Murder of a young child by their mother's partner. Learning includes: investing time both strategically and operationally in improving work with fathers will contribute significantly to the welfare of children, their families and communities; practitioners would be helped and supported in responding to the complexities of domestic abuse through the introduction of a practice model that systemically helps the whole partnership and external stakeholder to work to a holistic domestic abuse informed approach; a decision to cease multi-agency planning in totality without the necessary consideration of threshold step down risks children being exposed to escalating harm without adequate review mechanisms; no assessment that considers risk of domestic abuse should be accepted as complete without exhausting all options to include the alleged perpetrator of the abuse. Recommendations include: strengthen the multi-agency approach to domestic abuse by exploring and adopting a specific practice model that provides a perpetrator based, child centred, and survivor strengths approach; ensure that robust step-down and transfer processes that promotes independence at a pace that supports embedding of change are in place; develop a plan to publicise and generate the use of Clare's Law by educating both professionals and the community; ensure that step down and maintenance support is built into the commissioning of domestic abuse services to support sustained change for both victims and perpetrators.
      
    Serious Case Review No: 2022/C9494  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.      - 1 -        CHILD SAFEGUARDING PRACTICE REVIEW CHARLEY  FINAL 18.05.22         - 2 - 1 The circumstances which led to a Child Safeguarding Practice Review  1.1 Charley was the third born child to their Mother. Charley had two maternal half siblings, neither of whom resided with Charley. The mother’s older children lived separately with extended family members. . 1.2 Charley was the third child born to their Father. Charley had two paternal half siblings with whom there was no contact. The relationship between Mother and Father ended when Charley was approximately 7 months old. Charley had limited contact with Father beyond this point.  1.3 Charley was subject to a child protection plan under the category of neglect from birth until the age of 15 months. The primary cause of concern was a risk of domestic abuse and the consequent impact on Charley. Both Mother and Father had previous relationships whereby domestic abuse had impacted upon their children.  1.4 During the 15-month period of child protection planning, five child protection conferences and twelve core group meetings oversaw the child protection plan.  Mother accessed a domestic abuse counselling service having completed a Freedom programme during a previous episode of intervention. Father was offered a service but did not participate in any programme of work. The couple separated. By the final child protection conference, all professionals were confident that the risk from domestic abuse between the parents was no longer present and that Mother had increased insight into the indicators and impact of domestic abuse. Mother had been a single person for seven months and Charley was a thriving child, meeting all developmental milestones.  1.5 Two months after the cessation of the child protection plan, Mother formed a new partnership with a new partner, referred throughout as MP. They commenced living together some four months later.  1.6 MP had a history of domestic abuse in a previous relationship where he was also a parent.     - 3 - 1.7 Twelve months after this relationship began; MP was caring for Charley when he called an ambulance stating that Charley had fallen whilst he was out of the room. Charley was unresponsive when paramedics arrived and was taken to hospital. Charley had extensive injuries and never regained consciousness. MP was subsequently charged with murder.  2 Methodology for Child Safeguarding Practice Review 2.1 The purpose of the Child Safeguarding Practice Review is to consider the way in which professionals and agencies have worked together to address the needs and circumstances of the child and family and to establish, through an analysis of practice, whether there are lessons than can be learned about the strengths and vulnerabilities of the local safeguarding arrangements in the context of wider systemic issues.  2.2 A Review Panel of senior leaders representing the agencies that had been involved with Charley, Charley’s Mother and Father, as well as MP was established to oversee the review. The panel members coordinated their agency engagement with the review and provided an Agency Learning Report of their contacts and interventions with Charley and family as well as MP and their children, which took a reflective approach to single agency learning. The review involved another local safeguarding area, where the children of MP’s former relationship resided. This area is referred to as Area 2.  2.3 The timeframe for consideration by the review was the point of pre-natal maternity contact to the death of Charley. A multi-agency chronology was prepared, which enabled the review panel to understand what was known to who and when, and specifically how the partnership had worked together. The circumstances of Charley’s death was devastating to all concerned, and all agencies adopted a rigorous and objective analysis with a genuine desire to understand the critical pathway that led to the death of the child. 2.4 During the period of review, criminal proceedings were ongoing. MP pleaded guilty to the murder of Charley and received a custodial sentence.    - 4 - 2.5 The review involved practitioners that had worked directly with the family through a series of conversations. Practitioners met together with a combination of review panel members, this included the independent reviewers and members of the review panel.  Without exception, all participants were keen to explore their role with the family and to consider any points for learning.   2.6 The mother and maternal grandmother of Charley contributed directly to the review through a meeting with an independent reviewer. Contact with the Father was unachievable during the review period. It was not possible to involve MP directly due to the status of criminal proceedings.  2.7 The presenting information outlined the need to consider the following areas of practice:  To what extent did agencies identify key indicators of safeguarding  How were safeguarding systems utilised to support multi-agency safeguarding   Consider the approach to domestic abuse from the perspective of the child, the victim and the perpetrator  The arrangements for stepping down threshold application.   3 Overview of what was known to Agencies  3.1 Police records show that Mother and Father were in a relationship together for approximately three years before the birth of Charley. In those years, the police had several contacts from third parties and from Mother herself that alleged domestic abuse in the relationship. Police information indicates that on each occasion, Mother indicated that she did not consider herself to be a victim of domestic abuse and would not evidentially support a charging decision. This information was shared with partner agencies in a strategy meeting prior to the birth of Charley. During the Review, Mother has stated that she was never specifically asked to support any charges,       - 5 - 3.2 Mother presented to midwifery sixteen weeks into pregnancy. Mother advised the midwife that she had two children that had been removed from her care due to the violence of an ex-partner but presented as vague as to why the children continued to live with their extended family members. The midwife made a referral to Children’s Social Care. There was a mistake in the referral information, which indicated that Mother was thirty-two weeks pregnant however, when a strategy discussion took place it was established that the pregnancy was at eighteen weeks. In line with the additional assessment and planning opportunity, child in need support was offered in line with the inter-agency pre-birth protocol. An assessment was undertaken by Children’s Social Care, this concluded that the combination of family history, police information and   Father’s unwillingness to participate in the assessment was a cause for concern and indicated a need to verify further that there was no domestic abuse as reported by Mother and Father. A further multi-agency strategy discussion was held which agreed the need to proceed to an Initial Child Protection Conference. There was a concern that Mother was not being transparent about the ongoing relationship with Father and that Father was unwilling to make himself available to the social worker for the purpose of assessment.   3.3 Charley was made the subject of a child protection plan prior to birth under the category of neglect with an agreement that legal advice would be accessed if the child protection plan was not followed. Mother was in attendance at the initial child protection conference. Father was invited but did not attend. The plan agreed by multi-agency professionals and key family members was for Charley to reside with Mother at the home of maternal great grandmother. The arrangement included a stipulation that paternal grandmother would be present for all contact between Father and Charley. Both Mother and Father were encouraged to seek independent legal advice should they wish to challenge the expectations of the child protection plan.   3.4 Charley was born healthily five weeks early. A discharge meeting was held prior to Mother and Charley leaving hospital. There had never been any concern about Mother’s physical care of her children and there were no reported worries in terms of her care of    - 6 - the baby. The focus of the child protection plan was linked directly to domestic abuse, specifically in relation to mother’s understanding of the indicators and impact, Father’s capacity to change behaviour and the consequent risks for Charley. Mother entered into a counselling relationship provided from a commissioned domestic abuse service.   3.5 The first review child protection conference was held fifteen days after Charley’s birth. Father had met with the social worker and agreed to a referral to a domestic abuse service and to adhere to the supervision requirements within the child protection plan until further assessments could be completed. Father denied that verbal or physical abuse was a feature in his current or past relationships, stating that any calls to the police from his previous partner followed a legitimate visit to her home to seek contact with the children. Records held by Area 2 Local Authority clearly indicated that domestic abuse was a feature of Father’s past relationship and that his children’s mother had made a decision to cease contact with the children in order to prevent emotional harm to her children.   3.6 Multi-agency core group meetings commenced and took place monthly, generally attended by the social worker, health visitor and Mother. Mother had completed a Freedom Programme in 2012 and committed to a further programme of therapeutic counselling. Father was referred to a domestic abuse programme. The first provider advised they could not provide a service for Father because he had stated that he had no abusive behaviour and therefore saw no reason to change, indicating that the only reason he has attended as assessment meeting was because the social worker wanted him to. With this mind-set, he was unable to commit to the programme. By the second review child protection conference, the social worker had secured a second provider to undertake work with Father. Father attended one session but did not attend any further. The relationship between Mother and Father grew apart at this stage.   3.7 The couple had been planning to move into a home together and prior to the decision to separate, Father had progressed to staying within the home of the paternal great    - 7 - grandmother once per week and unsupervised contact with Charley in the community. At the point of separation, Mother advised that Father had made threats to harm himself as a means of controlling her actions and had also stated that he wanted no contact with Charley going forward. Mother continued the move to the property they had secured alone, and arrangements were made for the local housing scheme to ensure the property was safe and secure from the risk of Father attending uninvited.   3.8  After the separation, Father continued to be invited to attend the core group meetings with a plan to split the meeting to facilitate attendance of both parents in a safely planned manner. Father did not continue attendance and withdrew from communication with the core group.   3.9 By the third review child protection conference, Mother and Father had been separated for a period of three months. At this conference although there was a recognition that  Mother  had made good progress through the counselling, the social worker and health visitor shared a concern that Father would try to reignite the relationship once the plan ended and professional oversight discontinued. Father had also reignited a friendship with Mother’s previous partner who had also been violent towards her and they had social media contacts designed to intimidate her. Mother agreed with the professional’s assessment, and all supported a further period of child protection planning to ensure she continued to receive maximised support.   3.10 At the fourth review child protection conference there was a unanimous agreement that the child protection plan should cease. The closure summary documented the following agreement going forward:   That Charley was not having contact with Father, should Father want contact then an up to date assessment would be completed by the Local Authority  Mother to continue to access domestic abuse services  Mother to use Clare's Law and other knowledge to make informed choices about her future relationships.     - 8 -  That Charley would not meet any future partner until Mother is clear that there is no abuse / possibility of abuse.   3.11 There was no step down plan from the child protection plan in place, Children’s Social Care formally closed their intervention and health-visiting services resorted to universal service. The health visitor was present at the final child protection conference, although the minutes of that conference was not received by the health visitor.  3.12 Police information indicates that Mother became involved in a new relationship with MP two months later. The following month, Mother informed the health visitor during a home visit that she had met somebody new and was taking the relationship slowly. The health visitor records show that the health visitor asked if he had any children and Mother advised that he did not.  The records also indicate that Mother was encouraged by the health visitor to seek a Clare’s Law disclosure, Mother advised that she had no worries about MP but would consider it. It is noted that Mother has stated that the Health Visitor did not discuss Clare’s Law with her. Following this, the health visitor made a further two home visits and spoke once with Mother by telephone. On all of these occasions, the health visitor asked about the relationship with MP and Mother stated that there was no violence, aggression or control. Mother told the health visitor that MP got on well with her mother and that he was very caring to her and Charley. The health visitor met MP on the last visit made to the family home; she observed Charley playing happily and signs of an affectionate relationship with MP. The records indicate that the health visitor asked MP directly in the presence of Mother whether he had any children and he responded that he did not. It is noted that Mother has stated that this conversation did not happen in her presence.  3.13 Police information shows that MP had separated from a previous partner with whom he had a child. Due to a history of domestic abuse, the previous partner had secured a non-molestation order in respect of MP. The former partner had shared with Children’s Social Care that she was concerned that his cannabis use was preventing him from being able to parent.     - 9 -  3.14 There are three incidents reported to the police relating to his ex-partner that occurred whilst MP was in the relationship with Mother. On each occasion, their child was present. These incidents occurred as follows:   Shortly after their relationship commenced, MP approached his former partner whilst she was out walking with their child in a pushchair. MP was alleged to grab the handles of the pushchair whilst shouting. MP left when he believed the police had been contacted. A public protection notice (PPN) was submitted by officers who attended and spoke with the former partner but no positive action was taken with regard to MP.  Mother was not aware of this incident.   Four months into the relationship, MP became involved in an argument with his former partner when passing on the street. A witness observed MP raise his hand to the former partner and put themselves between them. The ex-partner stated to the police that she had experienced verbal, physical abuse, threats and damage to her property. Mother was not aware of this incident.   Ten months into the relationship with Mother, police were called to an incident whereby it was reported that MP had assaulted the new partner of his former partner during an incident where he was also abusive to the former partner whilst their child was present. A statement was taken from Mother who was identified as a witness and also as the current partner of MP. Mother told the attending officer that Charley was in the car at the time of the incident. A notification was made to Children’s Social Care in Area 2 in respect of MP’s child being present, however Charley was not identified as being present at the incident and therefore no information was shared with Children’s Social Care in respect of Charley.   3.15 Children’s Social Care in Area 2 responded to the referral made by the police by speaking with the former partner and on the basis of satisfying themselves that she was able to ensure the ongoing protection of her child, they did not make any contact with MP.      - 10 - 3.16 Review of MP’s medical records show that he approached a GP three years prior stating that he had a problem with anger management that he had a baby and it was affecting his relationship. The GP gave MP a leaflet for IAPT (Improving Access for Psychological Therapies) and advised him to contact for CBT. There is no further health record that MP followed this up.   4.        The Family Perspective  4.1 Mother and Maternal Grandmother met together with an independent reviewer and were asked to provide their experience of working with agencies. 4.2 Mother spoke about the context of working with services in relation to her two older children and reflected that she found workers to be unhelpful to her.  Mother spoke of the relationship with the Father of her first child as being extremely violent and a very difficult point in her life, she found professionals to be condescending and judgemental. Mother advised that the professionals she worked with in respect of Charley were a total contrast, the social worker and health visitor were very supportive and the social worker in particular helped her learn about herself and domestic abuse. Whilst initially the Mother spoke about how the counselling helped her to learn about abuse and the purpose of Clare’s Law, after reflecting on the content of this report, Mother has shared that she now reflects that she did not have a full understanding of Clare’s Law and has only come to appreciate this recently 4.3 Mother described the social worker and health visitor as reliable, inclusive and kept her informed at all times. Through this approach, Mother understood why a child protection plan was necessary and felt guided and supported through the core group meetings. Mother found it was very stressful that she could not persuade Father to engage in the plan and questioned whether he could have been helped differently. Mother spoke about how in general day to life he struggled to respond to instructions or what was being said. Mother wanted to    - 11 - make the situation with Father work and at times felt like she was being held responsible for him not being involved.  4.4 Mother said that Father was a better partner than she had experienced previously, and that she wanted the relationship to work. The separation was in the context of Father not participating in the child protection plan and Mother wishing to progress positively with the plan. Mother was in agreement with the continuation of the child protection plan at each review but also wanted to move forward independently once the plan had ceased.  4.5 Mother experienced MP as a kind and caring partner. Mother said it was for this reason she did not want to make a Clare’s Law application, she considered there was no need and would have felt guilty for doubting him.  4.6 Mother shared that MP would look after Charley when she was working and she had every confidence in leaving Charley with him. MP was liked by her family, and she believed that he had also established a good relationship with her eldest daughter  4.7 Mother said although she had witnessed the one incident in the street between MP and the partner of his previous partner, this caused her no concern, as it was ‘an argument between two males’. Mother said she did not think in any way that Charley might be unsafe left in the care of MP.   5         Analysis The analysis is structured around the four areas of practice and drawn from the agency’s written contributions to the review, the reflections of practitioners, the discussion and challenges that occurred within the review panel as well as the Reviewers own contribution.   To what extent did agencies identify key indicators of safeguarding  How were safeguarding systems utilised to support multi-agency safeguarding     - 12 -  Consider the approach to domestic abuse from the perspective of the child, the victim and the perpetrator  The arrangements for stepping down threshold application.   5.1 Charley was recognised as vulnerable and at risk of harm prior to their birth. Of particular significance was that two previous children born to Mother had been removed from her care with arrangements made to live permanently with extended family members to assure their care and protection. The first presentation to multi-agency services was the midwifery booking appointment. The midwife was clearly alert to safeguarding in this first contact and recognised the need to make a referral to Children’s Social Care based on the information that neither of Mother’s children lived with her and, although Mother described the reasons being attributable to their Fathers, the midwife felt that Mother was not forthcoming about why she had also been considered to pose an ongoing risk to their future welfare.   5.2 The receipt of the referral by Children’s Social Care was responded to in a timely manner, in particular because there was a recording error in the stage of pregnancy in the referral, which suggested a level of urgency. Once the strategy discussion established that birth was over five months away, the assessment process was appropriately slowed to enable a considered and engaged approach to working with the parents. The multi-agency safeguarding the Unborn Baby Pathway is aligned with statutory guidance and was followed faithfully. The Pathway provided a robust structure to support the pre-birth assessment and decision making, engage with the parents and ensured a clear safeguarding plan was in place prior to the birth of Charley.   5.3 The pre-birth assessment gathered all relevant information and demonstrates a good level of critical thinking skills, the conclusion was logical and the reasons for the judgement were understandable to all stakeholders including the Mother. The child protection plan reflected that Charley was exposed to a high level of risk from domestic abuse and whilst there had never been any reason to be concerned about the direct care giving skills of Mother, Father’s parenting capacity was less    - 13 - understood. The child protection plan is a high level of intervention but remains a voluntary agreement with the parent. In this instance, the plan included a requirement for Mother to live in a home with a family member and for Father to have only supervised family time with Charley. In such circumstances, it is important that the Local Authority are particularly mindful of Article 8 of the Human Rights Act 1998, the respect for family life and home. The social worker advised both Mother and Father to seek independent legal advice so that she could be assured that consent was being given with a full understanding of the voluntary nature of the agreement and that the parents were supported to challenge the expectations of the Local Authority should they wish to do so. A legal representative on behalf of Mother did make contact with the social worker and Mother has confirmed that she was in agreement and understood the reasons for the plan. It is not known if Father accessed legal advice but no legal representative made contact.  5.4 The plan drew upon the family’s natural resource network to create a safety plan within as normalised an environment as possible. There was good evidence that Mother’s extended family had formed a support network around Charley’s elder sibling and therefore reason to be confident in this arrangement.  5.5 The categorisation for the child protection plan was one of neglect. The child protection plan was exclusively focussed on domestic abuse and the impact that this would have on Charley. There was, from the outset, a high degree of confidence in Mother’s practical skills, but also a recognition that greater caution needed to be applied to Father, hence the requirement for supervision. The professionals were aware that abusive partners can also have inferior parenting skills, specifically associated with increased irritability, using more negative control techniques with children and having much less involvement in thinking about and delivering parenting. The risk of abusive head trauma should be in the mind-set of practitioners when considering domestic abuse and the impact on babies , this is most commonly associated with response to crying and presents the highest risk of fatality to children under one. The approach to addressing    - 14 - domestic abuse is thorough, there is however scope for some reflection about how agencies worked with Father beyond considering him in terms of risk factors to develop his parenting capacity and support the bonding and attachment with his child. Building a Picture of Fathers in the Family Justice System in England (2018): research project between University of East Anglia and Lancaster University published an analysis of Father’s involvements in care and recurrent care proceedings. The research found that Fathers were often viewed solely in terms of risk and because Fathers are able to opt out of parenting in ways not so readily available to mothers, services need to avoid the pitfall of seeing Fathers as optional or secondary parents. The research concludes that service adaptations are much needed to focus on support for fatherhood as a mechanism for change and accountability. The following suggestive examples are recommended as means to ensuring Fathers are supported:  Openness to responding to  Fathers as vulnerable, not just risky  The adaptation of parenting support for  Fathers without a child in their care  A focus on emotional regulation, particularly in terms of how pain, loss and shame are experienced by men, coupled with a wraparound service to respond to all aspects of a Father’s life as is more commonly experienced in working with women  A personalised approach to brokering links with other organisations that can help, noting that some element of men only space may be relevant to taking a peer-to-peer support to changing behaviour and facilitating change.   Point of Reflection Investing time both strategically and operationally in Improving work with Fathers will contribute significantly to the welfare of children, their families and communities.  See recommendation 1 and 4   5.6 A holistic approach to domestic abuse requires services to address three core elements, to protect the child including the unborn child, to empower the victim    - 15 - to protect themselves and their children and to hold the abusive partners to account and provide them with opportunities to change. This review has evidenced that all three aspects were met. When accessed as intended, this approach can facilitate lasting improvements in the safety of victims and children as well as enabling perpetrators to end a cycle of family abuse and develop healthy, non-abusive relationships. Given Mothers’ description of how she felt about interventions with her previous children, the social worker and health visitor are to be commended in enabling her to feel a genuine sense of participation and encouragement to accept her right to live free from abuse. Although Father was unable to participate in in the plan in any meaningful way, it is striking to note a second social worker was engaged as a further attempt to invest time in helping him to access services. When the first provider considered that Father could not participate in their programme because he did not accept that he needed to be there or needed to change, a second provider was identified and Father was continually encouraged to accept this need.   5.7 Ultimately, after attending one assessment session, Father withdrew from the service. This coincided with the ending of the relationship and his absence from the life of Charley going forward. The focus of multi-agency intervention then shifted solely to Mother and her ability to keep herself and Charley free from future harm. During the conversation with this review, the social worker was mindful and knowledgeable about the cycle of change. Department for Education published Assessing Parental Capacity to Change when Children are on the Edge of Care in 2014, a research report which reminds professionals that change is a complex but necessary process in safeguarding children that can be supported and promoted through multi-agency working but  cannot be imposed. The findings outline that professionals need a conceptual model of change as a framework through which analysis of a family’s circumstances and the factors that influence parental capacity for change can be measured. A widely used model for change (1992 Prochaska, DiClemente and Norcross) outlines six psychological stages through which individuals advance during a process of change, pre-   - 16 - contemplation, contemplation, preparation, action, maintenance and relapse. The model warns that relapse should be seen as the rule rather than exception across chronic behavioural disorders, this serves as a reminder to be realistic about the length of time achieving and embedding change will take. For Father there was a professional consensus that he had achieved the contemplation stages, he did attend two change programmes for assessment. He did not however prepare or action himself for change, what we understand less is what the inhibitors were and what would help to overcome them.   5.8 Whilst this review is putting some challenge to how the partnership can best support working with males, it should be noted that the needs of Father were by no means overlooked and the core group did keep Father central to and sighted within the child protection plan. The inclusion of a second social worker to specially target engaging Father in the child protection plan I would suggest is rare occurrence. There was also continued efforts to work with Father inclusively once he removed himself from family life by continuing to invite him to attend core group meetings with arrangements put in place for Mother and Father to participate separately. There was a real frustration for practitioners that Father did not engage in a change process, not least because his risk as a perpetrator of domestic abuse remained unresolved and would present further risk to Charley and to other women and children in the future. Although Mother’s later partner MP had not been involved in the same opportunities for change as Father, he too moved from a previous relationship where harm was caused as a perpetrator of domestic abuse. It is crucial that society and local safeguarding partnerships invest time in abusive males, they are the cause of much safeguarding activity and even when apart from the family they can remain a threatening presence to the family’s stability. The absence of concern about Mother’s direct parenting skills meant that there was less of a focus on the parenting skills of Father, which remained largely unassessed when he effectively absented himself from his child’s life. Men involved in child protection process often find it more comfortable to work with less formalised professionals in less formal settings. The opportunity    - 17 - for instance to work with a family worker skilled in encouraging and teaching parenting skills can enhance bonding and attachment with Fathers and babies which in turn can contribute to motivation for change. Arguably, the most important learning from this review is just how pro-active and serious the partnership needs to be about working with men as core business and how that is expressed and delivered through a range of services and resources.   5.9 The child protection plan continued for 15 months, during this time, alongside contacts at meetings and health clinics, the health visitor made thirteen home visits and the social worker over twenty five. Core groups took place on a monthly basis. Mother was referred to a domestic abuse service and commenced a therapeutic counselling relationship. The counselling service was delivered by a provider who also provided a wider domestic abuse offer, including the Freedom Programme. Mother had completed the Freedom Programme during a previous period of intervention and it was understood that Mother could be re-referred for a second attendance should this have been considered necessary once working with the service. It is evident that the health visitor and social worker had invested time in building a relationship with Mother , and the social worker spoke of the conversations she had with Mother which reassured her that Mother had increased her insight into domestic abuse and the impact on children. Whilst there was a considered approach to reviewing the impact of the counselling on Mother, there was no mechanism by which the domestic abuse service inputted to the child protection plan. The agency advised that the counselling service is a confidential service, however, the service has other opportunities through family and group work that presents an opportunity to contribute to assessment.   5.10 The framework for assessing the impact of the interventions relied on a generic approach to assessment. Practitioners spoke about the recent introduction of Signs of Safety as a practice model, but there is no specific practice model that is specifically adopted to support assessment, intervention and impact in domestic abuse. The multi-agency approach to domestic abuse would be strengthened    - 18 - through a specific practice model. A perpetrator pattern based model such as Safe and Together does align well with a Signs of Safety practice model. The Safe and Together practice model derives its name from the concept that children are best served when the partnership works towards keeping them safe and together with the non-abusive parent. The principles of a model that partners with domestic abuse survivors and intervenes with domestic abuse perpetrators was adopted by the core group for Charley but a model such as Safe and Together does shift thinking from beyond the ability to protect by the non-abusing partner to the consideration of perpetrator pattern as a means to identifying ongoing risk and ensuring that perpetrators are firmly held to account through all points of interventions.   Point of Reflection  Practitioner would be helped and supported in responding to the complexities of domestic abuse through the introduction of a practice model that systemically helps the whole partnership and external stakeholder to work to a holistic domestic abuse informed approach , allowing adult and child victims and survivors to feel secure that the safeguarding systems are by their  side, whilst also for the sake of their children, encourages consistent, positive and meaningful change in perpetrators of domestic abuse.  See recommendation 1   5.11 By the third review child protection conference, Mother and Father had been separated for several months and there was a shared confidence by professionals in Mother’s understanding of the indicators and impact of domestic abuse but a concern that menacing behaviour of Father together with Mother’s previous partner was exposing Mother to additional risks. The continued period of child protection planning was a measure of concern about the behaviour of the two men, not about the progress of Mother. Mother has told the review that she felt supported and safer with the continuation of the plan but by the fourth child protection conference felt the time was right for her to operate independently.    - 19 - The ending of the plan placed an emphasis on the actions that Mother could take upon meeting a new partner to keep Charley safe from any potential harm and key to this was a recommendation that Mother used Clare’s Law to aide her knowledge of any new partner. Clare’s Law was introduced nationally in 2014 in order to protect potential victims of domestic abuse. The Domestic Violence Disclosure Scheme has two functions, the right to ask, which enables someone to ask the police about a partner’s history of domestic abuse and the right to know, whereby police can proactively disclose information in prescribed circumstances.   5.12 The final child protection conference did not specifically consider a step down plan to maintain a lower threshold of intervention, the view of the professionals during this review was that the last period of child protection planning effectively negated the need for a step down plan. Step down does have an important function in ensuring that children have seamless support at the right time from the right professionals across the partnership. When children exit from a child protection plan, there is a significant reduction in oversight, which is eased gently through a step down plan. It is common to have a period of child in need planning or a step down to early help after a child protection plan and an important feature of any step down plan is an identified lead professional. The lead professional has a key role in bridging the transition between thresholds and ensuring that the reduction in threshold does not result in a diminished adherence to change commitments. The health visitor was the only professional that remained involved with Charley and Mother. Although the health visiting service reverted to a universal offer, the health visitor made three further home visits. Mother met MP the month following the cessation of the child protection plan and told the health visitor of this development during a routine visit. The health visitor recognised the need to be assured that the new partner presented no safeguarding risks and both in records and recall, although Mother does not agree that this occurred, advised that she talked to Mother about the potential for a Clare’s Law disclosure. The information of Mother’s new relationship was known only to the health visiting service.     - 20 -  Point of Reflection A decision to cease multi-agency planning in totality without the necessary consideration of threshold step down risks children being exposed to escalating harm without adequate review mechanisms.   See recommendation 2   5.13 Mother did not seek a Clare’s Law disclosure. This does raise a question about whether professional confidence in her ability to follow a safe pathway was misplaced. Mother is a woman who has experienced severe and chronic domestic abuse in her prior relationships At the initial child protection conference, Mother shared that the relationship with Father was better than her previous relationship because the abuse was not consistent, indicating that her judgement was impacted by relative merit. This came into play again upon meeting MP; Mother has reflected that this was the least abusive relationship she had, although information from the subsequent police investigation would suggest that she continued to experience abuse. Within the mind-set of making a relative judgement, it was difficult for Mother to fully recognise what she had learnt about safeguarding in personal relationships and how to put this into practice. Possibly the signs of abuse were different to previous relationships and Mother did not recognise what was beyond her experience. Mother told the review that making a disclosure application would have felt disloyal; this suggests she was worried about risking what she thought could be a good relationship. The health visitor undertook two further visits after being informed of MP’s presence, on each occasion asking about the relationship, domestic abuse and she was able to meet MP on one occasion. The health visitor advised that she was reassured to hear Mother say that her mother liked MP, having known the grandmother, the health visitor was further reassured by her belief that grandmother would make a referral to agencies if she had any worries. The health visitor was unaware at the time that she herself could make an application under Clare’s Law and did not seek safeguarding supervision to think though the potential implications of    - 21 - Mother  not following through the agreement made at the cessation of the child protection plan. MP was untruthful to the health visitor about not having a child and this would have been revealed through a Clare’s Law disclosure. Key learning from this review for the Heath Visiting and School Nursing Service is to ensure any agreements or bottom line issues at the point of child protection cessation are outlined and visible on the recording system and to help staff understand the need to seek safeguarding supervision at key trigger points of renewed risk such as new partner entry to a vulnerable family.   Point of Reflection The introduction of Clare’s Law was ground-breaking legislation with potential for huge impacts on safeguarding women and children at risk from domestic abuse. To maximise the impact, the partnership need to ensure that professionals have a full understanding of how it can be used to support professional safeguarding activity.  See recommendation 3  5.14 In the year that Mother spent with MP, there were three occasions that MP came to the attention of police in relation to incidents that involved his ex-partner, all of the incidents involved the presence of a child but only the last incident resulted in a referral to Children’s Social Care. This referral was made to area 2 in relation to MP’s child but because it did not identify Charley as being present in a car, no referral was made in respect of Charley. The response to the referral focussed on the child’s mother, and focussed on her ability to protect. There was a recognition that MP needed to be held to account for his actions but in the absence of a readily available point of contact, a conversation with MP was not pursued. The Learning Report for Area 2 noted that there was a recognition of the need to engage MP in the assessment in order to reduce risk, and outlines that this did not happen because a contact number or address was not readily available and no creativity was applied. The detraction from the actions of MP meant that    - 22 - curiosity was not applied as to whether he was in a position to present a risk to another child.   Point of Reflection No assessment that considers risk of domestic abuse should be accepted as complete without exhausting all options to include the alleged perpetrator of the abuse. This approach is pivotal to holding the right people to account for safeguarding children and also creates the opportunity to consider contextual risk factors and follow through actions to prevent and reduce further harm.  See recommendation 1 6.                Conclusions and recommendations   6.1 This review has shown that the identification or risk was robust by the partner agencies before Charley was born and that the local pre-birth protocol provided a solid framework from which to implement best multi-agency practice. The multi-agency structures were faithfully implemented and enabled a plan, which Mother felt, connected and engaged with.   6.2 The approach to domestic abuse by the practitioners had much to be commended. The approach to addressing the issue gave a focus to the vulnerability of Mother, the risks presented by Father and the safety needs of Charley. The social worker and health visitor were tenacious in their efforts to achieve a long-term impact by encouraging and empowering Mother during the period of the child protection plan and by supporting Father to participate in a programme of work designed to challenge his abusive behaviour and develop insight into the impact of this on his child. Despite this approach however, ultimately neither Mother nor Father achieved the position of safety in parenting that was intended. In these circumstances and in the spirit of learning we have to consider what can be learnt through this review to enhance the context within which good multi-agency working can have lasting impacts on the safety of children.     - 23 -  6.3 During the twelve months that Mother had a relationship with MP, there were three particular points at which there was an opportunity for the safeguarding partnership to gain an understanding of the relationship and analyse the risks that this may have posed to Charley. These relate the Mother sharing the relationship information with the health visitor but not adopting the safety plan that had been agreed at the cessation of the child protection plan and the opportunity to available to both the Police and Area 2 Children’s Social Care to identify that MP’s domestic abuse behaviour may present as a risk to Mother and Charley. The paragraphs above explore why these potential avenues were not pursued, and the recommendations are made to address the points of learning that arise from this.   6.4              Safeguarding children is not an exact science, where risk is present outcomes cannot be precisely pre-determined. Whilst social work theories uncover the ‘why’ in understanding human behaviour, it is the practice model that helps to use theory as a vehicle to create change. Practice models that are rooted in evidence-based research provide a framework to support best practice and provide multi-agency professionals with structure that supports challenge and quality assurance to decision making.   6.5 The cycle of change is central to the delivery of the child protection plan but it is not achieved simply because action has been completed. To complete the change cycle we must be assured that maintenance can also be achieved, this is a stage that requires a person to successfully avoid former behaviours or thinking patterns and keep up newly formed replacements. The Learning Report from Area 2 concludes by considering what can be learnt about how to “future proof” situations for families and reflected that family members could be more incorporated into safety planning for the future, and could for instance be tasked with seeking police information about new partner as part of family network and core group discussions as plans come to an end. The domestic abuse agency    - 24 - reflected on how what participants had learnt could captured in materials, which are given to them at the point of exiting the service, this can serve as a reminder and support maintenance.   6.6 The health visitor and school nursing learning report outlines the actions taken to date to address the opportunities to continually improve practice, this includes the launch of a domestic violence tool kit that will support standardised practice for all the workforce which will include how/when to screen for domestic abuse, what to do if disclosure is made, when to seek safeguarding supervision , when to encourage application to domestic abuse disclosure service and in what circumstances this should be actioned by professionals. Additional systems are in the process of being out in place to support best standards, this includes a new SystmOne process of recording ‘bottom lines’ when child protection plans cease,  and the launch of operation encompass for the health visiting and school nursing team.   6.7 The Police learning report acknowledged that in 2019, a HMICCFR inspection identified that the process by which the force shared information with partner agencies, public protection notices, needed to improve with regard to both content and compliance, subsequently extensive work has been undertaken to improve compliance. Professional development events for all staff have been widely undertaken and records regarding compliance rates has now become part of the forces performance framework. The learning from this review can be used as an instructive case scenario as to why professionals must be attuned to the contextual vulnerability of any other child when the potential for risk is identified for one child. It is noted that during the criminal investigation, police identified additional information that would indicate that MP posed a risk of domestic abuse within the relationship with Mother. Whilst this information was not available to professionals prior to the death of Charley. It is noted that the partnership intend to hold a meeting to reflect on whether there are any other opportunities for learning that is not captured within the remit and timeline of this review.     - 25 -  6.8  Key aspects of multi-agency learning from this review relate to the significance of endings, including the importance of step down, and the significant challenge that practitioners face in responding to risk of domestic abuse. There is a strong connectivity between domestic abuse and child abuse and this was reflected in the child protection planning for Charley. The key to understanding risk lay in the knowledge of domestic abuse and there is a salutary reminder of the challenges that face both professionals and family members in remaining alert to the reality of such risk, and our collective ongoing responsibility to ensure that all potential safeguarding systems are used to expose risk.   6.9 The closure summary outlined by the child protection conference effectively created a step down plan but without any process for oversight other than a reversion to universal services. The review has to consider what would have helped the health visitor see Mother’s reluctance to follow the plan that she had agreed only a short time ago as a measure of escalating risk and an indicator that change was not as embedded as was previously believed. The addition of trigger points for re-referral to children’s social care would have helped and including this advice in the closure of plans would ensure that the partnership remained sighted on specific risks for a child previously subject to a child protection plan.   6.10 This review outlines the endemic and pervasive nature of domestic abuse, the relationship with safeguarding children and the impact on the welfare of communities. The response to domestic abuse challenges safeguarding and community safety agencies nationally, the need to work together being a considerable drive across the multi-agency partnership. The response requires a consistency in approach derived from an underpinning ideology that responsibility and accountability are key to changing individuals, communities and cultures. Every action, seemingly small or big taken by safeguarding agencies can desist or detract from delivering a consistent message that supports victims and children and holds perpetrators to account for their actions.     - 26 -  6.11 In safeguarding, the phrase ‘healthy scepticism’ is commonly used; indeed, it is an ever present thinking process for professionals across the partnership. It is in this context that there can also be a sense of over-optimism about progress and without sufficient mechanism to test out the impact of change for a child; the optimism can become a vision rather than a reality. For all professionals supervision is in place to provide a challenge to the behaviour biases and mind-set that all can develop when a positive outcome seems achievable. Professionals providing universal services need to self-determine when supervision on a specific issue is needed and this is recognised by the Health Visiting report outlines that this is addressed through the recently launched domestic violence tool kit. This is a positive single agency development, but may have greater potential as a multi-agency approach in responding to the widespread problems of domestic abuse. The greatest strength comes from the partnership working together with a common ideology, tools and focus on outcome and impact. To this end, a recommendation is made that the partnership give formal consideration to a shared practice model of responding to domestic abuse.                   - 27 - Recommendations  1. The Partnership to strengthen the multi-agency approach to domestic abuse by exploring and adopting a specific practice model that provides a perpetrator based, child centred, and survivor strengths approach to achieving safe and secure outcomes for children and communities 2.  The partnership to be assured that robust step-down and transfer processes that promotes independence at a pace that supports embedding of change are in place, and specifically that there is review of the Local Procedure and Practice Guidance for Step Down in relation to the cessation of a child protection plan.  3. In collaboration with Community Safety Partnership, the Safeguarding Partnership to develop a plan to publicise and generate the use of Clare’s Law by educating both professionals and the community.  4. The partnership to seek assurance from commissioning services that step down and maintenance support is built into the commissioning of domestic abuse services to support sustained change for both victims and perpetrators of domestic abuse.   