Death of an 8-month-old boy in December 2013. Baby L was found not breathing at home; post-mortem showed he had an acute upper respiratory tract infection at the time of his death. Baby L and his siblings were subject to child protection plans between September 2012 and November 2013; at the time of Baby L's death they were subject to Child in Need plans. The home environment was often dirty and cold and children were exposed to passive smoking. Parental history of substance misuse, domestic abuse and offending. At the time of the incident mother and father were separated, with the father having supervised contact with his children. Identifies examples of good practice, including: child protection conferences arranged so mother and father could attend separately to reduce the risk of intimidation; and the potential consequences of non-engagement with children's services were clearly explained to the mother. Identifies areas for improvement, including: delay in recognising the impact that recurring incidents of parental substance misuse and domestic abuse were having on the children; lack of information provided to the father about the impact his lack of engagement with services could have on his future contact with his children; insufficient assessment of the potential safeguarding role of the children's grandparents; lack of challenge to the mother's repeated understatement of her levels of alcohol consumption; and failure to regularly review, update and circulate child protection plans. Uses the Significant Learning Process (SILP) methodology to systematically assess why the incident occurred, identify incidents of good practice and strengths that can be built on. Recommendations for the safeguarding children board include: all assessments should include an understanding of each child's lived experience; practitioners should ensure that fathers are aware of the implications of failing to engage with services and work should be done to raise awareness of the dangers of parental smoking.
      
 Title:  Serious case review: overview report: subjects: Baby L (aged 8 months), Sibling 3 (aged 4 years), Sibling 2 (aged 6 years), Sibling 1 (aged 11 years). LSCB: Sunderland Safeguarding Children Board Author: Adrienne Plunkett Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          1    Sunderland Safeguarding Children Board Serious Case Review    Overview Report Subjects: Baby L:  (Aged 8 months) Sibling 3:  (Aged 4 years) Sibling 2:  (Aged 6 years) Sibling 1: (Aged 11 Years)      Lead Reviewer:  Adrienne Plunkett  Final Version:  25 February 2015  2  CONTENTS:        PAGE 1. Background to the circumstances    3 2. Background to Serious Case Reviews    3  3. Introduction to SILP      4 4. Process for this SCR      4 5. Introduction to the family     6 6. Engagement with the family     7 7. Pre-Scoping Period      7 8. Scoping Period       10 9. Thematic Analysis       25 • Agencies’ response to domestic abuse • The children’s lived experience • Quality of assessments • Quality of inter-agency communication • Child protection processes • Parental smoking • Management oversight and supervision        10. Findings       • Good practice      45 • Areas for improvement     47  11. Developments underway     48 12. Conclusion        51 13. Recommendations for SSCB     53 Appendix A: Terms of Reference and Agency Template Appendix B: Key single agency recommendations Appendix C: Glossary Appendix D: References   3  1. Background to the circumstances 1.1 This Serious Case Review concerns a family of four children, the youngest of whom, Baby L, had suffered with respiratory difficulties since soon after birth. In December 2013, at the age of 8 months, Baby L was found not breathing at home and, despite attempts by the Paramedics and Accident and Emergency Department, it was not possible to resuscitate him.  The post-mortem showed he had an acute upper respiratory tract infection at the time of his death.   1.2 The family had been known to a range of agencies for many years due to a history of alcohol and drug related domestic abuse.  The children became the subject of Children Protection Plans following a domestic abuse incident in September 2012, during which Sibling 1 had sustained an injury.  The Child Protection Plans ceased in November 2013 and at the time of the death of the youngest child, the children were the subject of Child In Need Plans.   2. Background to Serious Case Reviews 2.1 Local Safeguarding Children Boards (LSCBs) have a statutory duty to undertake Serious Case Reviews (SCRs).  Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs, including the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) sets out an LSCB’s responsibility for:  5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.  (2) For the purposes of paragraph (1) (e) a serious case is one where:  (a) abuse or neglect of a child is known or suspected; and  (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 2.2 Working Together to Safeguard Children 2013, Chapter 4,1 contains guidance as to when and how to undertake a SCR. It emphasises the importance of each LSCB developing a Learning and Improvement Framework and outlines that case reviews should be completed in a way which: • recognises the complex circumstances in which professionals work together to safeguard children;  • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;                                                            1 Working Together to Safeguard Children:  A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, Schools and Families, March 2013.  4  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and  • makes use of relevant research and case evidence to inform the findings 2.3 Working Together 20132 also encourages LSCBs to use a variety of models for undertaking SCRs, including the systems approach.  The Significant Incident Learning Process (SILP) is one such model. 3. Introduction to the Significant incident Learning Process (SILP) 3.1 The SILP methodology reflects on multi-agency work systemically and aims to answer the question why things have happened.  Importantly it recognises good practice and strengths that can be built on.  SILP is a learning model which engages frontline staff and their managers in the review of the case, focussing on why those involved acted in a certain way at that time. . 3.2 The SILP model of review adheres to the principles of: • Proportionality • Learning from good practice • Active engagement of practitioners and managers • Engagement with families • Systems methodology  3.3 SILPs are characterised by a large number of practitioners, managers and Agency Report Authors coming together for a Learning Event. Agency Reports are shared in advance with participants and the perspectives and views of all those involved are discussed and valued. This same group then comes together again to consider the first draft of the Overview Report at a Recall Event.  4. Process for this Serious Case Review 4.1 On 21 February 2014 Sunderland Safeguarding Children Board’s (SSCB) Independent Chair made the decision to undertake a Serious Case Review in respect of the children.   It was agreed that the criteria to do so had been met under Paragraph 8.5., Working Together to Safeguard Children 2013.3  Furthermore a decision was taken that this SCR would be undertaken using the SILP methodology.  A Scoping Meeting to discuss the Terms of Reference (Appendix A) was held on 3 September 2014.   4.2 SSCB recognises that there has been a delay in completing this SCR. There were initial deliberations as to whether the case met the criteria for                                                            2 DCSF, 2013. 3 DCSF, 2013.  5  undertaking a SCR as there was a medical explanation for Baby L’s death, but as the impact of neglect could not be ruled out, the Board recognised that there were lessons to be learnt and it was decided to initiate the process. There was a further delay due to the demands on the SSCB of undertaking a number of SCRs at the same time. 4.3 The Scoping Period for this SCR is 1 January 2012, 6 months prior to the injury to Sibling 1 in July 2012, which was the trigger for the Initial Child Protection Conference, to 20.12.2013, the date of Baby L’s death.  4.4 Agencies were asked to provide a brief background of any significant events and safeguarding issues in respect of the children prior to the scoping period, e.g. domestic abuse episodes, substance misuse and treatment, referrals to Children’s Social Care, Early Help. This material would be used primarily to provide the background context and therefore needed to be concise and summarised, highlighting any particular learning points.  An exception to this was the Police, who were requested to provide full background information regarding their involvement with the family prior to the scoping period. 4.5 Agency reports were commissioned from: • Police (Including MARAC information) • Children's  Social Work Service • Children’s Services’ Independent Reviewing Service  • NHS Foundation Trust (Health Visiting and School Nursing) • Acute Hospital (Paediatric and Midwifery Services) • General Practitioner • Ambulance Service • Education (Schools) • Substance Misuse Service • Domestic Abuse Service, via the Commissioner   4.6 In addition, agencies which had limited involvement with the family were requested to provide a brief report of their involvement for information.  These included: • Probation Service • Registered Social Landlord • Early Help  4.7 It should be noted that in October 2014, following contact with the Commissioner, an Agency Report was requested from the Domestic Abuse Service, but was not received.  4.8 The Learning Event was held on 24 November 2014 and the Recall Day on 22 January 2015. All the Agency Reports were shared with the participants prior to the Learning Event, so that they had a wider understanding of agencies’ involvement.  The draft Overview Report was then circulated to participants  6  prior to the Recall Day, in order that it could be checked for accuracy and the findings and recommendations fully discussed on the Day.  The Overview Report was amended following this discussion.  4.9 The Learning Event was attended by practitioners, managers and Report Authors from the Police, the Acute Trust, NHS Foundation Trust, Clinical Commissioning Group, Father’s GP Practice, Education, Children’s Social Care, Independent Reviewing Service and Substance Misuse Service.  The Recall Event was attended by the same agencies. The Probation Service was invited to both Events, but did not attend, neither did the Mother and children’s GP or the Domestic Abuse Service.  4.10 The Lead Reviewer for this SCR was Adrienne Plunkett; a qualified Social Worker, with a MA in Child Studies. Ms Plunkett has substantial experience working in Children’s Social Care, including as a senior manager, and has managed a Local Safeguarding Children Board, holding responsibility for commissioning SCRs.  Ms Plunkett is a trained SILP Lead Reviewer and was supported in this SCR by Paul Tudor.   4.11 Mr Tudor had a 20 year career with the NSPCC leading teams who were responsible for child protection systems.  For 22 years Mr Tudor has been an Independent Safeguarding Advisor, conducted many Serious Case Reviews, and pioneered the SILP methodology in April 2010. 4.12 In the Overview Report the names of family members have been anonymised and ages are as at the time of Baby L’s death in December 2013. 5. Introduction to the Family 5.1 Genogram                Mother Aged 27 years   Uncle Sibling 1 Aged 11 years Sibling 3 Aged 4 years Baby L Died aged 8 months  Father Aged 30 years   Sibling 2 Aged 6 years Paternal Grand-mother Maternal Grand-mother   Paternal Grandfather    Maternal Grandfather (Deceased)   Aunt  Uncle  7  5.2 The family is White British, both Parents having lived in the local area all their lives. It is understood that for some of his childhood the children’s Father lived with his Grandparents. 5.3 During the time of the review, the family lived in privately rented housing in an area of social deprivation, with high levels of unemployment and above the national average number of children receiving free school meals. 6. Engagement with family members 6.1 An important element of a SILP SCR is the engagement with significant family members, so that their views of the services offered to the family can contribute to the process and can inform the learning and hence development of services. 6.2 Arrangements were made for the Lead Reviewer and SSCB Business Manager to meet with the Parents individually on Tuesday, 18 November 2014.  The Father was unable to attend, but the meeting with Mother went ahead.  The purpose of meeting was to ascertain her views of the services offered to her prior to Baby L’s death to see if there was any learning, i.e. what agencies did well and what they could do better. Overall, Mother gave a positive view of agencies’ engagement with the family and her views have been threaded through this Report. 6.3 Further attempts were made by the Lead Reviewer to meet with the Father, but he was unable to attend. Attempts have also been made to obtain the views of the Grandparents.  However, the Paternal Grandparents did not respond to the appointment letter and did not attend the proposed meeting. The working hours of the Maternal Grandmother have led to difficulties with making arrangements to meet with her.   6.4 Consideration was given as to how best to obtain the views of Sibling 1 and it was agreed this would be undertaken by the family’s current Social Worker.  Sibling 1 confirmed that she had understood the reasons why Children’s Services became involved with her family and that this was in relation to her Father’s anger and alcohol misuse.  Sibling 1 felt that she had been able to talk to the Social Worker and also to her Teacher at Primary School. Her view was that things had improved for the family.  However, she worries about her father and would like him to accept the help offered. 7.  Pre-Scoping Period 7.1 The Scoping Period for this SCR starts in January 2012, i.e. six months prior to Sibling 1’s injury which triggered the child protection process.  However, agencies were asked to provide details of any significant events prior to January 2012, which may have relevance to the Scoping Period. 7.2 The first contact with the family appears to have been by the Police in December 2005 due to an incident of domestic abuse, which was notified to  8  Children’s Social Care (CSC).  Over the next 6 years there were at least 11 further instances of domestic abuse.  7.3 These incidents were closely linked with alcohol and drug use by both Parents.  They included incidents when Father was at the family home drunk and abusive and when the Police arrived he left, others resulted in physical assault and injuries to Mother.  Incidents of particular note include November 2007 when Father was intoxicated and assaulted Mother, January 2009 when both parties were drunk and Father assaulted Mother, June 2010 when Mother was intoxicated and assaulted a Police Officer and May 2011 when Mother sustained significant facial injuries.  Some of the incidents occurred when Mother was pregnant, i.e. October 2006 and March 2009.  It is recognised that domestic abuse in pregnancy is an indication of increased risk of harm to a woman and her unborn child.  Mother consistently refused to co-operate with pursuing criminal charges in respect of these assaults. 7.4 In terms of the welfare of the children during this time, when the majority of incidents of domestic abuse occurred they were reported to be with their Maternal Grandmother.  The Police did observe that the condition of the family house was dirty and run-down on a number of occasions. 7.5 In the majority of domestic abuse incidents the Police completed Child Concern Notifications (CCN) which were sent to the Police Central Referral Unit and to CSC as either a notification or referral.   A notification is sent with no expectation of action and a referral is made with the expectation that some action will be initiated by CSC and the Police will be updated accordingly. Most CCNs were sent as notifications, rather than referrals.  The latter appear to have been sent when there were concerns about the state of the home, e.g. dirty and run-down, rather than concerns about the risk to the children from the domestic abuse in the household. None of the referrals resulted in CSC undertaking an Initial Assessment during this time. 7.6 Following the incidents Domestic Violence Notifications were also completed for Police internal use. In line with the Multi-Agency Risk Assessment Conference (MARAC) process, these notifications assessed Mother as very high, high, medium risk or standard risk.  At times during 2009 she was assessed as very high and high risk.  High risk is when there has been four or more incidents of domestic abuse in the previous 6 months. It does not appear that there was any link between the level of assessed risk to Mother and whether a referral or notification was made to CSC, indicating that an assessment of high risk to Mother was not viewed as high risk of harm to the children.   7.7 Mother’s safety was discussed at a MARAC in March 2009. At this time Mother was pregnant, was viewed as being at high risk and offered the support of an Independent Domestic Violence Advocate (IDVA).  Reports from Education indicated no concerns regarding the children. Mother refused to engage with the IDVA and the case was closed to the IDVA in April 2009 and remained  9  open to MARAC.  Following the serious incident in May 2011, the Police contacted Mother regarding safety planning, but she again refused support and safety measures offered. 7.8 In January 2006 Mother attended the ante-natal clinic for a booking-in appointment.  She had bruising to her face and arms and a referral was made by the Midwifery Service to CSC.  There is no record in Children’s Services of this referral, however, a copy has been provided to the Lead Reviewer by the Acute Trust’s Report Author.  The referral noted that the Midwife had spoken to the family’s Health Visitor, and that there was a history of domestic abuse, and that Mother had been referred to the substance abuse clinic.  The referral had an added note that the Midwife had spoken to a Social Worker.  There is no record of the Midwifery Service following up the referral with CSC. 7.9 In March 2006, Mother had a miscarriage and Midwifery records note that she had been using cannabis.  A referral was reportedly made to CSC, however, again there is no record of this in CSC’s records. 7.10 In November 2007 and February 2009, there are indications in the records that CSC was to undertake Initial Assessments, however, there is no record of these actually being completed.  In May 2011 CSC had a telephone discussion with Mother and at this point she spoke of ending her relationship with the Father.  It was agreed an Initial Assessment should be undertaken if she reconciled with him.   7.11 In June 2011 the Health Visitor made a referral to the Early Intervention Service.  The referral was in respect of Sibling 3 and noted there were ‘boundary issues’ with managing her behaviour. It also referenced recent domestic abuse.  The CAF Panel, held early in July 2011, agreed that two services should be offered; a nursery place and the involvement of a Family Support Worker (FSW).  The aim of the work was to support Mother with behaviour management.  A home visit was undertaken in July 2011, Mother agreed to undertake the Nurturing Programme due to start in September 2011, but she did not want individual support from the FSW.  In the event Mother declined to attend the Nurturing Programme, stating things had improved as there had been no further incidents of domestic abuse.  Therefore, there was no real engagement with the service.  The Agency Report Author notes that Parents need to engage voluntarily with early intervention services, however, the agency would now make greater attempts to engage with the family. 7.12 Mother had held a tenancy with a Registered Social Landlord between 2003 and 2011.  During this time there were numerous tenancy breaches relating to the Father’s anti-social and criminal behaviour and an Acceptable Behaviour Agreement was put in place.  Mother terminated the tenancy in 2011 and  10  moved to privately rented accommodation, which was very close to the Maternal Grandmother’s (MGM) home. 7.13 From June 2010 Mother was subject of an 18 month Community Order to the Probation Service, for the assault on a Police Officer.  Probation made a referral to CSC at the end of 2011, due to a domestic abuse incident.  Father was the subject of a 12 month Community Order with supervision and 150 hours unpaid work from July 2011 for handling stolen goods and allowing himself to be carried in a stolen vehicle.  He was classified as a Prolific and Priority Offender, which entailed enhanced supervision by a multi-agency team. Father’s co-operation with the Order was poor, with several breaches.  8.  Scoping Period  8.1. January 2012 – Sibling 1’s injury 8.1.1 It is understood that Father spent much of his childhood in the care of his Grandmother and her death early in 2012 had a significant impact on him.  He presented to the GP in February 2012 reporting an extremely high level of drug and alcohol use and was referred to Substance Misuse Service.  He was seen again by his GP in March 2012 due to difficulties with substance misuse and then on a number of occasions requesting ‘sick notes’ for Probation to explain why he could not fulfil the requirements of his Order.   There appears to have been no consideration by the GP as to whether Father had any parental responsibilities and no referrals were made to CSC.  8.1.2 In April 2012 the Foundation Unit (Education) made a referral to CSC.  Sibling 3, aged 2 years 10 months at this time, had stated that his Father ‘punches mam in the face’.  The staff spoke to the MGM who confirmed that the older children had said similar things to her. The Foundation Unit also informed the Comment:   There is a picture of periodic, alcohol/drug related, domestic abuse incidents in the family during the Pre-Scoping Period. Whilst the Police followed procedures, and a MARAC held and CSC informed of the incidents of domestic abuse, it would appear that neither the Police nor CSC considered the pattern of domestic abuse.   The views of the children were not gained and there is no evidence that the long term impact on them was considered.  Given that reports to the Police of domestic abuse are often the tip of the iceberg, it can be assumed that this was the pattern of life for the children. The failure of CSC to undertake an Initial Assessment meant that there was no engagement with other agencies and a wider view of family life was not gained.  However, there was no follow up or challenge by the agencies which made referrals during this time.   11  Health Visitor.  CSC has no record of this referral nor of any action taken in response. The Unit continued to monitor Sibling 3’s wellbeing, but did not follow up the referral with CSC.  No action was taken by the Health Visitor.  At the Initial Child Protection Conference in September 2012 the Social Worker reported that Sibling 3 had laughed when she made this statement, so there was concern that she was desensitised to the domestic abuse she was witnessing, i.e. it had become a normal part of her day to day life. 8.1.3 The Health Visitor undertook Sibling 3’s three year developmental assessment in June 2012.  She was reaching her developmental milestones, and had good communication skills, but was still using a bottle and dummy and attendance at the dentist was advised. 8.1.4 In May, June and July 2012 there were further domestic abuse incidents. In May 2012 CSC made attempts to contact Mother by phone and letter, but she did not respond and no further action was taken. In June 2012 the children were present during the incident and, when spoken to by the Police Officers, Sibling 1 said that her Father was ‘often abrupt’ to her. Following the referral to CSC, Mother was seen by a Social Worker.  She stated she wanted to end the relationship with the Father and was planning to seek an injunction.  CSC agreed no further action. 8.1.5 In July 2012 the Neighbourhood Policing Team were alerted to the domestic abuse and Mother was assessed as medium risk.  8.2. Sibling 1’s Injury to Initial Child Protection Conference (ICPC) 8.2.1 On 25 July 2012 during a domestic abuse incident Sibling 1 intervened to protect her Mother and sustained a fracture to her left little finger, which had been trapped in a door slammed shut by her Father.  Sibling 1 was taken to the Accident & Emergency Department by her MGM.  She was admitted and her finger required surgery.  Hospital staff identified quickly that this was a child protection matter, the Designated Doctor was informed and referrals made to CSC and the Police on the same day.  Sibling 1, aged 9 years, was Comment: During this time there were less domestic abuse notifications, but there were two significant referrals to CSC, one from the Foundation Unit and the other from the Police.  These are of particular note as they related to views expressed by the children and gave a flavour of what life was like for them.  Set against the earlier history, these should have been given substantial weight.  There is no evidence that the Foundation Unit or Health Visitor followed up on the referrals in April 2012 or of discussions with Safeguarding Leads in their agencies.  It is not known whether Father’s GP was aware of his parenting responsibilities, but following his presentation to his GP in February 2012, it is of note that the GP did not discuss with the Health Visitor or Named GP indicating a lack of consideration of his role as a parent, a failure to ‘Think Family’.  12  spoken to by a Social Worker in hospital.  She stated that her Parents fight, it had been happening for a long time and she was fed up with it.  There are no records of the other children being seen at this time.   8.2.2 There were conflicting accounts of this incident.  Mother said that Father had gained access to the home through the garage, but Sibling 1 said that her Mother had let him in.  It appeared the Parents had been drinking for much of the day. There was no reason not to believe Sibling 1’s account of the events.   8.2.3 There are no records in respect of a Strategy Meeting being convened, or of a multi-agency meeting being held prior to Sibling 1’s discharge from hospital.  Section 47 enquiries commenced on 25 July 2012, but were not concluded until the date of the Initial Child Protection Conference (ICPC) in September 2012.  A Core Assessment was not commenced.  An electronic hospital discharge summary was sent to the Health Visitor and School Nurse, but not to CSC.  Hence there was no multi-agency risk assessment or planning during this time, leaving Mother and the children highly vulnerable. 8.2.4 In August the Police visited Mother and offered victim support.  It was agreed Mother would be referred to the Domestic Abuse Service.  8.2.5 Following Sibling 1’s injury arrangements were made for Mother and the children to stay with the MGM. There is no record of a written agreement with the Parents concerning these arrangements or regarding Father’s contact with the children.   8.2.6 MGM reported to CSC that on 30 August 2012 Father had been phoning Mother for many hours.  Mother had not answered the phone and at 4.00 a.m. he had come to the MGM’s home calling for her.  MGM had asked him to leave, he was abusive but left.  8.2.7 There was a delay in the Social Worker requesting a date for the ICPC and this was held in September 2012, 6 weeks following Sibling 1’s injury.  The children were made the subjects of Child Protection Plans in the category of emotional abuse, which tends to be the category used for children living in situations of domestic abuse.  The Government guidance in force at the time, Working Together to Safeguard Children, 2010, 1.34, states that Emotional Abuse may involve ‘seeing or hearing the ill-treatment of another’.4 Initiating the Public Law Outline, i.e. the process prior to commencing legal proceedings, was to be considered by the Local Authority if the Parents failed to engage.  8.2.8 The school reported that the children were well settled, their attendance and attainment being satisfactory.  A report was requested from the GP for the Mother and the children, but this was not provided.  It was not identified that                                                            4 Working Together to Safeguarding Children, 2010  13  Father had a different GP from the Mother and the children and therefore no information was requested from, or shared with, his GP. 8.2.9 Mother told the Lead Reviewer was that once the children were made the subject of Child Protection Plans she felt she knew what she had to do, otherwise the children would be taken away, which included: • End her relationship with the children’s Father • Attend Service for women experiencing domestic abuse • Attend Substance Misuse Service • Attend meetings, e.g. Core Groups  8.3. ICPC to Review Child Protection Conference (RCPC) 8.3.1 Three days after the ICPC the Father went to the family home, intoxicated, and was removed by the Police.  Mother was assessed as at high risk of domestic abuse by the Police and the information was passed to the PVP Sergeant for management. 8.3.2 The first Core Group meeting was held on 17 September 2012, the allocated Social Worker was not available and another Social Worker stepped in.  The task of the first Core Group meeting is to develop the Child Protection Plan (CPP), drafted at the ICPC. However, there is no evidence that the CPP was developed and circulated to family and agencies, nor are minutes of this meeting available.  There was a further Core Group on 8 October, the one planned on 7 November 2012 was cancelled and rearranged on 15 November 2012.  Child protection monitoring visits were made to the family Comment:  After the long history of domestic abuse and parental substance misuse, it was Sibling 1’s injury which finally triggered the child protection procedures. From Sibling 1’s injury until the ICPC there were no multi-agency plans in place to safeguard the children, e.g. a written agreement with the parents regarding living arrangements and contact with their Father, which meant that Mother and the children were extremely vulnerable.  It appears that the lack of a timely Strategy Meeting contributed to the subsequent absence of multi-agency co-ordination. In addition, agencies may have been less concerned as Mother and the children had gone to live with the MGM and hence were considered to be safeguarded.  The failure to identify that Father had a different GP meant that highly significant information was not available to the ICPC. There is a record of Sibling 1 being spoken to by a Social Worker, but not the other children.  This was a missed opportunity to gain the children’s views and develop a much-needed picture of their lived day to day experiences.  14  on 26 September, 3 October, 24 October and 8 November 2012.  Recording indicates that the children and home were viewed as appropriately cared for.  There is no recording of the children being spoken to and the reasons for the CPPs discussed with them. In September 2012 Mother is reported as being uncertain about ending her relationship with the children’s Father. 8.3.3 In September 2012 the School Nurse undertook health assessments; Sibling 2 required an optician’s check and Sibling 1 a dental assessment.  Head lice was reported to be a recurring problem for Sibling 1.  Both children were obese and had high BMIs.  Referrals to the Lifestyle Activity and Fitness (LAF) Team were discussed with Mother, but she declined on the basis that she could not cope at that time.  At a review six months later, undertaken by the new School Nurse, Mother agreed to referrals and the children attended appointments with LAF in May 2013.  Mother recognised that the School Nurse had provided advice regarding managing the children’s weight.  8.3.4 On 3 October 2012 Mother’s safety was discussed at a MARAC meeting, due to the three alcohol related domestic abuse incidents in May, June and July 2012.  Actions agreed included offering Mother support from the Domestic Abuse Service in obtaining a Non-Molestation Order, but she did not accept this.  She did, however, accept extra security being fitted to her house, e.g. panic alarm, safety locks.  Also both Parents were to be referred to the Substance Misuse Service. 8.3.5 Following Sibling 1’s injury Mother and the children had been living with the MGM. On 4 October 2012 there was a discussion between the Social Worker and School Nurse about the family returning to their own home and this was agreed.  It is positive that this discussion took place, but there is no record of a discussion with the other Core Group members. The timing of this discussion is interesting as it was only a matter of a few days before the next Core Group meeting and there was no reason why the arrangement could not continue until then. 8.3.6 The Social Worker visited Father on 7 November 2012.  He had recently been released from Prison, where he stated he had completed a detoxification program.  Father agreed to make contact with the domestic abuse and substance misuse services. This was the first home visit to Father since the injury to Sibling 1 in July 2012.  15  8.3.7 The RCPC was held on 19 November, 2012. Reports regarding the care of the home and children were positive, but neither Mother nor Father had engaged with the domestic abuse or substance misuse services.  In addition, Father had not engaged with Probation or the Mental Health Service.  At this Conference the previous recommendation that Children’s Services should consider commencing the Public Law Outline (PLO) was removed.  It is not clear why this decision was taken given the Parents’ lack of engagement, which indicated a lack of understanding of the causes for concern.  8.4.  First RCPC to Pre-birth Child Protection Conference 8.4.1 The first Core Group after the RCPC was held on 11 December 2012, then on 8 January 2013 and 5 February 2013. In January 2013 the school reported that Sibling 2 was anxious in unfamiliar situations and in February 2013 that both Siblings 1 and 2 presented as anxious and reluctant to talk about their home life. 8.4.2 Mother had attended an appointment with the Substance Misuse Service in January 2013 and reported that she had reduced her alcohol intake since separation from the children’s Father. In February 2013 she was offered a service by an organisation offering services to women who had experienced domestic abuse. 8.4.3 In January 2013, just three days after the Core Group meeting, Mother had a consultation with her GP, having had a positive pregnancy test at home two weeks earlier. She had an appointment with the Midwifery Service the same day.  Mother thought she was 31 weeks pregnant, but was confirmed to be 28 weeks.  The Father of the unborn baby was the same Father as the older children. The Midwife completed the Vulnerability Tool, which was sent to the Health Visitor in February 2013.  The purpose is to share information, Comment:  It is interesting to note that the recording of home visits focussed on the home conditions and care of the children, rather than the reasons for the CPPs, e.g. the children being exposed to domestic abuse. There is a record of a discussion, and agreement, between Social Worker and School Nurse about the family returning home, which raises the question why this discussion could not wait until the Core Group meeting, four days later. This would have been a multi-agency discussion, involving Mother and Father, and the Core Group could have ensured that adequate safeguards were in place for Mother and the children.  There was a lack of engagement with Father, with the first visit to him taking place in November 2012, i.e. four months after the injury to Sibling 1. The CPPs continued at the RCPC, but the recommendation to consider PLO was removed.  It appears that consideration was not given to the fact that both Parents’ lack of co-operation was in itself a risk factor.  16  highlighting vulnerabilities and risk factors, which will identify if additional support and referral to CSC are required. 8.4.4 There were discussions at the time as to whether this was a concealed pregnancy.  The CCG Report Author notes that a concealed pregnancy is when: • An expectant mother knows she is pregnant, but does not tell any professionals  • When she tells another professional, but conceals the fact that she is not accessing antenatal care  • When a pregnant expectant mother tells another person/s and they conceal the fact from all agencies 8.4.5 0n 15 January 2013 Police were called to the family home.  Allegedly the Father had broken into the house through the garage and climbed into bed.  He was removed by the Police in handcuffs.  The children were at home and reported by the Police to be frightened and hiding under a duvet. The Police assessed Mother as being at high risk and informed CSC of the incident. In line with guidance the case was considered at MARAC on 6 February 2013, due to four or more reported incidents in six months. It was again recommended that Mother be supported by the Domestic Abuse Service and confirmation of Father’s involvement with the Substance Misuse service be confirmed.  Parents again failed to engage. 8.4.6 Child protection monitoring visits to the home were undertaken in December 2013 and March 2013.  In December Mother had bruising to her eye and stated this had been caused by a fight in a nightclub with another woman.   Mother was pregnant at this time.  In March 2013 the Social Worker discussed with Mother her lack of engagement with the Substance Misuse Service, which had offered 1:1 support.  Mother stated she did not have difficulties with alcohol, but the Social Worker encouraged her attendance. 8.4.7 The Social Worker visited the children at school in February 2013 following the domestic abuse incident in January 2013.  The children talked of being frightened by previous incidents and Sibling 1 said that she was happier having supervised contact with her Father.    8.4.8 On 12 February 2013 a Strategy Meeting was held regarding the unborn baby; the decision was made to convene a Pre-Birth CPC. This was held on 6 March 2013 and the unborn child was made the subject of a CPP in the category of neglect. The other children were not considered at this Conference. Recommendations included that a Legal Brief should be held and contact with Father should be supervised.  17   8.5. Pre-birth CPC to RCPC 8.5.1 On 20 March 2013 at the ante-natal clinic Mother stated that she had been using cannabis and tested positive for cannabis on urine toxicology. The Substance Misuse Midwife referred Mother to the Substance Misuse Service and informed the Health Visitor. The Midwife also tried to contact the Social Worker, but was unable to do so and spoke to the Out of Hours Service. 8.5.2 Core Groups appear to have been planned, but did not take place on 11 March, 8 April and 25 April 2013. The School Nurse contacted the Social Worker on 9 April 2013 to ascertain the new date. The Social Worker was unable to attend the meeting on 25 April 2013 at short notice, so the practitioners who attended held an Information Sharing Meeting, as recommended in SSCB’s Inter-agency Procedures in such circumstances.  A Core Group meeting should then be held within 10 working days of the Information Sharing Meeting, but this did not take place. 8.5.3 A child protection monitoring visit was undertaken on 28 March 2013, when the home conditions were noted to be ‘adequate, but cold’.  Mother was dressed in her coat and scarf. 8.5.4 Baby L was born on 20 April 2013.  The Midwife requested a pre-discharge meeting with CSC. There were difficulties with the Social Worker’s availability, but the Midwife persisted and a meeting was held.  It was agreed that Mother and the children would reside with the MGM following discharge in order to provide support and establish a routine. 8.5.5 The Social Worker and Team Manager made an unannounced home visit on 26 April 2013 to see how Baby L was progressing following his discharge from hospital.  They found Mother at home with two males, with evidence that they had been drinking alcohol, e.g. cans in garden and kitchen.  Mother said these males were her cousins.  Sibling 3 was present, but the other children were with Grandparents, Baby L being with his MGM.  Despite the purpose of the visit, Baby L was not seen. At the subsequent RCPC the Team Manager Comment:  The Learning and Recall Events debated whether Mother’s pregnancy had been concealed.  Mother had a pattern of late bookings, but she had known for at least two weeks that she was pregnant and had chosen not share this with professionals, e.g. at the Core Group. It is likely that Mother would have been worried about how she would explain the pregnancy to professionals as she had stated that she had not been in a relationship with the Father for some time. On balance, this would appear to be a concealed pregnancy. It was important for agencies to consider this factor, as it was an indication of how honest Mother was being with the practitioners working with her.  18  commented that she believed that the Father was in fact one of these two males.  Another visit was attempted on 1 May 2013, but the family was not at home. 8.5.6 As required the post-natal 24 hour Vulnerability Assessment was completed by the Midwife and received by the Health Visitor on 26 April 2013.  This Assessment identifies any risks to the baby.  The Health Visitor undertook the Primary Birth Visit on the same day.  Baby L was clean and well, although he was ‘snuffly’.  Safe sleeping was discussed with Mother.  The assessment by the Health Visitor included revisiting ‘the issues related to health and safeguarding risks’. No concerns were identified regarding post-natal depression or low mood. A further visit by the Health Visitor was undertaken on 3 May 2013 and Baby L was clean and well presented, although he had ‘snuffles’ and a slight rash.  He was seen later in the day by the GP with thrush and an upper respiratory tract infection. 8.5.7 In respect of the Public Law Outline (PLO) a Legal Brief was held on 19 April 2013 and it was agreed that PLO would be initiated.  The plan was that the Pre-proceeding Letter would be provided to Legal Services by the Social Work Team by the end of April 2013 and a PLO meeting with those holding Parental Responsibility be held on 10 May 2013.   However, due to staffing difficulties the letter was not prepared and the PLO meeting did not take place. 8.5.8 The RCPC was held on 15 May 2013.  It was agreed that the CPPs would continue, but the category would change to neglect.  Sibling 1 had written a letter to the Conference Chair expressing her wish that her Father should be allowed to return to the family home.  PLO was not being taken forward, but the reasons for this are not clear.  Comment:  No Core Groups were held during this period, which meant that the CPP for Baby L was not developed or circulated to agencies and the Parents. There is evidence that the School Nurse contacted the Social Worker for a date for the Core Group, but not that other agencies did so.  There is no evidence of escalation or discussion with Safeguarding Leads. It is positive that Core Group members held an Information Sharing Meeting in April when the Social Worker was unable to attend, but of concern that the next Core Group was not held within 10 working days, as required in SSCB procedures. Three child protection monitoring visits were attempted, in March, April and May, but the children were only seen on 28 March.  The visit in April, a few days after Baby L’s birth, is noteworthy, as the aim was specifically to see how Baby L was progressing.  However, this was not achieved.    This meant that Baby L had not been seen at home by CSC prior to the RCPC, when he was aged approximately 4 weeks.  This was an important time for the family, given the addition of a young, vulnerable, baby to the family.   19  8.6. Second RCPC to third RCPC 8.6.1 The Core Group planned in April 2013 was cancelled and the first Core Group since 5 February 2013 took place on 24 May 2013.  By this time a new Social Worker had been allocated to work with the family.  At this time Baby L was in hospital and the MGM was caring for the other children. The school reported that the children were happier. The school raised concerns about information sharing by CSC and the delay in the allocation of a new Social Worker. 8.6.2 The next Core Group took place on 21 June 2013, but the one planned for 15 July 2013 did not take place due to the unavailability of the Social Worker.  Again an Information Sharing Meeting was held by the practitioners present, but the next Core Group was not held within the ten day period.  Core Groups were then held at regular intervals on 23 August, 19 September and 18 October 2013, with the next RCPC taking place on 5 November 2013. 8.6.3 At the Core Group in June 2013 Mother had commenced working with the Domestic Abuse Service and was undertaking the Freedom Programme for women who have experienced domestic abuse.  The children were again reported to be more confident and Siblings 1 and 2 were attending appointments regarding their weight. In August and September 2013 Mother was continuing to engage with the Domestic Abuse Service and had also attended appointments with the Substance Misuse Service in respect of her use of alcohol.  The children were having contact with their Father at the Paternal Grandparents home at the weekend.   8.6.4 Regular child protection monitoring visits were undertaken in May, June, July, August, September, October and November 2013. Whilst there were some concerns noted about the home, e.g. piles of ironing in May 2013, bathroom needed cleaning in June 2013, overall the home conditions were viewed as satisfactory with age appropriate toys for the children. Previously it had been noted that the home was cold, but in November 2013 it was noted to be clean and warm.  There were some concerns about the sleeping arrangements, i.e. Mother sleeping with the three youngest children, and safe sleeping was discussed. The children presented as relaxed at home and with their Mother.  In July 2013 they told the Social Worker that they were happy at home and enjoyed seeing their Father on Saturdays at the home of their Paternal Grandparents. 8.6.5 Mother told the Lead Reviewer that the most recent Social Worker had been helpful to the family.  Mother was aware that the children needed to be at home when the Social Worker visited and on the visits she had talked to children and played games with them.  Mother was grateful to the Social Worker for raising money for bunk beds.    20  8.6.6 On 18 July 2013 Sibling 3’s 4 year developmental assessment was undertaken at home by the Health Visitor.  She was clean and well-presented and reaching all her developmental milestones.  8.6.7 Mother had her post natal check with the GP on 4 June 2013.  The GP assessed Mother’s mood as good and noted she was receiving support from the MGM.  It was not established whether Mother was smoking and required cessation advice.  The CCG Report Author references the NICE Guidelines and the fact that health risks posed to babies from smoking both antenatally and following birth are substantial in that more than a quarter of sudden and unexpected deaths in infancy are attributable to smoking. 8.6.8 On 12 June 2013 Baby L had his six week check with the GP; his development was normal. Mother was given advice about the Smoking Cessation Clinic, but did not take this up.  There was no discussion about the Child Protection Planning as would have been expected.  The Health Visitor conducted the 6/8 week development assessment the next day.  Baby L was smiling, a feeding routine had been established and he was developing on 9th centile.  The Health Visitor subsequently undertook Baby L’s three/four month developmental assessment on 13 August 2013.  He was clean and well presented.  His development was good, he was gurgling and there was ‘lovely interaction’ with his Mother. 8.6.9 However, during this time there were growing concerns about Baby L’s physical health: • 3 May: Taken to GP with Upper Respiratory Tract Infection (URTI) • 20 May: Inpatient for 7 days with bronchiolitis • 8 July:  Taken to GP with diarrhoea & vomiting • 15 July: Referred to Paediatric A & E Department by GP and admitted overnight due to shortness of breath and poor feeding • 25 July:  Admitted to hospital with chest problems.  Discharged same day • 2 August:  Referred to hospital by GP, unwell and irritable • 5 August: Taken to A & E Department due to shortness of breath, admitted for observation • 13 August: Taken to A & E Department due to shortness of breath • 9 Sept: Out-patient review.  Still coughing and mediation prescribed • 20 Sept: Taken to A & E Department with bronchiolitis and viral rash.    Discharged same day • 24 Sept: Taken to Hospital by ambulance from GP Surgery due to respiratory distress.  Oxygen required.  Admitted to hospital • 22 October:  Seen by GP.  Happy and feeding well.  Still wheezy and had nappy rash 8.6.10 The Agency Report Author for the Acute Trust noted that ‘it is widely accepted that children often have between 10 and 12 infections per year  21  and respiratory problems usually account for a large proportion of these.  These respiratory illnesses are usually minor and do not require admission to hospital.  Baby L had an above average number and severity of respiratory infections’. He had a number of medical investigations that concluded these infections were caused by a range of viruses and bacteria.  His immune function was checked and was normal.   It was recognised that Mother was a smoker and there is overwhelming evidence that children of smokers have an increased number of respiratory infections.  The Report Author noted that ‘while smoking is detrimental to a child’s health, it is so common that it is not specifically judged of being a sign of neglect.’ The Author also comments that the evidence in respect of a cold atmosphere increasing the frequency or severity of respiratory infections is scant, although there is some evidence that the ‘envelope’ that covers the virus becomes more rigid in cold conditions making it harder for the body to fight the virus. 8.6.11 The NHS Foundation Trust Report Author provides helpful information about Bronchiolitis, inflammation of the bronchioles, the smallest air passages of the lungs.  This usually occurs in children less than two years of age with the majority aged between 3 – 6 months. The symptoms include shortness of breath, wheezing and coughing, with some children also having feeding difficulties. Bronchiolitis is most commonly caused by a virus and the treatment of bronchiolitis is focused on the symptoms.  8.6.12 Advice includes: • Washing hands of the child and adults frequently • Washing toys and surfaces regularly • Keeping new born babies away from people with colds and flu • Preventing children being exposed to tobacco smoke 8.6.13 The Hospital followed procedures in terms of informing the GP and Health Visitor of Baby L’s admissions and discharges. However, there was no direct verbal communication between hospital staff and health staff in the community, and CSC was not informed of Baby L’s admissions.   This means that a holistic view was not taken of Baby L’s health needs or consideration given to social factors which might have impacted on his health.    8.6.14 In the main Mother was viewed as accessing medical services appropriately when Baby L was unwell.  Hospital staff noted that Mother stayed with Baby L during his admission, including overnight, and was observed to meet his needs.  However, the GP noted on 2 August 2013 that Mother was ‘frustrated’ at ‘being back and forth’ to the hospital.  There was also concern on 24 September 2013 when Baby L was taken to the GP surgery for routine immunisations and was found to be very unwell with another respiratory illness.  An ambulance was called and Baby L was taken to hospital from the surgery.  He was admitted and required oxygen.   The surgery was concerned about Mother’s response to Baby L’s illness on this occasion and whether she had  22  not been aware of how unwell he was.   Alternatively she may have been worried about making a fuss/being too demanding or she may have been somewhat over-whelmed by the demands of caring for Baby L.  Mother was upset and agreed to the Practice Nurse contacting the Health Visitor about arranging additional support.  The Practice Nurse did this, but no contact was made with the Social Worker. 8.6.15 Mother explained to the Lead Reviewer that the Health Visitor had visited every two weeks following Baby L’s birth and had provided the following advice regarding his health, which she had found helpful: • Not to smoke in the house (in garden) • Wash hands after smoking • Place Baby L on his back to sleep • Put Baby L to sleep in the Moses basket or cot  8.6.16 Mother also commented that Sibling 3 had similar breathing difficulties.  Heating in the home was a problem as it was ducted and got very hot very quickly, so she had to keep turning it off. 8.6.17 It was recognised by health practitioners that there is a link between parental smoking and the increased risk of respiratory infections in babies and Mother was provided with information about Smoking Cessation Clinics by both the GP and the Health Visitor.  However, it does not appear that this was pursued very robustly.  8.6.18 There continued to be occasional domestic abuse incidents during this period.  In June 2013 there was a verbal altercation in the street, both Baby L and Sibling 3 were present. The Police assessed Mother as high risk of domestic abuse.  In September 2013 Father came to the property and Mother refused to let him in, Baby L was present and asleep.  Mother appropriately contacted the Police on these occasions. 8.6.19 There were two significant events during this period.  On 24 July 2013 the Police received an anonymous referral from a male alleging that Mother was intoxicated whilst caring for the children. Police attended the property. A baby could be heard crying and, despite trying for 10 minutes, the Police had difficult rousing Mother.  Access to the property was obtained with the assistance of the MGM and, when Mother was woken, she was aggressive and abusive to the Police.  Alcohol could be smelt on her breath.  The children were at home and were left in the care of Mother and the MGM. On the visit on 6 August 2013 the Social Worker discussed this incident with Mother, who stated that she had been shocked which was why she lost her temper with the Police Officers.  She acknowledged she had had two cans of lager and agreed to self-refer to the Substance Misuse Service. 8.6.20 On 5 October 2013 Mother contacted the Police as Father was sending harassing text messages. He had come to the family home and was banging  23  and kicking the door, demanding to see the children.  The Police attended and Father left.  The Police reported that the children were home, they were ‘unharmed and seemed unaffected by this incident’.  On 16 October 2013 the Social Worker discussed this incident with Mother. She acknowledged that she had ‘had a couple of drinks’, but had been fit to care for the children.   8.6.21 Following the incident Mother was again the subject of discussion at MARAC on 20 October 2013.  This was a re-referral, due to four incidents of domestic abuse in four months, as per MARAC guidance.  It was noted that Mother had engaged with both the Domestic and Substance Misuse Services and the Substance Misuse Service was working with Father. 8.6.22 Mother referred herself to the Substance Misuse Service and had three brief sessions with the Hospital Liaison Team on 12 September, 27 September and 15 October, 2013, totalling 30 minutes.  The Social Worker advised the Service of the concerns, although the Mother told the worker that she only drank on Saturday nights when the children were not with her.  The Service provided was very much at the ‘lower level of support’ and a fuller assessment was arranged.  8.6.23 In respect of the Father, there was an incident towards the end of July 2013 when he was taken to A & E by the Police in the early hours of the morning.  He had been drinking heavily and been arrested.  He alleged to the Police that he had taken a cocktail of ecstasy, codeine and diazepam tablets.  He refused blood tests, was observed for five hours and discharged.  This information was shared with his GP, but it was not shared with CSC either by the Hospital, the Police or the GP, despite the children being the subjects of CPPs. 8.6.24 The Social Worker visited the Father on 17 October, 2013.  He denied any involvement in the recent incidents, but did agree to refer himself to the substance misuse and domestic abuse services.  This appears to be the second visit to Father in twelve months. 8.6.25 A RCPC was held on 5 November 2013.  The Social Worker had completed a Parenting Assessment with Mother, which was noted to be positive.  Reports from the school and health regarding the children were positive.  The children were attending school regularly and progressing well academically, with homework completed on time.  Siblings 1 and 2 had attended clinic appointments in respect of their weight.  Baby L’s attendances at hospital for respiratory difficulties were noted. The GP’s report raised concerns about Mother’s lack of understanding of Baby L’s health needs and noted her continued smoking.  There had been less reports of domestic abuse and Mother was engaging with agencies, including the Domestic and Substance Misuse Services. The Domestic Abuse Service was not represented at the RCPC and did not submit a report. The Substance Misuse Service was present,  24  but similarly did not submit a report. Father had failed to access any of the services offered to him.  8.6.26 Mother talked to the Lead Reviewer of feeling very nervous about attending the domestic abuse group sessions, but found it was okay once she got there and these had been helpful.  She felt it was a ‘really good’ service. She had attended 11 out of 12 sessions, but did not complete the final session, due to Baby L’s death. She has also found the substance misuse service helpful, although she only ‘drank at weekends’ and is ‘not a heavy drinker’. 8.6.27 It was unanimously agreed at the RCPC that the CPPs should cease but, in recognition of the family’s long-standing difficulties, that robust Child In Need Plans (CIN) should be put in place.  The Chair of the RCPC recommended that these should continue for a further six months in order that the family would continue to receive support.  8.7. RCPC to Baby L’s death 8.7.1 On 14 November 2013 Mother failed to attend an appointment with The Substance Misuse Service.  The purpose of this appointment was to commence a comprehensive assessment, i.e. to gain a fuller understanding of her alcohol use.  A follow up letter was sent, but there was no response, so no further appointments were offered or attended. 8.7.2 Baby L’s health difficulties continued.  He attended for a review with the Consultant Paediatrician on 16 November 2013 and was prescribed a Comment: This appears to be a more settled time for the family.  There were occasional domestic abuse incidents, when Mother contacted the Police. Mother had engaged with the service for women experiencing domestic abuse, but had had minimal engagement with the Substance Misuse Service. She advised that she only drank at weekends when the children were not with her.  However, there was evidence that this was not in fact the case and this was not challenged.  Father had failed to engage and remained an unassessed risk. During this period there was a change of Social Worker and from then Core Groups were held, and child protection monitoring visits undertaken, regularly. The children were seen at home by the Social Worker and Health Visitor, and appeared to be well and happy, but there is little recorded as to their feelings and views, hence it is difficult to gain a picture of their lived experiences and whether life had changed for them. Baby L’s development was good, although there were concerns about his health needs. Given the Parents’ long standing difficulties, going back to 2005, it was early days to assess the impact of mother’s engagement with services and whether this would be maintained and make a positive difference for the family.    25  salbutamol inhaler.  He was taken to the GP on 18 November 2013 with a wheezy cough and nappy rash and was seen by the Health Visitor at home on 3 December 2013 when he was chesty.  Mother felt that the inhaler was helping his breathing difficulties.  The Health Visitor discussed the risk of second-hand smoking and again suggested the Smoking Cessation Clinic.  Mother declined this, indicating a lack of appreciation of the dangers of smoking around young babies. Baby L’s weight had increased from 50th to 75th centile. It was noted the home was clean, tidy and appropriately furnished, with age appropriate toys.  The house required a new boiler, as there was only ducted heating in the house.    8.7.3 The Social Worker visited the family on 2 December.  The children continued to be happy and relaxed at home.  The bedrooms and bedding were noted as appropriate. 8.7.4 On 4 December Baby L was taken to hospital by ambulance, due to breathing difficulties and not feeding. He was admitted and discharged three days later on 7 December, with a referral to the Ear, Nose and Throat Clinic.   On 11 December the Health Visitor was informed by the hospital that on admission Baby L had nappy rash, which ‘looked bad’, and concerns had been noted about mother’s lack of interaction with him, e.g. lack of reassurance during medical procedures.  CSC were not informed of these concerns.  It appears that the nursing staff were aware of Baby L’s history and the previous child protection concerns.  However, the Consultant dealing with B at this time was not aware of the history and in the discussion with the Agency Report Author the Consultant stated that if he had known he would have had a discussion with the Social Worker prior to Baby L’s discharge.  8.7.5 The increased risk of respiratory infections in babies due to parental smoking is well recognised, but it does not appear that, despite Baby L’s continuing health difficulties, this was given due regard and the risks discussed robustly with Mother by hospital or community staff. 8.7.6 On 16 December the first CIN Review Meeting was held post the RCPC.  This was attended by Mother, Social Worker, Health Visitor and the school.  Things had continued to go well and the school reported that the children had increased in confidence, were making good academic progress and were communicative with staff. Baby L’s health continued to be a cause for concern, but it does not appear that the Acute Hospital’s concerns were shared.  A unanimous decision was taken to cease the CIN Plans, once contact had been made with the Father, despite the recommendation from the Chair of the RCPC that these should continue for six months in order to consolidate the changes.  26  8.7.7 On 20 December Mother called an ambulance as Baby L had been found not breathing.  Despite attempts by the paramedics and hospital staff it was not possible to revive him. The post-mortem indicated an acute respiratory infection, rather than a chronic disorder. The Police reported that the house was very cold, extremely untidy, without satisfactory bedding. This was a different picture to that gained by recent home visits by the Social Worker and Health Visitor, so raises a question as to whether there had been a deterioration in home conditions in a short space of time. It was known that there were difficulties with the heating in the house and Mother had reported this.  9.   Thematic Analysis The analysis section of the Overview Report will consider, and reflect on, the information above, which has been collated from the Agency Reports and discussions at the Learning Event and Recall Day.  The emerging themes are identified and discussed in sections, leading to the lessons that need to be learned from this SCR and recommendations for SSCB.  It is important to guard against hindsight in drawing conclusions and to bear in mind the context that practitioners were working in at this time. The Emerging themes include: 1. Agencies’ response to domestic abuse 2. The children’s lived experience 3. Quality of assessments 4. Quality of inter-agency communication 5. Child protection processes � Strategy meeting � Initial Child Protection Conference � Core Group working � Child Protection Planning � Decision Making:  Public Law Outline 6. Parental smoking 7. Management oversight and supervision  Comment:  Approximately six weeks after the RCPC, which had ceased the CPPs, the decision was taken to end the CIN Plans despite the clear recommendation that these should continue for six months in order to support Mother in maintaining the changes made.     ‘Step-down’ from a CPP to a robust CIN Plan can be very effective in working with families, supporting and promoting change, but only if sufficient time is allowed for changes in families to become embedded.  27  9.1. Agencies’ response to domestic abuse 9.1.1 In this case there is a substantial history of alcohol and drug related domestic abuse dating back to 2005 and a significant number of notifications and referrals were sent to CSC by the Police in the years following 2005 until the child protection referral in 2012 in respect of Sibling 1’s injury to her finger, which triggered the child protection processes.  9.1.2 A number of these incidents were serious: • Jan 2009:  Both Parents drunk, Father had punched Mother in the face.  Arrested for assault and criminal damage • June 2010:  Altercation between Mother and Father, both intoxicated.  Police attended and Mother assaulted a police officer • May 2011:  Mother sustained facial injuries and bruising.  Father arrested for assault occasioning actual bodily harm.  Mother refused treatment 9.1.3 There were also instances of domestic abuse when Mother was pregnant in October 2006 and March 2009.  Pregnancy is recognised as a time of increased risk for women and the unborn child. 9.1.4 There were additional indications of domestic abuse in the home.  In January 2006 Mother had a miscarriage and there was evidence of bruising, which led to a referral to CSC.  In April 2012 Sibling 3 told staff at the Foundation Unit that ‘dad punches mum in the face’. When this was discussed with the MGM  she commented that the older children have said similar things to her. 9.1.5 The process for dealing with instances of domestic abuse was discussed at the Learning and Recall Events.  It appears that Police routinely sent Child Concern Notifications (CCN) following incidents of domestic abuse, as either notifications or referrals, to CSC.  Referrals tend to be when children are identified in the family/present at the incident.  The volume of incidents and notifications that the police were dealing with at any one time meant that they were unable to thoroughly assess the notifications before sending to CSC, e.g. link with previous incidents and identify patterns.  The high volume is evidenced by the fact that in the last year the Police have dealt with 36,000 incidents of domestic abuse. 9.1.6 In respect of CSC’s response to the notifications between 2005 and 2012, there were broadly four types of responses:  • No further action:  2005, 2006, 2007, 2008, 2009, 2010 • Recommendation to undertake an Initial Assessment, but no evidence this was undertaken:  2007 and 2009  • Unsuccessful attempts to contact Mother, followed by NFA • Contact made with Mother: 2011, telephone discussion, agreed Initial Assessment to be undertaken should Mother reconcile with children’s Father  28  9.1.7 The risk to Mother was considered at one MARAC prior to the Scoping Period and three during the Scoping Period.  These are regular local meetings where information about high risk domestic abuse victims is shared between local agencies. By bringing all agencies together at a MARAC, a risk focused, co-ordinated safety plan can be drawn up to support the victim.    9.1.8 Mother was regarded as high risk at the MARAC Meeting in April 2009, the support of an IDVA was offered but declined by Mother, so the case was deregistered from MARAC 12 months later by the Detective Inspector.  Following incidents in May, June and July 2012 Mother’s safety was discussed at the MARAC Meeting in October 2012 and support was offered for her to obtain a Non-Molestation Order, but again she did not co-operate.  Further incidents led to subsequent discussions at MARAC in February 2013 and October 2013. For a considerable time Mother was reluctant to engage with the support being offered, apart from the fitting of some safety measures to the home.  It is not apparent that consideration was given by the agencies represented at MARAC to the fact that this lack of co-operation indicated a lack of appreciation by Mother of the continuing danger to which she was exposed and the risks of harm to the children, which increased the risks.   9.1.9 Police reports indicated that the children were often not at home, but in the care of the MGM, when the incidents of domestic abuse occurred. However, there would have been occasions when, at the very least, they would have seen their Mother with facial bruising, e.g. in February 2009 and May 2011.  It is recognised that incidents reported to the Police can be the tip of the iceberg, however, there was little attempt to talk to the children and understand the impact on them.  The few discussions held with Sibling 1 indicated that she had a real sense of her Parents’ difficulties 9.1.10 There was a long term history of domestic abuse incidents in this family, but none of the agencies were looking at the pattern, risks and the long term impact on the children, rather tending to deal with each incident in isolation.  The MARAC Process appeared to have had little impact, due to the Parents’ lack of engagement. Co-ordinated Activity Against Domestic Abuse (CAADA) is undertaking a review of the functioning and effectiveness of the MARAC processes in Sunderland and will be reporting on its findings and recommendations.   9.1.11 Mother told the Lead Reviewer that she had been advised to call the Police whenever Father came to the house and when she did this the Police always came out straight away.  There seemed to be some confusion by Mother as she thought she had a Restraining Order with a Power of Arrest, but the Police were not aware of this.  In fact, the records do not indicate that a Restraining Order was in place during the Scoping Period. 9.1.12 It should be noted that the Police Force has shown commitment to developing its service to the victims of domestic abuse.  In 2012 victimless  29  prosecutions could be pursued and in 2013 the DASH (Domestic Abuse, Stalking and Harassment) risk assessment model was adopted, which helps to decide the level of intervention.  Additionally there have been developments nationally; in 2014 the Domestic Violence Disclosure Scheme (Clare’s Law) and Domestic Violence Protection Notice/Domestic Violence Protection Orders were introduced.     9.2. The children’s lived experiences  9.2.1 The importance of seeking the views and feelings of children and young people and gaining a picture of their lived day-to-day experiences has been consistently highlighted in research arising from SCRs.5 An understanding of the impact of parental difficulties on children can be obtained not only from what the children say directly, but also by how they behave and from the observations of other significant people, especially family members, who can speak on their behalf.   9.2.2 From the Agency Reports and discussion at the Learning Event, it appears that until there was a change of Social Worker in April/May 2013, there was limited direct communication with the children.  However, there were occasions when there were spotlights on to the children’s world which, if drawn together, would have provided an overview. These included: • April 2012: Sibling 3, aged 2 years 10 months, told the staff at his Foundation Unit that his ‘dad punches his mam in the face’.  The MGM confirmed the older children had said similar things to her • June 2012:  Police attended a domestic abuse incident.  The children were present and Sibling 1 told the Police Officers that her Father was often abrupt and rude to her • July 2012:  Sibling 1 was injured when she intervened to protect her Mother during a domestic abuse incident.  Sibling 1 spoke of being angry and fed up with her Parents’ arguing • January 2013:  Police attended a domestic abuse incident, Father was arrested for Breach of the Peace and harassment.  The incident occurred in full view of the children, who were reported by the Police to be frightened and hiding under a duvet • February 2013:  Children told the Social Worker that they had been frightened by the previous incidents and Sibling1 said that she was happier to be having supervised contact with her Father                                                            5 Ofsted, The Voice of the child: Learning lessons from Serious Case Reviews.  A thematic report of Ofsted’s evaluation of serious case reviews from 1 April to 30 September 2010, 2011.   30  9.2.3 Evidence has been gained through this SCR that the children were living in a family where there had been long term issues of domestic abuse and substance misuse. However, their views, wishes and feelings were not sought.   Research suggests that children are much more aware of such parental difficulties than parents and agencies believe. Gorin’s literature review, Understanding what children say,6 examined what children say about living in families where there is domestic violence, parental substance misuse and/or parental mental health problems. The research highlighted that one of the most striking themes was the level of awareness that children have about what is going on within their family, reporting witnessing and experiencing a high level of violence and parental conflict.  Children talked about experiencing a range of feelings including love and loyalty, feeling frightened, sad, angry, embarrassed and isolated. 9.2.4 This Research has resonance for this SCR, as it is clear when the children were spoken to that they had a knowledge of what was happening between their Parents.  There were occasions when they would have seen their Mother with facial injuries.  Undoubtedly they would have experienced the feelings referred to above.    9.2.5 During the period when the children were the subject of CPPs, there is one example, in February 2013, of the Social Worker speaking with the children away from the family home about what was happening at home and it does appear that the children were able to speak openly.  However, this appears to be the only time that this happened.  All other contacts with the Social Worker were within the family home and the children were seen together rather than individually.  In addition, it is not clear that on these visits the Social Worker spoke to the children about their experiences at home, certainly this is not recorded.  9.2.6 The Government guidance in force at the time of the SCR, Working Together to Safeguard Children 2010, Chapter 5,7 states that the Lead Social Worker should develop a relationship of trust, a ‘therapeutic relationship’, with the child. The Lead Social Worker should see the child, alone when appropriate, in accordance with the Child Protection Plan, and regularly ascertain the child’s wishes and feeling, keeping the child up to date with the Child Protection Plan. The Lead Social Worker should record in the child’s Social Care record when the child was seen, who else was present and the reasons for deciding, or not, to see the child alone. 9.2.7 The Ofsted Thematic Report, Voice of the Child, 2011,8 which looked at the findings of SCRs found that the child was either not seen by the professionals                                                            6 Sarah Gorin, Understanding what children say:  Children’s experiences of domestic violence, parental substance misuse and parental health problems, National Children’s Bureau, 2007 7    DCSF, 2010 8    Ofsted, 2011  31  involved or was not seen frequently enough.  In other cases, even when the child was seen, they were not asked about their views and feelings.  SCRs also stressed the importance of ensuring that practitioners’ observations are clearly recorded and the consequences which can arise when this does not happen.  9.2.8 During the Learning Event the school noted that the children are very quiet, which is similar to their Mother.  However, this quietness could be interpreted in another way.  The NCB research,9 suggests that professionals should be proactive in talking to children, particularly if there are signs that they may be experiencing problems at home, e.g. being withdrawn or unusually quiet. Children’s accounts of coming into contact with professionals in relation to domestic violence indicated that, in some cases, professionals did not speak directly to them. 9.2.9 The staffing difficulties in CSC during the earlier part of the Scoping Period for this SCR undoubtedly impacted on building a relationship, and engaging, with the children.   There were difficulties in the recruitment and retention of Social Workers and managers, leading to a high level of agency staff. 9.2.10 The lack of engagement could also relate to the focus of agencies’ attention being on the needs of the Parents rather than the needs of the children, a factor identified in many SCRs.  Ofsted noted that practitioners tended to focus too much on the needs of the Parents, especially when working with vulnerable Parents, and overlooked the implications for the child.10 9.2.11 This lack of engagement with the children meant that agencies did not have an understanding of their lived, day to day, experiences nor of the risks to them from their parents’ difficulties and whether things had changed over time.  9.3. Quality of Assessments  9.3.1 The importance of timely, good quality, robust, assessments cannot be overstated.  However, there are a number of key aspects and points in this case where the assessments were lacking in quality.  These included: • Prior to the injury to Sibling 1 there were a large number of CCNs and referrals regarding domestic abuse from the Police to CSC.  Each of these incidents appear to have been dealt with as single event, rather than considering the ongoing pattern of domestic abuse and the impact that this would undoubtedly be having on the children. There appears to have been a misplaced unquestioning acceptance that the couple had separated. Many of the Police notifications/referrals                                                            9   Gorin, 2007 10  Ofsted, 2011  32  led to no further action, on two occasions there was a recommendation for CSC to undertake an Initial Assessment, but this did not take place, and on another there was a decision to undertake an Initial Assessment should the Parents reconcile • Following Sibling 1’s injury, Mother and the children went to stay with the MGM.  There is no evidence of a multi-agency risk assessment being undertaken, nor of a risk management plan being put in place.  This meant that there was no safeguards in place during the vulnerable period from Sibling 1’s injury until the ICPC, which was held 6 weeks later • One of the recommendations of the ICPC in September 2012 was that a Parenting/Risk Assessment would be undertaken.  No timescale was set for this, but at the time the statutory timescale for a Core Assessment to be undertaken was 45 days, however, it would appear that the ‘Parenting Assessment’ was not completed until October 2013.  A key element of a Core Assessment is in gaining an understanding of the Parents’ own backgrounds and the potential impact of this on their parenting capacity.  It was interesting to note that at the Learning Event, and in Reports, agencies were able to provide very little information about the Parents’ own histories • The assessment of Father was not completed.  From records it appears that only two home visits were made to him and the Paternal Grandmother and he failed to co-operate with the assessments and services offered to him.  An understanding of his mental health needs was never achieved, although at each of the CPCs a recommendation was made that Father should ‘fully engage with mental health professionals to address his depression’.  Hence, as noted in the CPC minutes, he ‘remained an unassessed risk’.  There lacked a full understanding of the nature of his contact with the children and of the impact of his substance misuse and mental health difficulties on this.  He attended Conferences but did not participate in the process.  He had never been to the children’s school or attended Parents’ Evenings.  Working Together 2013, Chapter 10,11 highlights the need for agencies to ‘Think Fathers’, noting that Fathers can have a significant impact on outcomes for children.  It highlights that Children’s Services can often be ‘Mother focussed’, without giving due regard to the role of the Father • There is evidence that both Maternal and Paternal Grandmothers (PGM) provided support to the family.  The children appear to have regularly spent time with their MGM at the weekends and she, together with Mother’s sister, also took the children to school and collected them.  The PGM had been supervising her son’s contact with the children following the injury to Sibling 1.  However, whilst the                                                            11 Working Together to Safeguard Children, 2013, DCSF.  33  Grandmothers were seen by Social Workers and invited to CPCs, there is no evidence that a thorough assessment was undertaken of the role they played in the family and could play in safeguarding the children.  Nor was there an understanding of their views of the day to day care the children were receiving.  This was a significant gap in information • An assessment of the Parents’ substance misuse, both alcohol and drugs, and an understanding of the impact of this on their parenting capacity, was never gained.  There were a number of examples of one or both Parents being intoxicated when the Police attended and Mother tested positive for cannabis use during two pregnancies (2006 and 2013).  Father failed to engage with the Substance Misuse Service.  Mother also declined to accept the service until September 2013, when she self-referred to The Substance Misuse Service, although this involvement was at a very superficial level.  It appears that, despite the evidence in July and October 2013 of Mother’s ongoing alcohol use, this was not sufficiently challenged. An appointment was offered for a more comprehensive assessment in November 2013, but not attended by Mother.  The University of East Anglia’s Report, Neglect and Serious Case Reviews highlights that; ‘Parents tended not to be honest with professionals about the extent of their alcohol or drug dependency and its impact was therefore often underestimated by professionals involved with the family.’12 The CCG Report Author references the Peter Connelly SCR (2010) which suggested that the responses parents and carers may make to inquiries may be ‘self-serving, minimising, misleading, evasive and in some cases untruthful’.  In this case there was no challenge or escalation by agencies • From a young age Baby L had significant health difficulties, leading to a number of hospital admissions.  There is no evidence that, given he was a child with a CPP, there was a multi-agency assessment of his health needs and whether any additional services were required.  There were no pre-discharge planning meetings.  The Report Author for the City Hospital notes that because discussions with the Health Visitor and Social Worker did not take place, ‘the opportunity to consider the social issues in conjunction with medical issues was missed’  9.3.2 There are two elements with regard to assessments which have been identified in SCRs nationally and which would appear to have relevance for the work with this family.  These are disguised compliance and the ‘toxic trio’, i.e. domestic abuse, substance misuse and parental mental health needs                                                             12 Neglect and Serious Case Reviews: A report from the UEA commissioned by NSPCC, UEA/NSPCC, 2013.  34  9.3.3 The NSPCC Briefing: Disguised compliance: Learning from case reviews, March 2014,13 defines disguised compliance as ’parents giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and to delay or avoid professional intervention.’  There would appear to be some evidence that Mother displayed disguised compliance.  Until mid-2013, her co-operation with agencies was limited.  It was clear from the Lead Reviewer’s discussion with Mother, that she had an understanding of the minimal requirements of the CPPs in terms of co-operation with CSC.  However, there was a history of non-engagement with the Early Intervention Service and with the support offered by the Police.  In addition, it was not until September/October 2013 that she began to engage with the Domestic Abuse and Substance Misuse Services.  In fact, even then the engagement with The Substance Misuse Service was at a ‘low level’ and the appointment for a more in-depth assessment, which would have involved greater challenge, was not kept.   There is also a view from health practitioners that Baby L’s pregnancy was concealed from agencies working with the family.   9.3.4 The term 'Toxic Trio' has been used by Ofsted14 to describe the combined issues of domestic abuse, mental ill-health and substance misuse which have been identified as common features of families where harm to children has occurred. They are viewed as indicators of increased risk of harm to children and young people.  Working Together to Safeguard Children 201015 notes that these issues rarely exist in isolation and there is a complex interaction between the three issues.  All these three issues were present in this case, but there is no evidence that this was recognised by agencies.   9.3.5 Information provided for the SILP would indicate that consideration had not been given by practitioners or managers to the significance of either disguised compliance or the toxic trio in this case and importantly the impact on the risks to the children.   9.4. Quality of inter-agency communication  9.4.1 The safeguarding of children and young people is dependent on effective communication between agencies.  This includes clear and timely information sharing, actions being agreed and recorded and any lack of                                                            13 Disguised compliance: learning from case reviews.  What case reviews tell us about disguised compliance, NSPCC, March 2014. 14 .  New learning from serious case reviews: a two year report for 2009 – 2011, Research Brief, Department of Education, 2012. 15 DSCF, 2010.  35  agreed action being followed up.  There are indications in this review that communication between agencies was not always fully effective.  9.4.2 Returning to the time prior to Sibling 1’s injury, there were a number of key points when information was shared by agencies following which action by CSC would have been anticipated.  Examples of this include the following referrals: Midwifery in 2006 when Mother had attended with bruising, the Police in February and December 2009 and May and August 2011 and the Foundation Unit in April 2012 following Sibling 3’s disclosure.  However, there is no intervention recorded by CSC in response to these referrals and no follow-up by the referrer.  It is not sufficient for agencies to simply pass information to CSC, referrers retain a responsibility to ensure this is followed up appropriately and to escalate if necessary.    9.4.3 The Foundation Unit had a clear disclosure from Sibling 3 that she had seen her Father hitting her Mother in the face, plus MGM had provided further information to support this.  Yet there was no follow up by the Unit, or by Community Health, when CSC did not respond to the referral.  Similarly, the Midwifery Service were concerned about domestic abuse in pregnancy, a time of increased risk for women and the unborn baby, and would have known that there was a young child in the household.  As discussed earlier, the Police appear to be unable to follow up on notifications/referrals unless there are criminal proceedings.  9.4.4 It has been noted that the Midwife completed the Vulnerability Form in respect of Baby L’s pregnancy and sent this to the Health Visitor and GP.   However, the CCG Agency Report Author commented that she would have expected Midwife to follow this up with a verbal discussion with the Health Visitor and GP.  In addition the GP had given Mother a written note to take to the Midwife, which should have been supported by a verbal discussion between the GP and Midwife.  9.4.5 There was a failure to identify that Father had a different GP to the Mother and children, this meant that important information was not shared with his GP and the GP was not approached for information for the Child Protection Conferences.  9.4.6 The Acute Trust’s Agency Report Author has noted the regular written communication between the hospital and community services in respect of Baby L’s admissions and treatment at the Hospital, e.g. with the Health Visitor and GP, but highlights that there was no direct verbal communication.   The Author also highlights the lack of communication with CSC.  Despite, the hospital staff being aware that Baby L was/had been the subject of a CPP (for neglect), it appears that no consideration was given to the home circumstances and the care he was receiving and whether this was  36  impacting adversely on his health.  There were no pre-discharge planning meetings.   Had staff been more aware of the concerns around the home conditions, e.g. smoking, problems with heating, this might have triggered a pre-discharge meeting.  There is also an argument that the Health Visitor and Social Worker should have sought further information and advice regarding Baby L’s health difficulties and the implications for his day to day care.  9.4.7 The Acute Trust’s Safeguarding Procedures state that the Named Professional should be informed when a child with a CPP is admitted to Hospital to ensure the necessary communication takes place. This was put in place following a SCR completed in 2011 (Baby A and Child C) when there were similar concerns about discharge arrangements.  This was not done in this case, if it had been then the communication referred to above would have taken place.   9.5. Child Protection Processes  9.5.1 As has been identified through this Report, there are a number of examples of where child protection procedures were not adhered to or where their implementation could be improved on.  • Referrals  9.5.2 As already discussed there were a number of referrals made to CSC, which did not trigger appropriate children protection processes.   • Strategy Meeting  9.5.3 The Acute Trust correctly informed CSC and the Police about Sibling 1’s presentation at hospital with the injury to her finger and both the Police and CSC responded in a timely way, Sibling 1 and her Mother were interviewed and Father was arrested for assault.  However, there is no evidence that a multi-agency Strategy Meeting, as required in SSCB’s Child Protection Procedures, where agencies could share information and action be agreed, was held.  Also there is no evidence that the other two children were spoken to at this time.  9.5.4 There was a lack of a risk assessment and of a multi-agency risk management plan to safeguard the children, e.g. arrangements for contact with their Father.  Discussion at the Learning Event concluded that the lack of a timely Strategy Meeting meant that agencies did not come together and jointly plan the way forward, setting the scene for the lack of robust multi-agency planning.  37   • Initial Child Protection Conference  9.5.5 The ICPC was held on 4 September, 2012, 6 weeks after the injury to Sibling 1.  This should have been held 15 working days after the Strategy Meeting, which agreed to the Section 47 investigation.  It was confirmed at The Recall Event that the Social Worker did not make a request to arrange the ICPC until 24 August 2012, 4 weeks after Sibling 1’s injury.  The lack of a timely Strategy Meeting could have led to this delay in arranging the ICPC.   9.5.6 Information for the ICPC was requested from the Mother and children’s GP but not provided.  Father’s GP was not identified.  Given Father’s history this was a serious gap in the information available to the conference.  • Core Group working  9.5.7 From May 2013, Core Groups were held regularly and there is evidence that this promoted more effective multi-agency working and helped to engage Mother proactively in the CPP.  9.5.8 In the earlier stages of the child protection planning the functioning of the Core Group, and hence the implementation of the CPP was inconsistent and weak. The role of the Core Group is to develop the outline CPP, put together at the Child Protection Conference, and each member of the Core Group has a responsibility to ensure that the Plan is implemented.  The first Core Group took place on 17 September 2012, the Lead Social Worker was unwell, but another Social Worker stepped in, which was good practice.  However, there appear to be no minutes from this meeting and the CPP was not developed or circulated to Core Group members, including to the family.  9.5.9 Another Core Group was held on 8 October 2012, again no minutes are available and the CPP was not updated.  The Core Group on 7 November 2012 was cancelled and rearranged on 15 November 2012.  Further Core Groups were held post the RCPC on 11 December, 8 January and 5 February 2013. Core Groups then appear to have been cancelled on 11 March and 8 April 2013, which meant that there was no Core Group between the Pre-birth CPC held on 6 March 2013 in respect of Baby L and his birth in April 2013.  On 9 April 2013 the School Nurse requested the date for the next Core Group and this was arranged for 25 April 2013.  However, the Social Worker was unable to attend, so the practitioners present held an Information Sharing Meeting.  This was very soon after Baby L’s birth, so the cancellation was not timely.  There is no evidence that this was then escalated as a matter of concern. In addition there is no evidence that any of the practitioners sought the advice of Safeguarding Leads in their agencies in respect of this matter.  38   9.5.10 SSCB’s Child Protection Procedures state that Information Sharing Meetings can be held when the Social Worker is unable to attend at short notice.  However, the next Core Group should be convened within 10 working days, which did not happen in this case.  9.5.11 The next Core Groups were held on 24 May 2013 (over three months since the last one on 5 February 2013) and 21 June 2013. On 16 July 2013 the School Nurse again asked the Social Worker for the date of the next Core Group. Further Core Groups are then held on 23 August and 19 September 2013.  9.5.12 There was a gap in Core Groups between February and May 2013, which was a significant time for the family with the birth of Baby L in April 2013.  It appears this was because the Social Worker was unwell. A new Social Worker was allocated to the family in May 2013 after which Core Groups become more regular.   9.5.13 Until this change the Core Group had not performed its function of reviewing the progress of the CPPs, evaluating the protective factors and level of risk to the children, analysing the significance of all the information available and updating the CPP as necessary.  For example there does not appear to have been consideration of the Parents’ failure to engage with the domestic abuse, substance misuse and mental health services and how this impacted on the risk to the children, nor of the support and protection offered by the Grandparents.  • Child Protection Planning  9.5.14 At the ICPC in September 2012 the children were made the subjects of CPPs under the category of emotional abuse. Sibling 1’s views about her Parents’ fighting were shared with the Conference.  The CPP included:   • Parents to engage with domestic abuse and substance misuse services • Father to engage with mental health professionals and Probation • Parenting/Risk assessments to be completed by the Social Worker (No date for completion) • Announced and unannounced child protection visits to be undertaken by Social Worker (No frequency) • Health Visitor/School/School Nurse to undertake a monitoring role • Referral to be made to Child and Adolescent Mental Health Services     9.5.15 The CPP does not appear to have been SMART - specific, measurable, achievable, realistic, with timescales.  Without realistic timescales it is very difficult to measure and evaluate progress.  Concern was raised at the Learning Event about the use of the term ‘monitoring’ in CPPs, as it lacks  39  clarity and purpose.   In addition, there was the lack of a contingency plan should the parents not comply or the plan not progress.  9.5.16 By the RCPC in November 2012 the Parents had failed to engage with agencies and there were worries that they were not taking seriously the concerns of professionals.  The parenting/risk assessment remained outstanding, so that the Father remained ‘an unassessed risk’.  However, it was noted that his contact with the children was supervised and no concerns were reported about this.   This could be seen as contradictory, as if the Father remained an ‘unassessed risk’ how could the contact be considered to be safe?  Reports in respect of the three children were positive, their health was good and they were progressing well at school.  However, there was no information in relation to the children’s views about how things were going at home. The decision of the RCPC was that the children should remain subject to CPPs, which were fundamentally unchanged, although a timescale of 10 weeks was set for completion of the parenting assessment, i.e. by February 2013.    9.5.17 In March 2013, the Pre-birth CPC in respect of Baby L was held.  Children’s Services held the view that this was a concealed pregnancy, as Mother had not booked into Midwifery Services until she believed she was 31 weeks pregnant and had not taken up opportunities to reveal her pregnancy to the Social Worker.  At this time Father had failed to engage with the Parenting Assessment.  Mother had attended an appointment with the Substance Misuse Service and had stated that alcohol misuse was no longer a feature for her.  The Service had recommended that she attend an alcohol awareness group, but she did not feel confident to do this.  Therefore, an individual session was offered, but Mother did not attend.  Similarly, Mother had attended two sessions with the Domestic Abuse Service and a group was recommended, but she failed to attend.  The Service was of the view that Mother was minimising the impact of domestic abuse on the family.  Baby L was made the subject of a Pre-birth CPP under the category of neglect.  9.5.18 At the Learning Event the view was expressed by practitioners that this Conference was something of a turning point for Mother, due to the straightforward approach taken by the Chair of the Conference, who conveyed clearly to mother the potential consequences of her failure to engage with the services being offered.  9.5.19 At the RCPC in May 2013 Parents had still failed to engage with the domestic abuse and substance misuse services and, given the concealed pregnancy, there were concerns about how open and honest they were being with professionals.  The Parenting Assessment had still not been completed, despite a timescale for completion of February 2013.  The decision was that the CPPs would continue, but there would be a change of category from emotional  40  abuse to neglect. It is not clear from the minutes why this decision was taken and this was discussed at the Recall Event.  It appears that the concerns about domestic abuse had lessened and the threshold for a CPP under the category of emotional abuse was no longer met.  There were, however, some concerns about the children’s care which indicated neglect, e.g. Siblings 1 and 2 being overweight, home cold, lack of routine.  It could be questioned as to whether the threshold for CPP under the category of neglect was also actually met. The CPPs remained virtually unchanged, although a recommendation was added that ‘Father’s contact to remain fully supervised with all of his children all of the time’.  This is the first time that there was a recommendation in respect of Father’s contact with the children.  9.5.20 Leading up to the RCPC in November 2013, Core Groups had been held monthly.   The Social Worker and Health Visitor had regularly visited the home and conditions were considered to be satisfactory, although sometimes cold, with evidence of toys for the children.  The children appeared happy and relaxed.  9.5.21 Mother had started to engage with agencies.  She had almost completed the Freedom Program with the Domestic Abuse Service, which reported that she had gained a greater understanding of domestic abuse.   Whilst there continued to be occasional incidents with the children’s Father, Mother contacted the Police appropriately. She had also had some engagement with the Substance Misuse Service and had ‘been receptive to advice’.    9.5.22 The Social Worker had completed the Child Protection Toolkits with the children and they were happy and enjoyed seeing their Father at weekends.  They were all continuing to make good progress at school and there were no problems with attendance.  In fact, Sibling 1 was making exceptional academic progress.   9.5.23 Baby L’s health difficulties were noted, as well as the fact that Mother sought medical advice appropriately, although the GP’s report raised concerns that Mother did not fully recognise the seriousness of Baby L’s condition and continued to be a smoker despite his chest problems.  Both the GP and Health Visitor had recommended Mother attend the Smoking Cessation Clinic, but she had declined to do so, indicating a lack of understanding of the impact of this on Baby L’s health and unwillingness to prioritise his needs.   9.5.24 Some concerns still persisted. There had been two incidents since the RCPC in May 2013, which were at variance with Mother’s claim that she only drank on Saturday nights, when the children were with their PGM, i.e. 24 July 2013 when the Police had difficulty rousing Mother and 5 October 2013 when there had been a domestic abuse incident and Mother admitted she had had ‘four cans’.    41   9.5.25 There were no written reports from the domestic abuse or substance misuse services and The Learning Event highlighted that the RCPC was under a misapprehension regarding Mother’s work with the substance misuse service.  The Agency Report Author was clear that the intervention had been at a very low level and had not looked in any depth at Mother’s use of alcohol and how this might impact on her parenting capacity.  An assessment was being arranged to complete this work. There appeared to be a general lack of professional curiosity and challenge about Mother’s alcohol use.   9.5.26 Father had not engaged with CSC’s assessment or with the domestic abuse, substance misuse and mental health services and remained ‘an unassessed risk’.  The long term concerns were in relation to domestic abuse and whilst there did appear to be less incidents reported to the Police, a MARAC had been held on 30 October 2013, less than a week before the RCPC, due to three reported incidents within a six month period.  Therefore, it was difficult to hold a view that the domestic abuse had been resolved.  The information from MARAC was available to the allocated Social Worker, but not available at the RCPC.  9.5.27 Therefore, whilst there were positive signs of progress in terms of Mother’s engagement with services and the children were progressing well, there were ongoing concerns.  The issue for consideration by the Conference was whether the progress would be sustained and built on if the CPPs ceased.  9.5.28 The unanimous decision of the RCPC in November 2013 was to end the CPPs and this decision was discussed at length at the Learning and Recall Events; in particular whether this decision was over-optimistic and, hence, premature.  It is important to be mindful of hindsight and to consider this decision from the perspective of the workers at that time.    9.5.29 The definitions of over-optimism include ‘unjustifiably optimistic’ and ‘a tendency to look on the more favourable side of events or conditions and to expect the most favourable outcome’. The Study of SCRs which had been undertaken between 2001 and 200316 identified the failure to protect vulnerable children as a result of a number of factors, including ‘over optimism particularly about parenting capacity in difficult situations’.  The Biennial Analysis of SCRs undertaken between 2007 and 201117 found that ‘there was a reluctance to make negative professional judgements about a parent’.                                                              16 Improving safeguarding practice: Study of serious case reviews 2001 – 2003, Research Report, Department for children, schools and families, 2008.  17 Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007 – 2009, Research Brief, Department for Education, 2010.  42   9.5.30 On balance, the Recall Event concluded that the decision to cease the CPPs, and put in place robust CIN Plans, was reasoned and evidence based.  Working Together 2013 outlines that a child should no longer be the subject of a CPP if ‘it is judged that the child is no longer continuing, or is likely, to suffer significant harm and therefore no longer requires safeguarding by means of a child protection plan.’18  There was a lack of evidence that the children were at risk of significant harm or that the threshold for a CPP under the category of neglect; defined in Working Together 2013 as ‘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’, was met.  CIN Plans can be effective in managing situations where the risks to the children have reduced and in supporting families to maintain changes made.   9.5.31 The period of child protection planning was discussed with Mother.  Her view was that she had been given the opportunity to comment on the information presented to the Child Protection Conferences, being asked for her views after each of the agency reports.  Mother felt that she had done everything that she had been asked to do in the CPPs and that things in the family had changed.   She talked about having more control and the children now being in a better routine. Father used to interfere and undermine her position with the children.  • Decision making: Public Law Outline (PLO) 9.5.32 The Public Law Outline (PLO): Guide to Case Management in Public Law Proceedings, which came into force in April 2010, aimed to streamline the procedures for dealing with public law children's cases.  The first stage of the procedure is a Legal Planning Meeting (known as Legal Brief in the SSCB area), which is the opportunity to consider the case in a legal context and for the Social Work Team to receive legal advice.  If the advice is that there are sufficient grounds to proceed, the Social Worker prepares a Letter before Proceedings, which is sent to those with parental responsibility, and a PLO (Pre-proceedings) meeting is arranged within 10 days of receipt of the letter.  The purpose of the meeting is to agree what actions will be taken in order to avoid the need for care proceedings to be initiated.  A review of the PLO is held after three months.  9.5.33 The decision making in respect of PLO in this case has been traced through the minutes of the Child Protection Conferences, discussion at the Learning Event and further information received from CSC.  At the ICPC in September 2012 there was a recommendation that ‘the Responsible Team Manager                                                            18 Working Together to Safeguard Children 2013:  A guide to inter-agency working to safeguard and promote the welfare of children, HMG.  43  should decide whether they wish to hold a legal meeting to discuss PLO or Care Proceedings’. In the CPPs this is developed to ‘Team Manager to consider Legal Brief with a view to proceeding to Public Law Outline (PLO) if Parents do not engage with services/CPP’.    9.5.34 At the RCPC in November 2012 it is noted that the ‘PLO is not required at this point’.  The reasoning behind this decision is difficult to understand given that both Parents had clearly failed to engage with services and hence with the CPPs.  Father had not co-operated with the Probation Service or followed up on obtaining a referral to the Mental Health Service through his GP. Neither parent had accessed services in relation to domestic abuse or substance misuse, which were at the root of the family’s difficulties. Until these issues were resolved it was unlikely that changes would be sustained, as evidenced by continued Police call-outs.  9.5.35 The recommendations of the Pre-birth CPC held in respect of Baby L in March 2013 included what appears to be a standard recommendation – ‘The responsible Team Manager to decide whether they wish to hold a legal meeting to discuss PLO or care proceedings’.   A Legal Brief, the first step in the PLO process, took place on 19 April 2013, attended by the Social Worker and Team Manager.  It was agreed that the PLO would be initiated; the Letter before Proceedings would be submitted by the Social Worker to Legal Services by 25 April 2013 with the aim of holding a PLO meeting on 10 May 2013.  Due to staff absence the letter was not sent, nor the PLO meeting held.  9.5.36 At the RCPC in May 2013, it was noted that ‘PLO proceedings started’, although in reality, they had barely progressed.  Then at the RCPC in November, 2013, when the CPPs ceased, there was no reference to PLO.  9.5.37 At the Learning Event, CSC shared that when case responsibility was transferred in May 2013, the new Social Work Team were advised that PLO should not be pursued, as there had been difficulty providing a consistent service to the family.  So, the family were to be given the opportunity to engage with the new Social Worker.  9.5.38 Therefore, there is a picture that the PLO did not progress as proposed due to the staffing situation in CSC and the change of Social Work Teams.  This led to a lack of clear, child centred, planning.  There was a different Social Worker and Team Manager at each of the Child Protection Conferences, which may also have contributed to the lack of a consistency in decision making.  This could be viewed as evidence of ‘start again syndrome’,19  where workers put aside knowledge of the past and focus on the present.                                                              19 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003 – 2005. DCSF, 2008.  44   9.5.39 The Senior Manager from CSC informed the Learning Event that a new, quality assured, decision making process in respect of PLO is being introduced in the Local Authority.  This will encourage greater consistency and remove discretion from individual Team Managers.    9.6. Child in Need Planning  9.6.1 At the RCPC in November, 2013, when the CPPs ceased, CIN Plans were put in place and the Chair of the Conference recommended that the Plans should continue for six months. There was evidence that Mother had begun to engage more with services, e.g. domestic abuse, and was taking appropriate protective action when Father came to the family home, but, there was a view that she continued to need support to maintain this progress.  CIN Plans can be used effectively as a ‘step down’ in such situations.  9.6.2 The first CIN Review Meeting was held 5 weeks later in December.  The Health Visitor and Social Worker had visited since the RCPC and reported positively.  Baby L’s health difficulties had continued and he had had a further admission to hospital.  During this admission concerns were expressed by staff about Mother’s interaction with him, although this was not shared with the Social Worker.  Mother had not attended the appointment with the Substance Misuse Service, the aim of which was to undertake a more comprehensive assessment.   9.6.3 The decision was taken at the CIN Review Meeting to cease the CIN Plans, following discussion with Father, and ‘step down’ to Early Help. This decision was reflected on at the Learning and Recall Events.  There was an indication that the Team Manager in CSC had been concerned that the workload demands on the Social Work Team meant that they were unable to provide a full service and that the family would receive increased support if the case was ‘stepped down’ to Early Help.     9.6.4 The discussions concluded that this decision was over optimistic and premature, given the length and nature of family’s difficulties.  It was very early to judge whether Mother was able to sustain the changes she was making.  In addition, little consideration appears to have been given to Baby L’s needs or to the impact of his health difficulties on the family overall.  There is some indication from the Police that home conditions may have deteriorated somewhat at the time of Baby L’s death.  9.6.5 It is recognised by CSC that during a significant part of the Scoping Period for this SCR, the Service was experiencing difficulties with the recruitment and retention of Social Work staff, both Social Workers and managers, and was  45  operating with a high level of agency staff.  This inevitably impacted on the service offered to the family.  As is noted in 11.1 below, CSC have undertaken a Service Review and currently have an Improvement Plan in place, which will address many of the issues identified in this SCR.    9.7. Parental Smoking  9.7.1 Baby L suffered with respiratory infections and had breathing difficulties from a very young age.  The increased risks to babies of parental smoking, both antenatal and postnatal, is well recognised, e.g. asthma, allergies, SUDI.   The British Lung Foundation advises parents that ‘Protecting your child from tobacco smoke is one of the best things you can do to give your child a healthy start in life, because tobacco exposure is a big risk for increased breathing and lung conditions in children. This is especially true if the mother smokes during pregnancy. Therefore avoiding smoking anywhere where children are present reduces this risk’.  9.7.2 Various health practitioners, e.g. GP and Health Visitor, spoke to Mother about the risks from smoking and advised her about not smoking near the baby and washing her hands after smoking.  It was noted that the home did not smell of cigarette smoke, nor were there full ashtrays. Mother was encouraged to attend the Smoking Cessation Clinic, which she declined.  However, it does not appear that this was pursued very vigorously or picked up by staff in the Acute Trust. There was a lack of a coordinated approach. Closer liaison between the Acute Trust and the services working with the family in the community may have led to a greater focus on the issue.   This was a missed opportunity to intervene.  9.7.3 It is likely that a high percentage of parents smoke in the area where the family live.  Research by the NHS Health Development Agency and Action on Smoking and Health (ASH) shows that smoking is highest in the least advantaged social groups at 70% and that 54% of children living in lower socio-economic households are likely to be exposed to tobacco smoke compared to 18% of children in professional households.  The rate of quitting smoking is significantly lower in the lower socio-economic groups and there has been very little change in the prevalence of smoking amongst those living on low incomes over the past 30 years.20  9.7.4 It may be that workers in this area are accustomed to high levels of parental smoking and to parents’ reluctance to access Smoking Cessation Clinics and may not pursue this as vigorously as workers in those areas where smoking is now less common.                                                             20 Smoking and Health Inequalities, NHS Health Development Agency and ASH.  46  9.8. Management Oversight and Supervision  9.8.1 Working Together to Safeguard Children 2010, Chapter 4,21 states that to ensure children are protected from harm requires sound professional judgements to be made.  It recognises that this is demanding work that can be both distressing and stressful and that all those involved should have access to advice and support from peers, managers, and Named and Designated Professionals. Those providing supervision should be trained in supervision skills and have an up to date knowledge of the legislation, policy and research relevant to safeguarding and promoting the welfare of children.  Supervision should enable the supervisor and supervisee to reflect on and evaluate the work undertaken.  Supervisors should be available to practitioners as an important source of advice and expertise and may be required to endorse judgements at certain key points in time. Supervisors should also record key decisions, and the rationale for them, within the child’s case records.  Supervision should be both educative and supportive and facilitate the supervisee to explore their feelings about the work and the family.  Effective supervision needs to be regular and provide continuity.  9.8.2 The lack of use of the Designated and Named staff and Safeguarding leads within agencies, i.e. Acute Trust, NHS Foundation Trust and CCG, has already been referred to, as there were a number of instances when their advice should have been sought and concerns escalated.  9.8.3 The NHS Foundation Trust Agency Report notes that in 2013 the School Nurse was new to her role and experienced long periods unsupervised due to capacity issues within the team. The School Nurse acknowledged with the Report Author that at times she felt overwhelmed with the demands of the post.  At other times safeguarding supervision was available, but it did not provide strong objective oversight and challenge at points where this should have occurred.  9.8.4 It is also concerning that the CSC Agency Report notes a total lack of evidence of supervision and management oversight during the period under review.  The importance of reflective and challenging supervision for Social Workers is well recognised.  This is particularly so when working with families where there are long term difficulties as workers can become overwhelmed by the family’s difficulties.  The earlier analysis in respect of the implementation of procedures, the timeliness and quality of assessments and progress with regard to the PLO may reflect this apparent lack of supervision and management oversight.  In addition, it is important that Managers record decisions made, as well as the rationale for these.                                                             21 DCSF, 2010.  47   10.  Findings   10.1. Good practice • The School provides support to the community, families and children which it serves, e.g. Breakfast Club and After School Clubs.  Mother certainly sees the school as very supportive • Child protection concerns were quickly identified by hospital staff following Sibling 1’s presentation with the injury to her finger, the Safeguarding Lead was informed and CSC and the Police were both notified • The departing Social Worker and the newly allocated Social Worker both attended the Initial Child Protection Conference • Mother attended all of the Child Protection Conferences and Father attended four of the five meetings. The Conferences were arranged so that Mother and Father could attend separately to reduce the risk of intimidation and ensure Mother’s safety.  Parents were provided with individualised minutes of the Conferences • The potential consequence of non-engagement were explained clearly and honestly to Mother by the Independent Chair of the Pre-birth Child Protection Conference in March 2013.  This is viewed as something of a turning point for Mother • On at least two occasions the School Nurse contacted the Social Worker to confirm the date of the next Core Group, i.e. escalated concern about the delay • At the Core Group in May 2012, the school raised concerns about communication with CSC and the delay in allocating a new Social Worker, i.e. provided challenge • Following Baby L’s birth, in the face of some resistance, the Midwife persisted with the request for a pre-discharge meeting and this was arranged, i.e. provided challenge • Between May and November 2013 the newly allocated Social Worker undertook child protection monitoring visits within timescales and arranged regular Core Groups.  This consistency of approach encouraged greater engagement by Mother with the CPPs and contributed to her improved co-operation with agencies • The Substance Misuse Service has a small team based in the Hospital to whom staff can refer, this means that the service is easily accessible • The Health Visitor and School Nurse routinely shared information with the Mother and children’s GP following Child Protection Conferences and Core Group meetings • The Chair of the Child Protection Conference wrote to Sibling 1 after she had prepared the Conference Toolkit for the RCPC in November 2013  48  • The Midwife completed the Ante Natal Vulnerability Assessment, highlighting the potential risks to the baby, in a timely way and sent this to the Health Visitor and GP • The children’s health assessments by the Health Visitor and School Nurse were completed in accordance with the Healthy Child Programme • Education and Health reports were prepared and shared with Mother prior to the Child Protection Conferences • The Practice Nurse discussed her concerns about Mother’s lack of understanding about Baby L’s health needs and need for additional support with the Health Visitor • GP’s report for RCPC in November 2013 highlighted concerns that Mother did not recognise the seriousness of Baby L’s condition and that she continued to be a smoker despite his chest problems • The underlying causes of Baby L’s respiratory difficulties were fully investigated by the Consultant Paediatrician • The Paramedic Crew’s effective use of advanced life support techniques  10.2. Areas for improvement • Lack of understanding of the children’s day to day lived experiences.  The children’s views, wishes and feelings were not evidenced in assessments, nor in the decisions and actions taken • Delay in responding to the pattern of substance misuse related domestic abuse incidents and recognising the impact of this on the children • Lack of follow up by agencies of referrals made to CSC and of evidence of the use of Safeguarding Leads within organisations for advice and escalation of concerns.  An agency’s responsibility does not end with the referral to CSC • Importance of timely, good quality, assessments, with evidence of the children’s lived, experiences and thorough analysis of the risks and protective factors • It should be made clear to a Father that when, despite efforts by practitioners to involve him in assessment and planning, he has demonstrated a lack of engagement, this will have an impact on future plans, e.g. an application may need to be made to court for contact with his children • Insufficient assessment and engagement with the children’s Grandparents in order to develop a full understanding of their role within the family and their potential to provide support and safeguard the children  49  • Lack of challenge in respect of parental substance misuse, despite evidence, over a long period, that Mother’s use of alcohol was not as she described • Lack of robust multi-agency Core Group working, i.e. CPPs were not regularly reviewed, updated and circulated to all members. CPPs should be SMART; actions clear with timescales.  The term ‘monitoring’ should not be used, as this does not convey what action is necessary • Importance of ensuring the right information is presented to Conferences (in written form) and to Core Groups • Lack of engagement with all the family’s GPs.  The importance of identifying if members of a family have more than one GP • Need to ensure improved hand-over when patients with histories of substance misuse, domestic abuse and mental health difficulties change GP, so that the new GP is aware of the key risks posed to, and by, the patient • Lack of multi-agency consideration of Baby L’s health needs and of the impact the social and home circumstances may have on these. Named Doctor in the Acute Trust should be informed of all children with a CPP who are admitted to Hospital, but was not in this case • All front-line practitioners should take responsibility for actively promoting messages about safer sleeping and the dangers of parental smoking  11. Developments already underway  11.1  Children’s Social Care  1. The Council initiated a Service Review and now has an Improvement Plan in place, which is supported and scrutinised by a multi-agency Board.  This includes: � Children’s active involvement in assessment and care planning to ensure their needs are better understood � Introduction of a Protocol for caseload management, including a Workload Management Tool � Protocol in respect of ‘step down’ from specialist services to early intervention, and of ‘step up’ � Review of the capacity of the Independent Reviewing Service (IROs/Conference Chairs) � Improving quality and effectiveness of Child Protection Plans (Signs of Safety)  � Ensuring Core Group members are fully aware of their role, to be audited in case file audits 2. Multi-Agency Safeguarding Hub (MASH) is now in place to ensure the consistent application of thresholds and management of risk, timely  50  and good quality assessments and appropriate signposting and tracking 3. A quality assured, decision making process in respect of Public Law Outline is being introduced, which will encourage greater consistency and remove discretion from individual Team Managers 4. The electronic recording system is being upgraded in order to provide improved management performance information. This will monitor arrangements for Core Groups and flag up those which have been missed 5. A Principal Social Worker has been appointed, whose focus is the development of Social Work practice in the authority.  Training, including seminars, is underway to develop Social Work skills and practice 6. Strategic Plan is in place to address the recruitment and retention of Social Workers 7. In line with Government guidance a new single assessment will be introduced during 2015 8. Supervision Policy has been revised and supervision records are audited bi-monthly 9. Reflective case file audits are undertaken monthly by senior managers, including the Director of Children’s Services and Head of Service  11.2  Independent Reviewing Service  1. A review of capacity of the service has been undertaken which has led to an increased in number of Independent Chairs 2. Improvements to:  • Conference Agendas:  Re-launched to enhance information sharing • Format and timely distribution of CPPs to facilitate SMART planning, with clear contingency plans • Child Protection Conference minutes:  Work to  improve format 3. A challenge log has been introduced which evidences increased challenge regarding delays in progressing CPPs and Care Plans for looked after children  4. An Independent Chair/Independent Reviewing Officer has been identified to link with each of the social work teams to share knowledge and expectations  11.3 Education  1. Lack of a consistent standardised method of documenting and storing notes/events at the school is being addressed  51  2. M/A Advisable for education to adopt a set template and procedure for recording events and episodes, including a chronology of telephone calls and emails to professionals 3. Developing skills to constructively challenge other professionals  11.4 The Substance Misuse Service  1. A representative of The Substance Misuse Service now attends SSCB 2. Procedures in staff handbook have been developed.  Staff are taken through the procedures during induction and asked to sign that they have read and understand the contents 3. Procedures and training now includes briefing and direction for staff attending Core Group meetings 4. Established dedicated Safeguarding Hub which: � Provides training, coaching and support to staff � Manages more complex cases and offers support to staff which concerns about less complex cases 5. Introduced triage assessment completed at the point of referral in order to determine the level of need and act accordingly 6. Do Not Attend (DNA) protocol introduced 7. Enhanced safeguarding supervision arrangements 8. Guidance and training for writing reports for safeguarding meetings has been provided.  Reports are checked and signed off by a manager and upcoming Core Groups/m/a meetings are discussed at the daily complex needs Safeguarding Hub meetings 9. Discussions underway with organisation which can offer lower level of support for those who do not meet The Substance Misuse Service criteria and a pathway is being developed for referral/signposting to this organisation 10. The Substance Misuse Service now attends weekly Care Navigation Meetings, which discuss cases of concern.  These meetings are useful in sharing information and managing risk 11. The local authority, as commissioner of services, has appointed a Safeguarding Manager for Substance Misuse  11.5 Acute Hospital  1. DNA policy has been developed in 2014 to address potential safeguarding concerns that a child not being brought for a medical appointment may indicate 2. Infants have own single set of records with a copy of any safeguarding concerns in their notes, including the pre-birth arrangements (An additional copy is kept in the maternal notes.)  Mother’s electronic  52  records are flagged with a VIP flag to indicate that there are safeguarding concerns 3. The role of the Paediatric Liaison Nurse is being reviewed, with the intention of a greater focus on safeguarding children and young people  11.6 NHS Foundation Trust  1. The School Nurse Health Assessment documentation is being reviewed to ensure this incorporates the views, wishes and feelings of the child. This Assessment is undertaken with children who have identified health needs and with all children subject to protection plans 2. Information following attendance at multi-agency meetings is copied to fathers’ GPs when known   12. Conclusion  12.1  This SCR was undertaken as Baby L and his siblings had been the subjects of CPPs, which ceased shortly before his death.  The CPPs had been made in the category of neglect and there were questions for the SSCB as to whether neglect could have been a contributory factor in his death and whether agencies had worked effectively together to safeguard Baby L and his siblings.   12.2 From a very young age Baby L had a history of bronchiolitis, inflammation of the airways (bronchioles), which caused breathing difficulties and necessitated admission to hospital on a number of occasions in his short life.   The cause of his death was recorded as an acute respiratory infection.    12.3 Despite his health difficulties, Baby L was gaining weight, developing well and achieving his developmental milestones.  He was a responsive and happy baby, showing a good attachment to his Mother.  Whilst there was some concern expressed as to whether Mother fully understood his health problems, in the main she sought, and acted upon, medical assistance appropriately.    12.4 At the time of Baby L’s death, family life was more settled and reports from the school were positive regarding his siblings.  However, it is apparent that they were not living in optimal conditions, with the background of domestic abuse and substance misuse in the family, plus the home conditions were not well suited to a baby with Baby L’s health difficulties.  It had been noted that the home was sometimes cold, which can impact on respiratory conditions, but more significantly, Mother continued to smoke.     53  12.5 Research highlights the strong link between parental smoking and increased risk of respiratory infections, as well as the higher prevalence of smoking in low income families.  Some would argue that parental smoking constitutes the neglect of a child, but the power and influence of cultural norms should be recognised. 54% of children in lower social-economic groups, as Baby L, are likely to be exposed to tobacco smoke.  The impact of this on practitioners working in the area needs to be considered, i.e. whether they accepted parental smoking as the norm.  As one of the Report Authors notes, while smoking is detrimental to a child’s health, it is ‘so common that it is not specifically judged as a sign of neglect’.   12.6 Whilst weaknesses in multi-agency working have been identified in this SCR, these tended to be historical and, at the time of Baby L’s death, agencies had been working more effectively together for six months and Mother had been demonstrating greater engagement with the services offered to her.  The one area of weakness with regard to addressing Baby L’s health needs was the lack of direct verbal communication between community services, both Health and Social Care, and the Acute Trust, and of a multi-agency plan to address these.  12.7 Sadly, Baby L died due to an acute medical condition.  However, it does appear that parental smoking was a significant modifiable factor, which was likely to have impacted adversely on his health.  If he had been living in a smoke free environment, it is possible that he would have been less susceptible to the frequent infections that he was experiencing.   13. Recommendations from Serious Case Review  Agency Report Authors have identified single agency recommendations, which are listed in Appendix 3.  However, the Lead Reviewer has additionally identified two further recommendations as below.  13.1. Single agency  1. When undertaking Section 47 Enquiries and/or assessments, Children’s Social Care should ensure that thorough checks are made with other agencies and care is taken to identify whether family members are registered at the same GP Practice in order that full information is obtained 2. Independent Reviewing Service should add a question to the Invitation List for Child Protection Conferences asking if all family members are registered with the same GP Practice and identifying who the GPs are   54  13.2. For Sunderland Safeguarding Children Board  The Lead Reviewer has been made aware of recent SCRs undertaken by SSCB, notably Baby A and Child C, and of the fact that recommendations have been made previously which are relevant to this SCR.  These include:  • SSCB should examine the processes it has in place so the Board can be assured that statutory assessments, and those agreed at multi-agency meetings, take place within agreed timelines, are robust and of good quality • SSCB should ensure that frontline practitioners have an understanding of the impact of the toxic trio, i.e. domestic abuse, parental substance misuse and mental health needs • SSCB should  assure itself  that effective escalation policies are in place and well understood by all partner agencies • SSCB should re-evaluate how multi-agency plans relating to children in need and child protection are formulated and recorded, using where possible an agreed template which places the child at the front of the deliberations and allows for realistic and meaningful monitoring and review • SSCB should ensure there is a robust process for regular scrutiny and challenge of CIN and CP Plans • SSCB should consider ways in which the Board can be satisfied that practitioners who chair multi-agency meetings relating to the safeguarding of children and young people, have the requisite skills, knowledge and confidence to do so assertively • The SSCB should develop learning opportunities for managers across all agencies to improve their skills and knowledge about reflective supervision and the links this has with better outcomes for children  Therefore, rather than repeating the same, or similar, recommendations, it is recommended that the Board should seek assurance that momentum is continuing in addressing the above in a timely way.   Below are the recommendations arising from this SCR:  1. SSCB’s Child Protection Procedures and training should embed the principle that all assessments should include an understanding of each child’s lived, day to day, experience, regardless of their age, level of understanding or communication skills, and that this should influence the decisions made and actions taken.  Practice should be audited through single agency and multi-agency and case file audits 2. Practitioners and managers should ensure that Fathers are aware that a failure to co-operate, and engage with the services offered, will be given consideration in assessments and will have an impact on decisions made and actions taken  55  3. SSCB has undertaken a multi-agency audit of agencies’ responses to families where there has been a pattern of domestic abuse (3 incidents in 6 months), to identify whether the response is timely and effective.  SSCB should take forward any recommendations made in response to the findings of this audit 4. Co-ordinated Activity Against Domestic Abuse (CAADA) is undertaking a review of the Multi-Agency Risk Assessment Conference (MARAC) processes in Sunderland.  SSCB should receive a copy of this Report and work with the Community Safety Partnership to ensure that the recommendations are progressed in a timely way.  If not highlighted in the CAADA review, consideration should be given to the involvement of the Acute Hospital Trust in the MARAC Process 5. SSCB’s procedures and training should emphasise that an organisation’s responsibility does not end with a referral to CSC, but continues until there is agreement about the action to be taken, if necessary invoking the escalation procedures 6. SSCB should receive assurance that the role of Safeguarding Leads, e.g. Designated and Named Doctors and Nurses, is widely understood and promoted within organisations 7. SSCB should consider ways of strengthening Core Group working, in order that Core Group members are fully aware of their individual and collective responsibilities to develop, regularly review and update the Child Protection Plan.  This could include the development of a SSCB leaflet for members of Core Groups 8. SSCB should seek reassurance from the Acute Trust and CSC that there is improved communication and closer liaison, e.g. telephone conversations, pre-discharge meetings, between the key agencies when a child who is the subject of a Child Protection Plan has a chronic health condition and/or is admitted to hospital to ensure that increased vulnerabilities are recognised and acted upon 9. SSCB should work with NHS England and the Clinical Commissioning Groups to strengthen the engagement of GPs in safeguarding and, through its Performance Framework, monitor the contribution of GPs to Child Protection Conferences 10. SSCB should promote health education regarding the dangers of parental smoking (e.g. through activities of the Child Death Overview Panel)     56  TERMS OF REFERENCE       APPENDIX A    Sunderland Safeguarding Children Board   TERMS OF REFERENCE & PROJECT PLAN SUBJECTS: Baby L:  (Aged 8 months) Sibling 3:  (Aged 4 years) Sibling 2:  (Aged 6 years) Sibling 1: (Aged 11 Years)    57  1.  Introduction: The Children’s Social Work Service’s first became aware of Baby L’s family in December 2005 when they received a referral from the Police concerning an incident of domestic violence from Baby L’s Father and Mother.  The Police made a total of 12 notifications and referrals in relation to domestic abuse perpetrated on the children’s Mother by the Father between December 2005 and July 2012.  These incidents were longstanding and severe, including verbal aggression, harassment and physical violence which have led to Mother being injured and have also occurred whilst she was pregnant.   Father had not engaged with any services around his alcohol misuse and the violent and aggressive incidents appear to be when Father is under the influence.  Mother had also been reported to be intoxicated on some occasions.   In July 2012, Children’s Services received a referral from the Police. Mother had been asleep in bed when Father accessed the property, woke her, accused her of cheating and punched her to the face causing injury. Sibling 1 awoke to arguing between her Parents and attempted to intervene to stop this. As Sibling 1 was running, Father had slammed a door shut and her finger became caught. Sibling 1 later attended Sunderland Royal Hospital with an open fracture to her finger which required surgery.  A Section 47 investigation was undertaken.   On 4 September 2012, an Initial Child Protection Conference was held and Siblings 1, 2 and 3 became subject to Child Protection Plans under the category of Emotional Abuse.   By late September 2012 Mother was unsure if she wished to maintain her relationship with Father.   On 3 October 2012, the family was discussed at MARAC panel. It was reported that there have been domestic violence incidents in May, June and July 2012 and Father was under the influence of alcohol on all of these occasions.  Father was in custody until October 2012.  Mother was provided with extra locks and security for her home due to the risk Father posed to her.   Between early September 2012 and December 2013 a further 6 referrals were made to Children’s Services in relation to Father harassing Mother and he received custodial sentences during this time due to harassing Mother.    Mother was referred to the Substance Misuse Service as part of the Child Protection Plans although there was a delay in her engaging with the service and, also, with the Domestic Abuse Service which she was also referred to.   On 19 November 2012, the Police made a further referral to Children’s Services as Father had attended the home address and Mother had activated her alarm.  On the same day a Review Child Protection Conference was held when the children remained subject to Child Protection Plans, under the category of emotional abuse.  Professionals agreed that progress had been made, but Mother had not engaged with the domestic abuse or substance misuse services.   Father had not engaged with Probation and been sent to prison.    58  On 14 January 2013, Children’s Services were advised by the Midwifery Service that Mother had attended a booking in appointment and was thought to be around 31 weeks pregnant. It was later established she was 25 weeks pregnant and she reported that the Father of the baby was the same as the older children.  This was despite both Parents claiming to no longer have a relationship with each other.  A Pre-birth CPC was held on 6 March 2013 in respect of the unborn baby, who was also made subject to a Child Protection Plan under the category of emotional abuse.  By this point Mother had not engaged with the domestic abuse or substance misuse services.  Father had not engaged with any services.   At the Review Child Protection Conference held on 15 May 2013, the children remained subject to Child Protection Plans under the category of neglect. Baby L was born on 20 April 2014 and required medical intervention, including hospitalisation, on a number of occasions for Bronchiolitis.   On 5 November 2013, a Review Child Protection Conference was held. Mother was said to have engaged well with agencies and completed nearly all of her work with the Domestic Abuse Service, which had given her a positive report. Father had not engaged with services for his alcohol misuse or domestic violence, however, his contact remained supervised once a week. There were no concerns in relation to Mother being able to meet the children’s health and education needs and although Baby L was unwell quite frequently Mother acted appropriately and sought medical attention when required. The decision was to end the Child Protection Plans in favour of Child In Need plans. On16 December 2013, a Child in Need meeting was held. There were no concerns expressed from school, the children were doing well and there were significant improvements with their confidence. Siblings 1 and 2 were exceeding academically. Health visitor reported that Baby L was chesty again and Mother had taken him back to the hospital the previous week.  He may have a blockage but they were going to look at this further in the New Year.  It was agreed that given the progress the family had made consideration would be given to the case closing to CSWS once further discussions had taken place with Father about his engagement with agencies. Baby L was found unresponsive by Mother in his own bed at 2:50 a.m. on Friday, 20 December, 2013.  He had recently had a virus.  Baby L was subject to a Child in Need plan at the time of his death.    The SSCB Chair agreed on 21 February 2014 that the criteria for a Serious Case Review was met in respect of Baby L and further that this should be undertaken using the Significant Incident Learning Process (SILP) methodology.      59  2. Statutory Framework: Working Together to Safeguard Children, 2013, states that Serious Case Reviews should be undertaken in ‘every case where abuse of neglect is known or suspected and either a child dies or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child’.  They should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings. Working Together Chapter 4, further states: • LSCBs may use any learning model which is consistent with the principle in this guidance, including the systems methodology recommended by Professor Munro. And that • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice. (Working Together to Safeguard Children, March 2013)  3. Scope of Serious Case Review: 3.1. Subjects: Baby L:  (Aged 8 months) Sibling 3:  (Aged 4 years) Sibling 2:  (Aged 6 years) Sibling 1: (Aged 11 Years)    60  Whilst the children are the subjects of this Serious Case Review, agencies should also include relevant information in respect of the Parents, in particular the GP. The Parents are: • Mother:   (Age 27 years) • Father:   (Age 30 years) NB:  Ages are at the time of Baby L’s death in December 2013.  3.2. Timeframe:  1 January 2012, 6 months prior to the injury to Sibling 1 in July 2012, which was the trigger for the Initial Child Protection Conference, to 20.12.2013, the date of Baby L’s death.  3.3. In addition Agencies are asked to provide a brief background of any significant events and safeguarding issues in respect of the children, e.g. domestic abuse episodes, substance misuse and treatment, referrals to Children’s Social Care, Early Help. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points.  An exception to this is the Police, which is requested to provide full background information to its involvement with the family prior to the scoping period.  4. Chronology: Agencies are asked to populate key events on the chronology template. It is essential that this is limited to significant events only, which impacted, or had potential to impact on the outcomes for the children.  5. Agency Reports: Agency reports will be commissioned from: • Police (Including MARAC information) • Children's  Social Work Service • Children’s Services’ Reviewing Service  • NHS Foundation Trust (Health Visiting & School Nursing) • Acute Hospital (Paediatric and the Midwifery Service) • General Practitioner • Ambulance Service • Education: Schools   61  • Substance Misuse Service •  Domestic Abuse Service, via the Commissioner • Early Help/Intervention Service  Agencies which had limited involvement with the family are requested to provide a brief report of their involvement for information.  These include:  • Probation Service • Early Help • Registered Social Landlord  6. Generic Analysis: a. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to have taken a different course? Were assessments conducted effectively and appropriate conclusions drawn? b. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. c. Demonstrate whether your agency/service heard and responded to the child’s voice. d. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. e. Were professionals proactive in escalating concerns and effecting challenge where appropriate? f. From an inter-agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? g. Did your agency identify any issues of ethnicity, diversity, language, culture (e.g. poverty)? If so, how did your agency address these issues? h. Is there any evidence that multi-agency safeguarding training supported the practitioners in this case or is training identified as lacking in a particular area? i. Identify examples of good practice, both single and multi-agency.    62   7.  Particular areas for consideration:  a. Was the decision to cease the Child Protection Plans and step down to Child In Need Plans evidence based and was there a good level of understanding of the children’s lived experiences at this time?  What progress was subsequently made in implementing the Child In Need Plan? b. What was agencies’ understanding of the impact of the parental substance misuse, both drugs and alcohol, on the day to day care of the children?  Was there any evidence of disguised compliance from either or both Parents? c. What were the inter-agency arrangements for sharing information about domestic abuse in the family and what was agencies’ understanding of the impact of this on the children?  Were the interventions that were taken in response appropriate and effective? d. Is there a common understanding of SSCB’s Threshold Guidance?  Is there any evidence of an over-tolerance of neglect, i.e. high threshold, and was the impact of neglect considered in respect of the children’s individual needs, e.g. the family’s sleeping arrangements, Baby L’s health needs. 8. Engagement with the family: SSCB has already informed the Parents that this Serious Case Review is being undertaking and the purpose has been explained to them.  Further contact will be made to invite them to participate in the form of a home visit/ interview/correspondence/telephone conversation.  Their contribution will be woven into the text of the Overview Report and they will be given feedback at the end of the process. In view of the young age of the children, they will not be invited to contribute directly to the SCR, but wherever possible their views and experiences will be included in the Review and in the Report. Hopefully any interviews will take place prior to the Learning Event so that their voice will be heard at the Learning Event. 9.  Documentation: The “bundle” for the Learning Event will comprise: • Integrated Chronology  • Agency reports  63   10.  Timetable: Scoping Meeting (Terms of Reference) and Authors’ Briefing 3 September 2014 Draft Terms of Reference to SSCB 10 September 2014 Commissioning letters to agencies 26 September 2014 Agency Reports submitted to SSCB 7 November 2014 Agency Reports quality assured 7 - 14 November 2014 Distribution of material to all attendees 14 November 2014   SILP Learning Event   24 November 2014                                 Draft Overview Report distributed 5 January 2015                                        SILP Recall Day       22 January 2015                                      Distribution of Overview Report   9 February 2015 Presentation to SSCB 25 February 2015                                                                                                                                                                                                                                                                                                                                  64  Key single agency recommendations:                    APPENDIX B  Below are the key single agency recommendations, as identified by the Lead Reviewer.           • Children’s Services:  1. IT system should be developed to ensure the children’s individual voice and experience is captured.  This should be monitored through the monthly case file audits.  • NHS Foundation Trust:  1. Health professionals should follow up with statutory services when information is shared a child may be at risk of significant harm. 2. Health professionals should receive reflective safeguarding supervision which is open and supportive, focusing on the quality of decision, risk analysis and improving outcomes for children and young people. 3. Health professionals should be confident to constructively challenge when concerns persist with regard to children. 4. The role of the Safeguarding Advisors in professional challenge should be revisited.  • NHS England/Clinical Commissioning Group:  1. GP safeguarding children meetings to have an agenda with list of families to be discussed and formal minutes to be taken. 2. CSC to review their policy to ensure both parental GPs are contacted for information as part of an initial assessment and Section 47 enquiries.   • Acute Hospital:    1. Should be an accurate recording of family structure to aid the holistic understanding of the family in which a child live and evaluation of the safeguarding risk.  2. Must ensure that any child or YP admitted to the ward with known CP concerns or a CPP, SW and HV should be contact during the admission by the ward staff to alert them to the admission and Father any relevant community information.  This would ensure a more timely transfer of information and ensure a safe discharge plan, with consideration of a discharge planning meeting. 3. The PLF and Paediatric Liaison process should be reviewed to optimise the City Hospitals info sharing of safeguarding issues.  65  4. Robust system to ensure discharge letter consistently sent to HV/School Nurse/SW when appropriate in addition to GP. 5. Hospital to consider how to meet responsibilities with regard to DA/MARAC     66  GLOSSARY         APPENDIX C  LSCB:   Local Safeguarding Children Board SSCB:   Sunderland Safeguarding Children Board SCR:   Serious Case Review SILP:   Significant Incident Learning Process CSC:   Children’s Social Care A & E:   Accident and Emergency Department MGM:   Maternal Grandmother PGM:    Paternal Grandmother CCN:   Child Concern Notification (Police) ICPC:    Initial Child Protection Conference Pre-birth CPC: Pre-birth Child Protection Conference RCPC:   Review Child Protection Conference CPP:     Child Protection Plan PLO:   Public Law Outline CIN:     Child in Need MARAC:   Multi Agency Rick Assessment Conference IDVA:    Independent Domestic Violence Advocate   67  REFERENCES         APPENDIX D                                                     Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, Schools and Families, March 2010.  Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, Schools and Families, March 2013.  Disguised compliance: learning from case reviews.  What case reviews tell us about disguised compliance, NSPCC, March 2014.  Ofsted, The Voice of the child: Learning lessons from Serious Case Reviews.  A thematic report of Ofsted’s evaluation of serious case reviews from 1 April to 30 September 2010, 2011.  Improving safeguarding practice: Study of serious case reviews 2001 – 2003, Research Report, Department for children, schools and families, 2008.  Department for Children, Schools and Families, Analysing child deaths and serious injury through abuse and neglect: what can we learn?  A biennial analysis of serious case reviews 2003 – 2005, DCSF 2008.  Department for Children, Schools and Families, Understanding Serious Case Reviews and their Impact:  A Biennial Analysis of Serious Case Reviews 2005 – 07, DCSF 2009.  Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007 – 2009, Research Brief, Department for Education, 2010.  New learning from serious case reviews: a two year report for 2009 – 2011, Research Brief, Department of Education, 2012.   68  Sarah Gorin, Understanding what children say:  Children’s experiences of domestic violence, parental substance misuse and parental health problems, National Children’s Bureau, 2007. 