Learning lessons review examining the circumstances in which serious indicators of child abuse were overlooked for siblings R and Q, born almost one year apart. Both children had the same undiagnosed neurological condition resulting in multiple physical and learning difficulties. Child R and Q received a high level of multiagency services in their early years. Child Q died of natural causes and Child R continued to receive multiple services over the following six years. Mother reported shaking Child R from the age of 3-months, which was initially understood to be the cause of his disability. This information was widely known to agencies but mother was permitted to continue caring for Child R and later Child Q without any assessment of the risk to the children. Professionals reported mother's lack of understanding of and intolerance to the children's disability. Issues identified include: absence of robust assessment and planning; absence of the child's voice; insufficient interagency communication and challenge; focus on the needs of the adult carers at the expense of the children; need for greater understanding of indicators and conditions for harm of disabled children. Makes various interagency and single agency recommendations.
      
 Title:  Learning lessons case review in respect of Child R and Q. LSCB: Rochdale Safeguarding Children Board Author: Rochdale Safeguarding Children Board Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          1   Learning Lessons Case Review in respect of Child R and Q      This report is the property of Rochdale Safeguarding Children’s Board  September 2013                      2   Contents   1.         Introduction  2. Conclusions and Recommendations                                        3  1. Introduction  1.1 This Learning Lessons Review was convened by Rochdale Safeguarding Children Board in order to critically examine the circumstances within which very serious indicators of child abuse had been overlooked for two children.   With the support and challenge of the review panel, each agency has openly identified where there have been shortfalls in expected standards of practice and addressed through recommendations and an action plan what is needed to secure their safeguarding systems.  1.2 Child R and Q are siblings born almost one year apart. Their mother was 18 years old when Child R was born. The children share the same parentage, Mother MQR and father FQR. Then their parents separated resulting in the children experiencing life with MQR and P1 until the age of approximately 3 and 4 years and then subsequently with MQR and P2.   1.3 Both children had the same undiagnosed neurological condition, as a consequence of which the children experienced multiple physical and learning difficulties. Both children received a high level of multi agency services in their early years; very sadly, Child Q of natural causes.   1.4 Over the following six years, Child R continued to receive many services, in the main co-ordinated through the Children with Disability service operated by Children’s Social Care.  Both children received care from multiple carers, which included many hospital admissions, respite care establishments, children’s hospice and additional home carers. There were a number of occasions whereby there was reason to be concerned about aspects of Child R’s care in particular, and these will be detailed in this report.   1.5 Concerns about alleged physical abuse of Child R culminated in the convening of a Child Protection Conference in 2011, at which point a very detailed chronology of the history of services and adult engagement was prepared. Through reviewing the history of the case from a safeguarding perspective, it was immediately apparent that there were a number of very serious concerns about how agencies have responded individually and collectively to the historical indicators of risk to both children.   1.6 The report will set out what the services and the practitioners have known about the children throughout their lives,  and use this story as an instructive case scenario to try to understand what supports  or desists practitioners in responding to the overall welfare needs, including the safeguarding needs specific to disabled children.      4  2.    Multi Agency Learning and Recommendations   2.1 Child R and Q were both solely dependent on adults to care for all of their needs. The nature of their disability also meant that they were unlikely to ever achieve a greater level of independence. The causation of the disability has never been established, but MQR stated from the age of three months that she had shaken Child R and it was initially considered that this was the most likely cause of disability. Despite this, and the information being widely known to core safeguarding agencies, MQR was permitted to continue parenting Child R and her subsequent Child Q without any assessment of what risk she could pose to the children. MQR was a very young parent, during the period of review she had three partners, all of whom she relied on heavily to provide care to her children. There are many descriptions of MQR showing a lack of understanding of, and intolerance to the children’s disability, which culminate in a picture of a mother was who was unable to cope with the constancy of care.  The professionals around the children and MQR wanted to support the situation, so much so, that they lost sight of what daily life was like for the children and could not see the need to focus on risk and protection above the desire to empathise and support. This changed with the advent of a new social worker in 2011, and through the opportunity of an objective and fresh perspective, the historical information was reviewed with an enquiring and open mind and a differing judgement was reached.   The professionals approach to this case can be categorised into three main phases: (i) an early concern for Child R which was not addressed by  responsiveness services  to the presence of safeguarding indicators, coupled with a medical view that the disability was likely to be a result of a shaking injury ; (ii) a sea change of the medical view of causation once Child Q was born and displayed the same symptoms, coupled with an empathy and desire to support MQR and her partners; (iii) a series of safeguarding events that that were responded to by P2 that led some professionals, in particular a recently allocated social worker, to reach a judgement that Child R was at risk of significant harm.  The phases are only apparent in hindsight, and there is no sense that professionals were conscious of the changing factors which influenced the mindset of how the case progressed.   There a number of significant factors which impacted on the effectiveness of the operation of the child protection system and these are the areas from which key learning needs to be drawn. The Factors include the following:   The absence of robust assessment and planning framework  5  Three months into the life of Child R, it was apparent that he was subject to risk which needed to be assessed urgently. It is simply astounding that the admissions of MQR in particular coupled with the medical view that shaking was the most likely causation of disability never resulted in a formal investigations or referral to the police.  The continued approach to the management of the case was outside of any formalised procedures that incorporated a multi agency approach to planning and review, so despite the existence of child in need, safeguarding and CAF processes,  in the main, agencies predominantly worked to a single agency remit which meant that information sharing was poor and often untimely and key risk factors remained dormant.    The absence of a robust assessment meant that services were not targeted as addressing pressing aspects for high level emotional care, and the consistent application of good standards of physical and quasi-medical care. Additionally, the changing male care givers in the family were never subject of any assessment.  The Health Overview Report concludes that the use of CAF is not embedded into the assessments of all health practitioners who are providing healthcare to disabled children, and that this has a significant impact on the co-ordination of services.   The Absence of the Child’s Voice  Hundreds of pages of information has been provided to this review about the services provided to Child Q and R, yet from this, it has been very difficult to extract and information which would suggest that attempts were made to gain an understanding of how Child Q and R felt about their environment and experiences of care. Clearly because Child Q and R had limitations in their ability to express verbal reasoning and opinion gaining this information was a greater challenge, however, all children express their feelings through a range of mediums and observations about Child Q and R’s wishes and feelings should have central to the planning and review of services.  Disabled children represent a high proportion of children in need within the Borough yet currently there is no specific inclusion programme to assist disabled children to take part in general youth inclusion projects.    The Absence of Interagency communication and challenge  Central to a safe child protection system is the need for feedback about whether the objectives for children are being met, and challenge to provide checks and balances within the system. Although there were occasions when professionals did have concerns about the management of the case, these did not result in any sustained representations. So whilst the Early Years Service accurately identified not just concerns about the children’s care but also doubts about MQR’s capacity to make and sustain change, the lack of response meant that the issues remained unaddressed and the pursuance needed to secure a better outcome for the children did not happen. Similarly, despite the high level and number of respite providers involved, the review of the children’s respite arrangements did not take place under 6  looked after children arrangements, and therefore lacked the independent scrutiny that could have been in place through the Independent Reviewing Service. Whilst many meetings took place which reflected multi agency attendance including LAC and SEN reviews, professionals meetings and strategy meetings, none of theses meetings resulted in any evidence of sound multi agency information sharing or a level of challenge that should have enhanced the protection and welfare of both children. The lack of challenge from health is particularly concerning in this case. Whilst there are examples over a ten year period of health professionals either documenting or having access to information which should have caused concern, there are no examples that provide evidence to support that health agencies saw safeguarding as their primary concern and where consultations did take place with other agencies, there is a feeling that professionals used this to assure themselves that the matters now belonged to another agency to assess for risk.  The Health Overview Report concludes that this case demonstrates a need for health professionals to develop skills which challenge parents in an open and honest way without the fear that that their partnership is diminished, but this review would also suggest the same is true for their approach to professional interagency challenge.   The inconclusive outcome of the injuries to Child R in 2007 represent a significant missed opportunity to take a greater multi agency oversight of Child R’s welfare and protection needs.  Despite a clear diagnosis of non accidental injury, the investigation fell well short of expected standards from the perspective of health, police and CSC.  It was because MQR and P2 alleged that the injuries happened at RRH1 that the investigation began under professional abuse procedures. Once it was established that the injuries had not occurred in the residential home, the only alternative was that they happened at the family home. The advice from the Conference and Review Unit was flawed, there is no doubt that such a complex situation with no apparent explanation to such a vulnerable child should have resulted in the convening of an initial child protection conference. Give the particular responsibilities of LADO to signpost to appropriate procedures in safeguarding, stronger ownership of cases considered outside of the borough could be achieved by the LADO having final oversight and a quality assurance role before an investigation that began in another borough is completed within borough.   The lack of clear arrangements in relation to assessment, planning and review and case co-ordination   This case provides a good example of why renewed statutory guidance for short break was introduced in 2010.  The arrangements for the children’ care cannot be located in a single assessment or a care plan and the reviews which did take place lacked focus on the children as individuals. The lack of objectivity in reviewing the care plans of the children contributed to poor management oversight arrangements. The review is informed that arrangements for the reviewing of short break care are now talking place in line with statutory requirements, chaired by an Independent Reviewing Officer.  There was no indication that professionals were clear about the process within which the children were receiving services with what appeared to a haphazard 7  approach to the structuring of multi agency meetings that had no consistent or common terminology.  Significantly, the meetings with MQR and P2 provided feedback they were confused by the roles of various professionals.  Although there is mention of the concept of a Lead Professional, this was never applied through a multi agency structure. The Team Manager requesting that the social worker and a health worker shared the role of lead professional demonstrated a lack of appreciation as to why one nominated person is necessary to the role, additionally the absence of a planned arrangement left scope for the CAMHS worker to claim the role as a parent advocate rather than a child focussed approach.   The DCSF Lead Professional Guidance 2009 states that  ‘ All children and young people with additional or complex needs requiring support from more than one practitioner should experience a seamless and effective service in which one practitioner takes a lead role to ensure services are co-ordinated, coherent and achieving intended outcomes’. The use of a Lead Professional remains underdeveloped in Rochdale, with consideration being given on a ‘case by case’ basis, rather than through a defined multi-agency process and expectation. Clearly the strengthening of such an approach would benefit  case co-ordination and the experience of children and parents/carers as service users.   Poor Understanding of Parental Responsibility   This case shows that there has been a poor understanding of the meaning of parental responsibility across agencies. Families are often complex, in cases where there have been parental separations and new partnerships it is important to understand and not assume who has Parental Responsibility. This case evidences not just assumption but a clear and misguided interpretation of parental responsibility and how that can be acquired from a legal perspective. The tendency to record by titles and not names in case recording does not assist the questioning of parental responsibility, for instance, from P2 joining the family, he was almost always called ‘Dad’.  The Central Manchester University Hospitals NHS Foundation Trust made a recommendation that procedures for gathering and recording Parental Responsibility are understood and that consent to treatment for children is gained from adults legally entitled to provide it. This was not merely an issue for one health service however, and to this effect a multi agency recommendation is made.   The acceptance of uncertainty   There is a obvious question that arises from examination of this case, that being why were professionals comfortable with high degrees of uncertainty. This occurred in relation to the understanding of the origins of the children’s disability and the possibility that shaking was the cause, and in relation to the outcome of the investigation of the non accidental injury to Child R in 2008.  There is a sense of not just not knowing what happened, but also of being too ready to accept that as the status quo. What this case demonstrates therefore is a lack determination to resolve seemingly intractable issues in order to reach robust judgements about safeguarding.  8  There was little sense that medical and Social Care services worked together to understand the origins of the children’s disability, each passively content to rely on assumption that the other service was not raising any concern therefore no concerns existed.   Too great a focus on adult carers at the expense of the child  The lack of defined process around the case management resulted in a situation whereby the child/en were not recognised as the central focus. This case did not lack resources, the adults needs for support were well provided.  The way in which that support was organised however did not prioritise the impact on the children who received care from many individuals and organisations which increased their vulnerability. The diagram of the children’s whereabouts shows that the home did not always appear to be the primary place of residence, and Child R was at home, direct care was provided to a great extent through a domiciliary care agency. Through a care plan that did not place the child as paramount, Child R in particular experienced multiple change in care, placements and expectations.    The need for greater understating of indicators and conditions for harm of disabled children  The report ‘It doesn’t happen to Disabled Children’ succinctly outlines the particular vulnerability factors for disabled children, this report was published in 2003 and one would expect that practitioners from a specialist team for disabled children  would be better attuned to seeing child protection as part of general social work activity than was the case. The splitting of the child protection function from the core social work task creates latent conditions which support practitioners not seeing themselves as responsible for safeguarding in the both a wider and case specific sense.  The extent to which the particular needs of disabled children are embedded in general safeguarding practice was discussed within panel meetings.  It was a particular concern that the Departmental structure for the provision of services to disabled children is placed outside of the core children’s services and safeguarding delivery and as such, potentially there is a danger of replicating the separating of the needs of disabled children from safeguarding and being understood by services as children first.  The provision of training specifically targeted at safeguarding for disabled children is limited, no more than two courses each year. The basic safeguarding training acknowledges the particular needs of disabled children, but not the key indicators of risk.   The need for safeguarding to be a central feature to commissioning of services   The responsibility for safeguarding needs to be an integral part of any services commissioned on behalf of children. Where this is not explicit, it creates an 9  environment within which it is possible for practitioners to see safeguarding as somebody else’s responsibility.   The Child Protection system needs skilled professional judgement  Professional judgement is central to safeguarding work in all agencies. There is no overriding evidence in this case to suggest that the framework for assessing need and delivering services was impaired, more that professional judgements were at times flawed and this resulted in the procedures not being utilised as they should. The Munro Review of Child Protection (May 2011) was commissioned in 2010 to address a central question of what helps professionals make the best judgements they can to protect a vulnerable child?’. The report sets out proposals, which in combination are intended to create conditions that enable professionals to make the best judgements.  Rochdale Children’s Trust and LSCB have a joint action plan in response to the recommendations made by the Munro Review, the only action plan available to the review however was outdated and as such progress could not be evidenced.    Much of the information in this review has been supplied through records rather than personal reflections and recollections because of the historical nature of much of the information.  Through the provision of IMR’s agencies have addressed identified deficits and made recommendations where necessary.   This report is not intending to replicate those recommendations but rather to focus the overarching learning that can be used to create safer systems for children.   In addition to the single Agency Recommendations, the Review makes the following overarching recommendations:    1. The Board need to be satisfied that:   the strategic placing of services for disabled children outside of core safeguarding services does not compromise the strength of safeguarding arrangements or connectivity to mainstream children’s processes and procedures;  cases of disabled children are subject to the same assessment, planning and review  processes of non disabled children. The review of this case may indicate that there are other  cases with long standing history where similar judgements have been applied with current consequences;  Lead Professional Guidance is used to maximise professional co-ordination across services and enhance service user experiences in cases where children have complex and additional needs.   2. The Board needs to be satisfied that multi agency arrangements for working with children through all continuum of need include a robust focus on 10  safeguarding and promote the level of interagency challenge necessary to maintaining safe systems;    3. There is a need to review and refresh the focus on disabled children in safeguarding training, in particular, there is an urgent  need to ensure that the IRO service is sufficiently knowledgeable to provide a necessary level of challenge;   4. The LADO procedures should ensure that in all cases which relate to a Rochdale child and have been considered by another Local Authority LADO, there is a final oversight by the Rochdale LADO for quality assurance purposes;   5. The Board should be satisfied that multi agency practice in this case is not replicated in other cases that have received the same operational and contemporaneous services. Cases of complex health/ highly vulnerable disabled children should be selected for a 360 audit focussing on multi agency working systems and management oversight;  6. The Board should lead by example and ensure that inclusion of young people and the voice of the child is specifically championed through engagement with disabled children;  7. That the Board ensures that all agencies understand the requirement for deep commitment to both Learning Lessons Reviews and Critical Incident Reviews and that the impact of the recommendations and outcomes can be clearly demonstrated.    