Education, Health and Care Plan (EHCP), unless there is a reason not to do so. Where parents are not living in the same household, agencies should not rely on one parent to share this information with the other parent. Practitioners need to be aware of the potential support and protection that can be offered to the child by the parent not living in the household and their wider family. (Single agency recommendations)  4. Working with resistant families: Practitioners require the knowledge and skills to positively promote engagement with families who are resistant and hostile to 29  co-operating with services offered, whilst understanding the inherent risks to the wellbeing and safety of children.  (Recommendation 1)  5. Professional fatigue:  Managers need to be alert to professional fatigue and ensure that regular reflective supervision is in place for practitioners and give consideration to the use of multi-agency group supervision where this is appropriate.  6. Child in Need Planning: The importance of the involvement of all practitioners and agencies working with a family being involved in the development and implementation of a Child in Need plan, notably health agencies.  This is particularly vital when a child has a disability. 23  7. Investigation of neglect:  When a strategy meeting is held and a section 47 enquiry initiated where serious concerns for cruelty/neglect of a child are identified, all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation.  If it is deemed that, on the balance of probabilities, the cruelty/neglect is likely to amount to a criminal offence then the crime will be recorded by police in accordance with NCRS/HOCR. Where a joint investigation is agreed Children’s Social Care and Police should then ensure that all available evidence is collated and analysed. (Recommendation 2)  8. Neglect & Accidents: Accidents are sudden, unexpected, events without forewarning, but for children experiencing neglect there can be a range of factors which mean that incidents, although not directly predictable, have some element of forewarning.  9. Child Protection Planning:  The category of harm should reflect the risks to the child and these risks should be articulated in the Child Protection Plan (CPP), with actions to address them within specified timescales. CPPs are dynamic documents and should be updated after every Review Child Protection Conference to reflect the current position and identified risks. All agencies represented at the CPC and Core Group have a responsibility to ensure that the CPP is an effective tool in safeguarding the child.  24 (Recommendation 4)  10. Family Court Proceedings:   ➢ Statements for Family Court proceedings should articulate clearly all the risks of harm to a child.   ➢ Importance of social workers and practitioners, who are providing reports to courts, having sufficient time to prepare the analysis, together with reflective discussions in supervision.  Recommendations to the court should be clear about the impact on the child if the recommended course of action is not agreed.  ➢ Consideration should be given as to how partners can inform the family  23 Protecting disabled children: Thematic Inspection.  Ofsted 2012. 24 Protecting disabled children: Thematic Inspection.  Ofsted 2012. 30  court process to ensure the best evidence is made available and to promote the value of evidence available from professionals who have had significant involvement with a child and family over a period of time, e.g., health, education.  10. Recent Developments:  Education Welfare Service:  • Since 2020 staffing levels have Improved, including the appointment of Children Missing Education (CME) and Elective Home Education (EHE) Officers.    • February 2020 Elective Home Education and Children Missing Education Groups established to provide strategic oversight of the development of services.  • Relationships with schools strengthened.    Housing:   • In line with best practice, Local Authority Housing no longer places families in B & B accommodation.  Whenever possible, homelessness is prevented, and a planned move secured to self-contained accommodation.     • When CSC accepts a duty to accommodate a household, Housing and CSC work collaboratively and Housing provides support in sourcing suitable accommodation.  Police: • In response to a previous LCSPR, Thames Valley Police have produced a training package around providing a service to individuals with neuro developmental conditions, which is mandatory for operational Police officers/staff.  • This training is being implemented within the vulnerability training for all new intake officers as part of their introductory training.  • Operational guidance is being reviewed to establish if it requires amendment for Police Officers.    Children’s Social Care:  • Child Protection Conference Team:  ➢ Training on developing SMART Child Protection Plans, which are child centred and outcome focused, and on identifying the category of harm.   ➢ Child Protection Conference Manager undertakes quarterly quality assurance activity, including audits of child protection plans and 31  observations of child protection conferences.  ➢ Child Protection Chairs routinely audit any repeat child protection plans. Learning is shared with the Heads of Service.  • Social work staff (Including the Child Protection Conference Team):   ➢ Motivational Interviewing Training to promote the values of Family Safeguarding: valuing strengths, solution focussed, high support/high challenge.  ➢ Mandatory cultural competence training, ensuring cultural and identity needs are considered in the development of safety plans.  ➢ Training in working with difficult to engage with parents, practical ways to creatively look at resistance and how to break down barriers and improve communication.    11. Conclusion:  11.1. This local child safeguarding practice review concerns N, a young boy diagnosed with autism spectrum disorder, who fell from a second storey window and sustained serious, life-threatening injuries.  At the time N was the subject of a child protection plan and the Local Authority had, for the second time, initiated care proceedings, two months earlier. The fall cannot be considered an accident, it was an incident ‘with an element of forewarning’.25 11.2. LCSPRs routinely identify concerns about the robustness of risk assessments, the quality of communication between agencies, the timeliness of action taken by agencies and crucially a lack of focus on the needs of the child. Whilst some important learning has been identified in this LCSPR, none of the above perennial concerns are evident in the intervention by agencies, individually or on a multi-agency basis. 11.3. The increasing risks to N, a child with additional needs, from neglect were recognised and the level of intervention was escalated appropriately, through a Child in Need Plan, a Child Protection Plan and Family Court proceedings. Importantly, the focus was maintained on N’s individual needs and protection, on the impact of the lack of services, including specialist services, being accessed by the family, as well as the serious concerns about N’s safety and wellbeing.   11.4 The key learning relates to the need for cultural awareness and sensitivity in agencies’ work with families, the importance of engaging with a parent not living in the household to assess the potential for support and protection from the wider family, the need for practitioners to develop the skills in working with resistant individuals and the value of robust child protection plans, which clearly identify the key risks, how these will be managed and the timescale for doing so.  25 Brandon, Bailey, Belderson and Lasson: The Role of Neglect in Child Fatality and Serious Injury. Child Abuse Review Vol 23: 235 – 245 (2014) Wiley Online Library. 32  11.5. There has been careful consideration of the evidence presented to the review and it appears that the outcome of the Family Court proceedings in August 2019 was a significant point. The Judgement was that no orders would be made by the court and that services to N and the family would be offered through a Child in Need Plan.  11.6. There was substantial evidence indicating that Mother was likely to have difficulty in co-operating with a Child in Need Plan and this would impact on N’s wellbeing in the short and long term. It appears that the outcome of the court proceedings somewhat undermined the authority of agencies working with the family and impacted on the Local Authority’s Children’s Social Care practitioners who faced challenges in creating any positive change for N.  11.7.  N became the subject of a further Child Protection Plan and, as referred to above, some of the key learning from the review relates to the effectiveness of this process, notably the recognition of the risks to N’s physical safety, which had implications for the quality of evidence presented in the second set of family court proceedings. 11.8. The learning from this LCSPR will be disseminated by the Safeguarding Board.  The recommendations below are already being taken forward and these, together with the single agency recommendations, will be closely monitored by the Board. 12. Recommendations: 1. The Safeguarding Board should consider how agencies can develop practitioners’ knowledge and skills in working with resistant families, including developing guidance for inclusion in the multi-agency safeguarding arrangements procedures and promoting training and reflective supervision.  2. When a strategy meeting is held and a section 47 enquiry initiated where serious concerns for neglect of a child are identified, all circumstances should be reviewed to ascertain if the threshold is met for a joint agency investigation.  If it is deemed that the neglect is likely to amount to a criminal offence, then Children’s Social Care and Police should ensure that all available evidence is collated and analysed. 3. The Safeguarding Board’s partners should undertake a review of their safeguarding training to ensure that cultural awareness and sensitivity is promoted and report on the findings of the reviews to the Board. 4. The Child Protection Service should undertake an audit of the categories of harm identified for children who are subject to child protection plans to ascertain if the categories reflect the identified risks and these are addressed in the actions and timescales agreed.  The findings and any recommendations of the audit should be presented to the Board’s Quality Assurance Subgroup. In addition, the Child Protection Conference Service’s Annual Report should routinely be presented to the Board to ensure this receives multi-agency scrutiny. 33  5. The report of the LCSPR should be shared with the Local Family Justice Board and with the President of the Family Division, as advised in the President’s Guidance Judicial Cooperation with Serious Case Reviews 26.   26 President’s Guidance Judicial Cooperation with Serious Case Reviews.  Sir James Munby, President of the Family Division, 2 May 2017. 34  Appendix A References: • Bankole, Olatokunbo, Involving African families in the education of their autistic children, National Autistic Society, 4 April 2016.  • Autism in Black, Asian and Minority Ethnic Communities: A Report on The First Autism Voice UK Symposium. 2020.  • Brandon, Bailey, Belderson and Lasson: The Role of Neglect in Child Fatality and Serious Injury. Child Abuse Review Vol 23: 235 – 245 (2014) Wiley Online Library.   • NSPCC learning: Neglect:  Briefing summarises the risk factors and learning for improved practice around neglect.  September 2015.  nspcc.org.uk/learning.   • Safeguarding disabled children: Practice Guidance.  DCSF 2009  •  Protecting disabled children: Thematic Inspection.  Ofsted 2012.  • The Child Safeguarding Practice Review Panel Annual Report 2018 to 2019:  Patterns in practice, key messages and 2020 work programme.  • Working with families who display disguised compliance: Guidance for Professionals. Wirral safeguarding Children Board, December 2017.  • Case no: b4/2021/1517:  N (children: refusal of placement orders):  In The Court of Appeal (Civil Division) on appeal from The Family Court at Liverpool.  • Public Law Working Group: Recommendations to achieve best practice in the child protection and family justice systems. Final Report (March 2021).  • President’s Guidance Judicial Cooperation with Serious Case Reviews. Sir James Munby, President of the Family Division, 2 May 2017.  