Death of a 1-year-11-month-old boy in July 2013 following methadone ingestion. His mother had given him the substance to pacify him. Mother was sentenced to six years for manslaughter. Mother had a history of: substance misuse, criminal activity, anxiety and depression, and involvement in sex work. The mother's other child had previously been subject to a child protection plan for emotional abuse. Learning includes: the importance of considering any potential safeguarding issues relating to parents' methadone use or substance misuse, substance misusers' lack of engagement with medical reviews should be seen as a significant risk factor in regard to children, and methadone must either be kept in safe storage by the client or consumption should be supervised. Uses a systems approach to examine why and how decisions and actions were made. Sets out desired outcomes for children based on key findings from the review, including: timely pre-birth assessment of risk to unborn children of parents who misuse substances or are subject to methadone programmes, and for the voice of children to be heard by professionals.
      
 Title:  Board Response to Case Number BSCB 2013-14/2: overview report LSCB: Birmingham Safeguarding Children Board  Author: Paul Sharkey Date of publication: 2016  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. Birmingham Safeguarding Children Board has chosen to include identifying details of the children and the perpetrators as this information has been in the public domain.                            Final Version 21.03.16 1         Birmingham Safeguarding Children Board Response to Case Number BSCB 2013-14/2             Final Version 21.03.16 2   Case Number BSCB 2013-14/2 Birmingham Safeguarding Children Board Response into the death of Fenton Hogan (DoD 01.07.13) 1.1 This Serious Case Review (SCR) was conducted following the tragic death of Fenton Hogan as a result of ingesting a lethal dose of methadone administered by his mother. His mother did not intend to take his life, and the findings of manslaughter at her trial confirm this was the case. Fenton’s death was neither predictable nor intended, and none of the agencies involved with him and his mother did anything which directly contributed to his death.    1.2 The Birmingham Safeguarding Children Board (BSCB) received this Serious Case Review at their Executive meeting of 20th October 2015. The Board accepted the Report in full, as it provide extremely important learning for the Board about how to improve practice and ensure similar risks of methadone ingestion (both accidental and deliberate) are minimised in future. The Board recognised that whilst no agency or individual contributed to his death, there were many agencies and professionals involved during his short life. Between them they could have taken steps to better promote his and his sister’s safety and wellbeing, reduce the risk of ingestion and its potentially fatal consequences, and improve their life experiences.  1.3 This is of considerable regret to the Board and it is imperative that his death is a catalyst for major improvements in safeguarding and support services to all other children and families in the city and across the West Midlands when substance abuse impacts on their lives and safety. It is also of considerable regret that much of the learning was already known and available regionally and nationally as a result of similar Serious Case Reviews and research into the treatment of substance abuse of those who are also parents.   1.4 Much of the learning in the report was addressed and applied during the process of undertaking the review. Of particular importance for BSCB during this process was the fact that the specialist provider of substance abuse treatment involved in Dudley, CRI, won the tender to provide integrated substance abuse services in the whole of Birmingham. The learning informed the commissioner relationship with CRI as well as the way CRI implemented their service here. The service “went live” in March 2015 and the Board have sought assurance from the commissioners and from CRI at regular intervals.  1.5 The SCR recognises that most parents with substance abuse problems can and do parent their children appropriately. The report also recognises there is an inherent risk in working with such parents in balancing their right to parent and Final Version 21.03.16 3  be supported to do so, and the right of their children to be safely parented and get all their needs met. It is how agencies responded to the need to constantly undertake such a careful balancing exercise that is the issue in this SCR  1.6 Following a decision by agencies (after the Board meeting) to be family member led in terms of our approach to publication, we have subsequently consulted with both the maternal and paternal extended family. In undertaking that consultation, we have weighed up in particular the best interests of Fenton’s older sibling.  1.7 We had two different views expressed. The paternal family wanted us to publish the case proactively. The maternal family were appropriately protective of Fenton’s sibling, and whilst accepting a form of publication was necessary, did not want that to be proactive. After careful consideration the Independent Chair has decided to publish the report reactively, primarily and most importantly to minimise the chance of very distressing coverage two and a half years after Fenton’s death for his maternal extended family and in particular his older sibling who has important exams at the end of the summer term 2016.   1.8 On considering the SCR the Board has agree that • Fenton’s death was a tragic one that should not have happened • His mother has spent time in prison as a result of her action in giving Fenton methadone • There is no doubt things could have been done differently by those professionals involved with Fenton and his family. This did not directly or causally result in his death but the review concludes this would have reduced the possibility. This is a matter of considerable regret and we have collectively let down Fenton and his family • Much of what we have learnt reflects learning from similar SCR’s across the region as well as national learning and research. This is also a matter of serious regret for all the many agencies involved in this SCR in that the learning available had not been applied across the areas involved.  • A significant number of different local authorities, police, probation, NHS and substance abuse services were involved during Fenton’s life as the family moved regularly. Birmingham was the last local authority area they lived in. Although there were some individual areas of good practice, none of the areas or agencies were as effective as they should have been. • The learning indicates it is the understanding, knowledge, rigour and assertiveness of front line practice that most needs to change. This requires extensive workforce development, learning and improvement activity across the West Midlands as well as in the City of Birmingham Final Version 21.03.16 4  • Better support is required for frontline staff working with substance abusing parents in order to ensure they are able to identify, assess and manage the balance between drug treatment activity and empowerment of those parents to parent, and the risks of doing so • Prescribing and administering alternatives for the management of opioid dependency properly, in a way that minimises the risk of accidental or deliberate ingestion by children, is essential • Listening to and engaging family members and especially siblings in terms of understanding what is happening is essential • It also requires changes in the way those services involved supervise, performance manage and quality assure their practice in relation to substance abusers who are also parents, to ensure respectful uncertainty, high support and high challenge are all common features of practice Board Action Points 2 In response to the SCR and the learning points contained in it we have agreed a serious of actions as follows:  2.1 The Board agreed to remit the learning points for specific agencies for those individual agencies to review and act on as necessary. The Board will maintain a record of which learning points were disseminated to whom, and review progress on those actions when they receive each organisation’s section 11 self-assessment and audit, Annual Report for 2015/16 and Annual Assurance statement. Any areas not sufficiently addressed will be followed up with individual agencies.  2.2 The Board also agreed to produce a “learning bulletin” for wide circulation by agencies to their front line staff delivered through learning briefings, workforce development activity, training and learning activity, team briefings and supervision addressing the overarching key learning from the SCR report. This will be done after publication. These lessons relate to the following key learning points: • All learning relating to pre- and post-birth recognition and risk assessments of parental substance misuse, what evidence tells us about best practice, what is expected of front line practice, and where to find appropriate guidance and support on the Board’s policies, procedures and processes • The central importance of recognising, listening to, and talking to children and young people living in families where substance misuse is a key part of their daily life experiences • The importance of recognising when intervention requires escalation into formal safeguarding processes and ensuring that occurs • The learning from the six key findings from similar SCRs.   Final Version 21.03.16 5  2.3 Each agency agreed to disseminate the bulletins and expect their front line managers to ensure that staff use it to improve their own professional practice and managers use it to assess the impact of that learning in their working practice as part of their regular assurance activity.  2.4 Following discussions after the completion of the SCR with NHS West Midlands we also noted the need for substance abuse services and clinicians to consider when prescribing and administering treatment for the management of opioid dependency, what the safest treatments are, whether methadone is more appropriate than buprenorphine and what most facilitates a family centred approach to safe treatment.  2.5 The Independent Chair will write to chairs across the West Midlands, drawing their attention to the review, the learning points and the common themes reflected in the review of all six SCR’s in the area, asking them to consider whether there should be some regional thinking about how best to promote the learning.  In addition, the BSCB agreed to  • Work with the Birmingham Early Help and Safeguarding Partnership (EHSP) as it develops assessment tools and intervention tools which support a “think family” approach to families where adults have issues in their own lives which require professional support and which can potentially compromise their parenting ability  • Ensure the EHSP integrates the learning from this SCR into the development of those tools  • Take and develop for agreement and implementation any proposals put forward by the EHSP for establishing a comprehensive “Think Family” policy, and practice framework • Develop specific learning and development material to be used by agencies that provide services to adults with challenges in their lives who might also be parents, for specific focussed training and learning to improve the skills of those professionals. 2.5 The Board will consider during 2016/17 whether to undertake a thematic audit or review of agencies’ work with parents who are misusing substances, in order to evaluate the application of the learning from this review. Jane Held 21st  March 2016    Final Version 21.03.16 6        SERIOUS CASE REVIEW   ‘Working Together to Safeguard Children’ In respect of the death of Fenton Hogan.    Case No. BSCB 2013-14/2 Report by: Paul Sharkey (MPA)  November 2015   Final Version 21.03.16 7    Contents  1. Introduction        3 2. Parental Substance Misuse-The Wider Context   3 3. Summary and Overview      4 4. Purpose of the Serious Case Review    7 5. Terms of Reference       8 6. Timescale of Serious Case Review    8 7. Methodology        8 8. Parallel Enquiries       10 9. Family Involvement       10 10. Summary of Family Circumstances    10 11. Summary of Key Events: February 2011-July 2013  11 12. Analysis of Key Issues      24 13. ToR1         24 14. ToR2         52 15. ToR3         64 16. ToR4         65 17. Family Views        66 18. Key Learning and Findings from Similar SCRs   70 19. Key Findings, Learning and Desired Outcomes   72 20. Finding 1        72 21. Finding 2        73 22. Finding 3        73 23. Finding 4        79 24. Finding 5        84 25. Finding 6        91 26. Finding 7        92 27. Finding 8        93 28. Seven Overarching Lessons     94 29. Glossary of Terms       95 30. References         97 31. Appendix 1        99 32. Appendix 2        101 33. Appendix 3        102 34. Appendix 4        103 35. Appendix 5        105 36. Appendix 6        106 37. Appendix 7        110  Final Version 21.03.16 8  Introduction 1. The subject of this Serious Case Review is the child, Fenton Hogan1 who was born on the 18.07.11 to Kelly Emery at Russells Hall Hospital, Dudley in the West Midlands.  He died on the 01.07.13 at home in Birmingham, just two weeks short of his second birthday; the cause of death being methadone ingestion.  He was given the substance by his mother to make him sleep whilst she took cocaine.   2. Kelly Emery was found guilty at Nottingham Crown Court on the 5 March 2015 of the manslaughter of her son and sentenced to six years imprisonment2.  She was a long standing substance misuser of heroin, cocaine and alcohol and had been on a methadone programme with a substance misuse support agency in Dudley since 2009.  She had a criminal record for shoplifting and other forms of acquisitive crime to support her drug habit and was also known by the West Midlands Police to be a sex worker.   3. Fenton’s father (FFH) was serving a custodial sentence at the time of the death of his son.  Fenton also had a half-sister, (SFH) who was twelve at the time of her brother’s death. The child had spent the weekend before his death with his paternal grandparents who had played an important role in his short life.   4. The Serious Case Review sub-group of the Birmingham Safeguarding Children Board discussed the death on the 13.12.13 and recommended to the Independent Chair of the Board that the criteria3 was met for  the holding of a Serious Case Review.  The Chair, after consideration, agreed that the criteria were met and duly decided on the 19.12.13 to commission this Serious Case Review, hereafter referred to as a SCR.   Parental substance misuse and the impact on children and young people  The Wider Context 5. The significance of the dangers to children from parental substance misuse was brought to early professional attention with the publication of ‘Hidden Harm’ by the Advisory Council on the Misuse of Drugs in 2003. The publication contained a number of recommendations aimed at raising professional awareness of the impact of parental substance misuse on children and taking steps to decrease                                                            1 His real name is being used as it is already in the public domain through press reporting of his death and his mother’s subsequent trial. Likewise, his mother’s name has also been used.  2 This also included a guilty cruelty verdict to run concurrently.  3 See Government statutory guidance, ‘Working Together to Safeguard Children’ (2013) at paragraph 12, page 68. The guidance was updated in March 2015 but this SCR has been completed under the 2013 guidance given that it was commissioned in December 2013.  Final Version 21.03.16 9  the risk of harm to them through co-ordinated inter-agency working between adult drug services and services for children.   6. Reportedly (Adfam; 2014), as of 2009, there were around 120,000 children in the United Kingdom living with a parent who was engaged in drug treatment. Moreover, there were 60,596 adults in treatment in England in 2011-12 who had parental responsibility, an opiate problem and were receiving a prescribing intervention.  7.  Adfam (2014) found that there were 20 Serious Case Reviews between 2003-2013 where Opium Substitute Treatment (OST) drugs such as methadone were ingested by a child. These Reviews involved 23 children of which there were 17 deaths. Methadone was referred to in 19 of the Reviews and was the cause of 17 deaths, all of which were very young children (with an average age of two) who had been given the substance by a parent, usually in the misguided belief that it would pacify them.   8. Whilst every child death is a tragedy, the incidents of methadone ingestion, both accidental and parent administered are very rare, when set against the wider context of the number of parents in OST and their children. Arguably, it is this relative infrequency of intentional administration by parents that accounts for the minimal recognition by professionals of the possibility of such an eventuality  (Adfam;2014)  9. However, as commented on by Adfam, whilst low in incidence, deliberate parental administration of opiate substitutes such as methadone are, ‘Not isolated, but that they have happened with quite depressing regularity’.  (Adfam;2014;4)  Report Summary and Overview  10. Fenton was born in Dudley in July 2011 and lived with his mother and older sister (SFH) in nearby Sandwell in the West Midlands until February 2012 when the family moved to Birmingham where he remained until his death in July 2013. His father (FFH) was absent during Fenton’s short life whilst serving a custodial sentence. Fenton had significant contact with both sets of grandparents. He died after being given a lethal amount of 10 mls of methadone by his mother to pacify him and enable her to take illicit drugs.  11. Kelly Emery was found guilty of manslaughter at Nottingham Crown Court in March 2015 and given six years custody. The act of manslaughter by definition Final Version 21.03.16 10  meant that she did not intend on killing Fenton. The evidence of this SCR and the criminal trial suggests that his death was not predictable.  12. However, there were many agencies and professionals involved with Fenton and his family during his short life that between them could and should have taken steps to have better promoted his and his sister’s (SFH) safety and wellbeing. Tragically, this was not done. Indeed, as will be evidenced in the following sections of this report, there were significant shortcomings in the way that agencies, both individually and collectively, responded to the safeguarding needs of Fenton and his sister.   13. That said, it is not possible to conclude with any causal certainty that Fenton’s tragic death could have definitely been prevented had there been effective multi-agency intervention, given his death was manslaughter and that Kelly Emery did not intend to kill him. However, the Review concludes that the likelihood of his death could have been reduced had effective inter-agency action been taken to recognise and assess the known risks to Fenton and his sister from Kelly Emery’s substance misuse, methadone use and lifestyle; and implement an effective inter-agency response.   14. His mother Kelly Emery was known by West Midlands Police and the drug agency that was treating her with methadone, to have been a substance misuser of heroin and crack cocaine prior to Fenton’s birth. The specialist midwifery service responsible for her ante-natal care was aware that she was on a methadone programme. None of these agencies recognised or assessed the potential risks to the unborn child from Kelly Emery’s substance misuse and methadone usage.   15. There should have been a joint early review of the potential risks from Kelly Emery to Fenton by the drug agency and specialist midwifery service and a referral made to Sandwell Children’s Social Care for a pre-birth risk and needs assessment. This episode was an early missed opportunity to have done so. Had this happened it is possible that Fenton and his sister would have been made the subject of some kind of co-ordinated  early multi-agency intervention such as a Common Assessment or a Child in Need Plan or possibly, even a Child Protection Plan and placed on the inter-agency ‘Radar’. This did not happen and the reasons why are analysed in later sections of this report.   16.  To its credit, the Staffordshire and West Midlands Probation Trust which was supervising Kelly Emery in 2011/12 for shoplifting offences had assessed her as a medium risk to her children because of her substance abuse and made a child protection referral to Sandwell Children’s Social Care shortly after Fenton’s birth. Sandwell Children’s Social Care should have undertaken an initial assessment in compliance with its own procedures but did not, partly because of staff shortages Final Version 21.03.16 11  and internal organisational difficulties, but also because of sub-standard practice and ineffective managerial oversight.   17. Instead, it closed the referral down on the basis of some overly positive information from involved agencies and Kelly Emery herself, which suggested that she was being well supported by the drug agency, midwifery and health visiting services and her extended family. The reality was that this was not the case as evidenced by her very sporadic engagement with the drug agency, move to Birmingham in the Spring of 2012 following harassment from threatening individuals in December 2011 and tensions with her mother. This episode was another missed opportunity to have assessed the potential risks to Fenton and SFH from Kelly Emery’s methadone use and substance misuse.   18. Kelly Emery’s involvement with the Probation service ended on completion of the community order in June 2012 by which time Kelly Emery and the two children were resident in Birmingham. The drug agency in Dudley should have transferred the responsibility for Kelly Emery’s methadone treatment to the service in Birmingham but did not. Kelly Emery continued to receive her methadone prescription by post despite sporadic engagement, missing reviews and no provision of drug test samples. There was no liaison with Kelly Emery’s new GP in Birmingham as there had not been when she was in Sandwell. These were risk factors that were not recognised or acted upon by the drug agency which should have reviewed Kelly Emery’s treatment regime and reverted back to the practice of, ‘supervised consumption’, i.e. taking her methadone in the pharmacy under supervision. The agency did not consider the wider needs of the children and continued down a misguided ‘silo’ path of adult focused ‘harm reduction’ with Kelly Emery.   19. The new health visitor in Birmingham (actually from Worcestershire Health and Care NHS Trust) did not become involved until November 2012 because of a delay in transfer of notification from the Sandwell health visiting service. The Worcestershire health visitor did not consider the potential risks to Fenton from Kelly Emery’s methadone use or contact the drug agency for more information.   20. The West Midlands Police had involvement with Kelly Emery and the children in January and November 2012 regarding reports that she was dealing in drugs from her home and involved in sex working. The responses were ineffective in relation to the potential risks to the children on both occasions with no internal referrals being made to the Police specialist child protection unit or a child abuse non-crime number generated. These episodes were missed opportunities to have intervened and gained an understanding of the children’s situation in the care of their mother.   Final Version 21.03.16 12  21. Kelly Emery’s GP service in Birmingham was aware of her methadone treatment and periods of depression in 2013 but did not seek to liaise with her drug support agency in Dudley or consider the impact of the methadone and mental health issues on the children.   22. SFH’s school became aware of concerns from neighbours about her and Fenton in April/May 2013 that included allegations of drug and alcohol abuse. Standard safeguarding reporting procedures were not followed by staff and the concerns were not referred onto Birmingham Children’s Social Care.   23.  Birmingham Social Care received referrals on the children in August 2012 (anonymously) and April 2013 from the West Midlands Police burglary unit. The first was ineffectively responded to by a Referral and Advice officer and closed without going for an initial assessment with Children’s Social Care. The second was subject to an initial assessment by Children’s Social Care which wrongly concluded that there were no concerns about Kelly Emery’s care of the children and no evidence of harm to them. The case was closed in May 2013. These were two further opportunities for a multi-agency intervention that could have safeguarded and promoted the children’s wellbeing.   24. Thereafter, there was no further involvement from the agencies, apart from ongoing health visiting and a proposed visit in July to offer some parenting support to Kelly Emery which was sadly, made irrelevant by his death in early July 2013.    Purpose of the Serious Case Review   25. The overall purpose of a SCR is to,  • ‘Look at what happened in the case, and why, and what action will be taken to learn from the review findings, so that, action results in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and   • There is transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final report of the SCR with the Public’ ( ‘Working Together to Safeguard Children’, 2013, page 65, paragraph 4)  26. The reasons for the SCR were that;  • Fenton died.   Final Version 21.03.16 13  • Abuse, through being given methadone by Kelly Emery, was a known factor in his death.    Terms of Reference (ToR)  27. See Appendix1   Timescale of the SCR  28. The timescale of this SCR is from mid-February 2011 when Kelly Emery first booked in her pregnancy with the Russells Hall midwifery service to the beginning of August 2013, some two weeks after Fenton Hogan’s death.   Methodology  The SCR Panel  29. The SCR Panel (henceforth known as the Panel) comprised senior agency representatives who considered the information obtained from agency chronologies, Individual Management Reviews, the Learning Event, supplementary follow up commentary from agencies, and Court documents.    30. The Panel (see appendix 2 for membership) was chaired by Mrs Sheila Sutherland who qualified as a social worker in 1972. She has over thirty years’ experience in working within or managing social care services for children; including a total of fourteen years as Head of Services for Children and Families in Cumbria and Blackpool. Since September 2009 she has worked as a self-employed consultant to Children’s Social Care Services. She worked for three years with the Centre of Educational Leadership (CEL), Manchester University, as Social Care Learning Development Consultant on the development and delivery of Children’s Social Care Leadership Programmes. She continues to be a consultant to CEL Leadership and Change, on social care issues. She has worked as a consultant with Blackburn, Blackpool, Bury, Bradford, Cumbria, Leeds and Rochdale on both Serious Case Reviews and as an investigating officer in case and staff conduct enquiries. She has had no previous involvement with the Birmingham Safeguarding Children Board or any of its partner agencies prior to this SCR.  Additionally, she has had no previous involvement with the other three Local Safeguarding Children Boards, namely Sandwell, Dudley and Worcestershire or their partner organisations.  Final Version 21.03.16 14  31. The Lead Reviewer was Mr Paul Sharkey (MPA)4 who has wide experience of both writing and chairing Serious Case Reviews since 2002.  He is presently an independent safeguarding consultant with over thirty years background in both statutory and third sector child protection agencies.  He completed the Department of Education/NSPCC/Action for Children/‘Improving Serious Case Reviews’ course in July 2013 and is on the Association of Independent Chairs of LSCBs register for independent SCR Chairs and Lead Reviewers. He has had no previous involvement with the Birmingham Safeguarding Children Board or any of its partner agencies prior to this SCR.  Additionally, he has had no previous involvement with the other three Local Safeguarding Children Boards, namely Sandwell, Dudley and Worcestershire or their partner organisations.  32. The Overview Panel met on the following dates,  • 8 May 2014 • 24 June 2014 with IMR authors • 22 September 2014 • 6 October 2014 with IMR authors • 10 November 2014 with IMR authors • 8 December 2014, Learning Event • 16 February 2015, Scrutiny of Draft 1 of Overview Report • 20 April 2015, Scrutiny of Draft 2 of Overview Report • 15 June 2015, Scrutiny of Draft 5 of Overview Report  33. Individual Management Review [IMR] authors spoke to their reports with the Panel on the above dates (see Appendix 3 for the list of agency IMRs). Key Practice Episodes5 (see appendix 4) were identified by the Panel and the Lead Reviewer. These informed the basis of analysis of the four Terms of Reference conducted at the Learning Event of 8.12.2014, which all Panel members, IMR authors and relevant front line practitioners attended.  34. The Learning Event was facilitated by the Lead Reviewer using the, ‘5 Whys’ and the Cause and Effect/Fishbone’, analytical techniques in an attempt to understand from a systems perspective why and how decisions and actions were made within the context of prevailing organisational and agency practices and expectations of the time. The Panel and Lead Reviewer were mindful of hindsight and outcome bias in conducting the analysis. The Panel critiqued a draft of the                                                            4 Master’s in Public Administration ( 2007) from Warwick University Business School 5 These are episodes from the case that require further analysis and are thought to be significant to understanding the way the case developed and was handled. They are not restricted to specific actions or inactions but can extend over longer periods. See SCIE ‘Learning together to safeguard children, developing a multi-agency systems approach for case reviews (2008).  Final Version 21.03.16 15  Overview Report on the above dates and agreed the final draft in September 2015  35. This SCR took longer than usual to complete. This was because of delays in receiving finalised agency Independent Management Reviews. In addition it was necessary to wait for the receipt of the transcript of the trial judge’s sentencing comments which informed this SCR. This was received at the end of August 2015. The interviews with family members in late July also prolonged the length of the Review and Kelly Emery could not be interviewed until late October 2015.   36. The SCR Overview Panel had sight of the draft report in late August/early September 2015 and ratified it on the 18.09.15. The final draft of the SCR was seen and commented on by the Birmingham Safeguarding Children Board Serious Case Review sub-group on the 09.10.15 and ratified by the Executive Board on the 20.10.15.    Parallel Inquiries  37.  The West Midlands Police started a criminal enquiry into the death of Fenton in July 2013 which reached a conclusion on the 5 March 2015 at Nottingham Crown Court when Kelly Emery was found guilty of the manslaughter of (and cruelty to) Fenton and sentenced to six years imprisonment.  Family Involvement 38. Both sets of grandparents and Fenton’s father were seen by the Chair of the SCR Panel and the Lead Reviewer in late July 2015. Kelly Emery was seen by the Lead Reviewer and Overview Panel Chair on the 26 October 2015.    39. For the purposes of identity protection and confidentiality a family structure and genogram is not provided in this Report.  However, a full genogram was compiled as part of the overall Review process.  Summary of Family Circumstances  40.  Fenton Hogan (hereafter referred to as Fenton) was born on the 18.07.11 at Hospital 1(Russells Hall) in the West Midlands. He lived with his mother (Kelly Emery) who was born in 1980 and his elder sister SFH who was born in 2000.  His father, FFH who is in his early thirties did not live with the family during Fenton’s lifetime. Fenton had regular contact with his paternal grandparents (PGP) and his maternal grandmother, (MGM). He died at the age of nearly two years on the 01.07.13 of methadone toxicity as a result of being given the substance by Kelly Emery to pacify him so that she could take drugs.    His father was in custody at the time of his son’s death. The family lived in Birmingham at Final Version 21.03.16 16  the time of Fenton’s death.  They had previously lived in Sandwell and moved to Birmingham in April 2012.   41. The family are of white British heritage from the West Midlands whose only language is English. It is not known what, if any, their religious background is.   42. Kelly Emery had a long standing background of substance misuse (heroin, cocaine, cannabis and alcohol), acquisitive criminal behaviour and involvement as a sex worker.  She had been involved in a methadone programme with a substance misuse agency in Dudley since 2009, having been with a previous Dudley service for methadone users since 2007.    43. Fenton’s sister (SFH) was placed with relatives following her brother’s death.  She had earlier been subject to a child protection plan (emotional abuse; concerns around Kelly Emery’s substance abuse and lifestyle) in 2009 (30.01.09-09.07.09) whilst living in Sandwell.  The case was closed by Sandwell Children Social Care on the 25.08.09.   Summary of Key Events: February 2011- July 2013  2011  44. Kelly Emery booked in for her ante-natal care (for Fenton’s birth) with the midwifery service at Hospital 1 at 20 weeks gestation; around mid-February 2011.  Kelly Emery was known to have been a methadone user (recorded on the 02.03.11) and receiving services from Dudley Crime Reduction Initiative (CRI), the aforementioned voluntary sector substance misuse support agency.  Kelly Emery was also linked to a specialist substance misuse midwife during the period.  There was no contact made with Sandwell Children’s Social Care (CSC) or any evidence of a risk assessment being done regarding the impact of parental substance misuse on the unborn child by either the midwifery service or the substance misuse agency.   45. Between May to July 2011 Kelly Emery was brought into custody four times by the West Midlands Police. She was visibly pregnant and known to be using drugs.  Kelly Emery had told custody staff on the 12 May that she was a methadone user and had taken cocaine that morning and admitted occasional use of heroine.  Kelly Emery had tested positive for cocaine.  None of the investigating officers or custody staff generated a child abuse non-crime number for the unborn child (Fenton) or SFH.  There was no record of a referral to Final Version 21.03.16 17  Sandwell CSC.  A single intelligence log of the information was submitted on the 19.05.11 but was not disseminated.6  46. Fenton was born at Hospital 1, Dudley, on the 18.07.11.  Kelly Emery and baby were discharged on the 21.07.11 into the care of the community midwife (CM1) and health visitor (HV1) (Sandwell and West Birmingham Hospitals Trust/ Sandwell PCT).  Fenton showed no signs of drug withdrawal (neo-natal abstinence) but arrangements were made with the hospital to monitor this through visits to the neo-natal unit.  No safeguarding concerns were raised at this time.  47. In early June 2011, Kelly Emery was subject to a twelve month Community Rehabilitation Order to Staffordshire and West Midlands Probation Trust for a shoplifting offence.  She was assessed by the agency on the 24.06.11 as a medium risk of harm to children. This was based on her drug use; she had told a duty officer on the 20.06.11 that she, ‘occasionally had a line of cocaine’, the last being the previous week; and her methadone use (65 mls daily) was known to the agency.  Kelly Emery mentioned that SFH had previously been subject to a child protection plan in 2009.  On the 06.07.11 The Probation Service Officer (PSO1) was informed by Kelly Emery’s GP certificate that she was suffering from depression which was also known about by the midwife.  PSO1 made a referral to Sandwell Children Social Care on the 20.07.11, based on Kelly Emery’s   ‘medium risk’ to children classification; also expressing concerns about Kelly Emery and her partner’s methadone use.  The Probation worker felt that a social work assessment was required given the presence of the new baby.  48. Sandwell Children Social Care contacted the Probation Service on the 22.07.11 to say that there was no involvement from them.  A duty social worker from Sandwell Children Social Care spoke to a community midwife on or around the 22.07.11 who said that Kelly Emery was engaging with and receiving support from Dudley CRI, the specialist substance misuse midwife, the health visitor, family and friends.  The duty social worker contacted the Probation service to say that there would be no input from Sandwell Children’s Social Care at that time.  Advice was given to make a referral to Children and Young People Services in the event of any further concerns, or to complete a Common Assessment if Kelly Emery needed any further support.  There was no indication that the midwife (including the specialist midwife) or Dudley CRI had considered the implications of any risk to Fenton or his sister from their mother’s methadone/substance misuse.                                                              6 The WMP IMR views this period as a ‘significant lost opportunity’ for professionals to have intervened to protect FH-page 13.  Final Version 21.03.16 18  49. A Probation visit by PSO1 and the Probation Officer was made on the 02.08.11 when Fenton and his sister were seen.  Kelly Emery said that Sandwell CSC had recently visited (there was no evidence that this had, in fact, happened) and was liaising with the midwife who would shortly be handing over to the health visitor.  Kelly Emery said that she was also getting support from her mother but was vague about any support from Fenton’s father. Follow up calls were made by the Probation service to Sandwell CSC in September 2011 and February 2012 to check if there were any further concerns.  Sandwell CSC reported that there was no open case and that the family were receiving support from other professionals and the wider family.  50. On the 02.08.11, a care plan review was held on Kelly Emery by the Dudley CRI.  She did not attend.  It was decided to take her off the Dudley case load and transfer her to the Sandwell drug intervention programme, given she lived in Sandwell.   51. On the 11.08.11, Kelly Emery and Fenton were discharged from the care of the neo-natal midwife.  The health visitor (HV2) saw them both at the home of the maternal grandmother on the same day and reported Fenton to be feeding well with good weight gain and appeared settled.  HV2 noted that Kelly Emery was on a methadone programme and was given contact details of her drug’s worker.  Kelly Emery’s partner was said to be ‘working away’ and that support was being given by the grandparents.  HV2 made a telephone call to the drug’s worker the next day but with no reply.   52. Fenton was taken to the GP practice by his mother on the 19.08.11 for his six-eight week check and first immunisations with ‘satisfactory development parameters’ recorded.  Kelly Emery and Fenton attended a Probation office visit on the 23.08.11 and were seen by the duty officer who recorded that Fenton appeared happy and healthy with no safeguarding issues identified.   53. A Probation office visit on the 13.09.11 by Kelly Emery (with Fenton) recorded that she was coping ‘OK’.  She said that she was not ready for a proposed reduction in her methadone dosage, that she was stressed looking after Fenton and lacked sleep.  She was now at home (having left her mother’s home) and being supported by her mother and Fenton’s paternal grandmother.  Although her partner (who was, in fact in prison) was not living with her, Kelly Emery said that he visited every day which suited her as she felt they got on better under this arrangement.  On the same day the health visitor recorded the receipt from Hospital 1 of a missed appointment for Fenton on the 06.09.11 at the neo-natal clinic.  A further appointment was offered for three months’ time.  Fenton attended a Sure Start clinic on the 14.09.11 where his weight was recorded as 5.68 kgs with no centile recorded.     Final Version 21.03.16 19  54. Kelly Emery was sentenced on the 26.09.11 to a twelve month Community Order and forty hours of unpaid work for a previous shoplifting offence of the 31.05.11 and a breach of a conditional discharge.  The Probation Service Officer (PSO1) contacted Sandwell Children’s Social Care on the 27.09.11 querying the previous referral of the 22.07.11 and was advised that Kelly Emery had a lot of support from her family and other agencies.  The Children’s Social Care view did not indicate that there were any concerns about Fenton.  Agencies should continue to monitor the situation and refer if any new concerns arose regarding Fenton or his older sister.   55. Kelly Emery was seen by PSO1 on the 28.09.11 and maintained her status as a medium risk to children because of her continued use of methadone.  A further Probation assessment review took place on the 17.10.11 which continued with her ‘medium risk’ status on the basis of her daily methadone use and previous class A drug misuse.  It was recorded that Sandwell CSC had concluded that there were no concerns about the wellbeing of the children as the mother had a good support network from her family, the drug services and Sure Start.  Part of the community order concerned work around drug awareness and drug testing on a voluntary basis by the Dudley CRI.   PSO1 tried to contact the substance misuse worker on the same day by telephone to check up on Kelly Emery’s progress but there was no reply and a message was left.   56. Kelly Emery and Fenton were seen by PSO1 at the office on the 25.10.11 when the baby was reported as appearing well and had his first injections the previous day. Kelly Emery was seen again on the 10.11.11 and the 22.11.11 when she was commended for her good progress on the community order.  It was reported that her drugs worker was to visit her the following week; that she was stable on her current methadone dosage and was coping with caring for Fenton, with the support of the grandparents.  It was also recorded that the baby ‘appeared to be thriving’.   57. Kelly Emery was recorded by PSO1 at an office appointment of the 06.12.11 as appearing stressed due to money worries and having gained no relief by refraining from drugs and trying to do things the right way.  She reported that her methadone use remained stable.  The Sandwell health visiting service recorded on the 15.12.11 that baby Fenton had defaulted on his second neo-natal appointment to Hospital 1, scheduled for the 08.12.11.  Another appointment was arranged for three months hence.   2012  58. The PSO1 saw Kelly Emery on the 03.01.12 at an office visit.  She mentioned moving to an area that was not linked to drug use, possibly to be near her father in Rubery (Birmingham/Worcestershire border) who could offer her some Final Version 21.03.16 20  support.  The health visitor (HV1) did a home visit on the 06.01.12 and saw both Kelly Emery and Fenton who was noted to be below the 75 centile.  Kelly Emery said that she had been burgled on the previous 25 December and had reported this to the Police.  She felt insecure and invaded and wanted to move.  Her methadone use was discussed; she said that her usage was monitored and she was supported daily.  Safe storage was discussed.  Neither of the missed neo natal appointments for Fenton at Hospital 1 were mentioned.  There was no record of HV1 following up with the Dudley substance misuse service to corroborate Kelly Emery’s self-reporting or engagement with the programme.   59. The West Midlands Police filed an intelligence report on the 10.01.12 suggesting that Kelly Emery was dealing drugs from her house (a smell of cannabis) and that various males had come to her property over the Christmas period.  On a separate occasion the drugs worker (DW1) from the Dudley CRI visited the home on the 17.01.12, noted a broken front window and agreed to contact a housing officer.   60. A further Police intelligence log was made on the 28.01.12 suggesting that Kelly Emery was drug dealing from her home (in Sandwell) where there were also young children.  Kelly visited PSO1 on the 31.01.12 on her own (she said that Fenton was with his paternal grandmother) and reported that he was going through his ‘clingy’ stage and she was finding it difficult to get on with anything around the house.  She was finding it difficult to cope on benefits and hoped to be moving to Rubery, nearer to her father where she could be more supported.  PSO1 agreed to contact the Housing department on her behalf.   61. On the 10.02.12 Kelly Emery reported to the Police that a brick had been thrown through her window.  She told DW1 (Dudley CRI) on the 13.02.12 (via the telephone) that she would be looking for hostel accommodation following the brick throwing incident.  There was no recorded follow up by DW1 in liaising with other agencies regarding the safety and welfare of Kelly Emery or the two children.  An assessment review by PSO1 on the 16.02.12 identified increased difficulties for Kelly Emery around her finances.  She had been receiving support from Fenton’s paternal grandmother but felt that her own mother had given her little credit for her progress and was quite critical of her.  PSO1 recorded that she had tried unsuccessfully to contact the drugs worker (DW1) to discuss the case.  CRI’s records indicate they had responded but had indicated they needed consent to share information with PSO1. However, there had been no concerns raised by other agencies and no indications from Kelly Emery that she was at risk of relapsing or having difficulties in coping with her situation.   62. DW1 was informed by Kelly Emery by telephone on the 24.02.12 that she was in temporary housing in Birmingham.  She failed to attend an office supervision appointment with PSO1 on the 28.02.12. PSO1 enquired with Sandwell Children Final Version 21.03.16 21  Social Care on the 29.02.12 whether there were any concerns about the two children and was told that there was no open case regarding them.   63. On 29.02.12 PSO1 managed to speak on the telephone to the drugs worker (DW1) who confirmed that Kelly Emery was drug free and stable.  It was not evident as to how DW1 knew this to be true.  He told PSO1 that he was not going to transfer Kelly Emery’s script to another agency (as he was told to do in supervision of the 02.08.11) as she did not have stable accommodation and might be remaining in the area (i.e. Sandwell).  He planned to keep responsibility for the case until Kelly Emery had settled in permanent housing.  DW1 and PSO1 discussed whether there were any concerns regarding the children.  DW1 said that he had undertaken home visits and an assessment and felt that Kelly Emery was coping well.  Any concerns he had were linked to her living in the previous address and the recent two incidents of criminal damage to the windows.  DW1 thought that Kelly Emery would do better now she was in the process of moving to another area.  It was mentioned that her partner/ex-partner (Fenton’s father,) was in prison and PSO1 made a note to ask Kelly Emery about this matter.   64. Kelly Emery phoned PSO1 on the 29.02.12 and told her that she had moved with Fenton to temporary hotel accommodation in Northfield.  SFH was staying with the maternal grandmother to facilitate her continuing her schooling. On the 06.03.12 Kelly Emery visited PSO1 and said that she was still in temporary accommodation in Smethwick awaiting rehousing.  Fenton’s care was being shared between herself and her mother with SFH being at her maternal grandmother’s.  Her partner was in prison and her father had not been supportive whilst she was in the hotel.  She was told to keep PSO1 informed of her whereabouts and any final moving address.  DW1 was told over the phone by Kelly Emery on the 23.03.12 of her temporary address.   65. Sandwell health visiting service received notification from Hospital 1 on the 28.03.12 of Fenton’s third missed neo-natal appointment of the 08.03.12.  A new health visitor (HV3) made a ‘futile’ unplanned home visit to the former Sandwell address on the 02.04.12 to be told by an unknown female that the family had moved.  HV3 asked that her details be passed on to Kelly Emery with a request to contact her.  There was no record of HV3 liaising with the GP practice or other services to try and locate the family.   66. Kelly Emery failed to attend two office supervision appointments in early April with the PSO and warning letters were sent to her.  PSO1 tried to contact the drugs worker (DW1) by phone on the 11.04.12, leaving a message to contact her with Fenton’s current address but received no reply. CRI has no record of this call.  Final Version 21.03.16 22  67.  A medical review by DW1 and Dr 1(the prescribing doctor) was held on the 16.04.12 in Kelly Emery’s absence which was caused by a reported ‘death in the family’.  There was no recorded evidence of any link or liaison with the Probation service or any other agency to inform the medical review.   68. On the 18.04.12 Kelly Emery did attend an appointment along with Fenton with PSO1 and said that she would be moving to a new permanent address in Rednal, Birmingham, in two weeks.  She also said that her methadone usage was stable.  DW1 was informed over the telephone by Kelly Emery on the 20.04.12 of her new address to which she would be moving in four days’ time.  She and Fenton were seen by DW1 on the 27.04.12 at the service; and both looked well.  An appointment was made for Kelly Emery to see Dr 1 about reducing her methadone.  69. Kelly Emery and the children eventually moved into their accommodation in Frankley, Birmingham, on or around the 15.05.12.  Her final Probation appointment was on the 17.05.12 when she saw a duty officer (PSO1 was not available).  She believed that she had done well in completing the order and said that she and the children were settled.  She was reminded that the order did not finish until the 6 June. On the 21.05.12 Kelly Emery had a medical review with Dr 1 and discussed the transfer to the Birmingham substance misuse service.  She was not keen to do so as she had been working with DW1 (from Dudley CRI) for some time.   70. On the 29.05.12 the GP and health visitor in Sandwell were notified of a defaulted neo-natal appointment at Hospital 1 for Fenton.  A further appointment was offered for September 2012. Kelly Emery finished involvement with the Probation service on the 06.06.12 on completion of the order.  It was noted that there were no current concerns regarding the children raised from Sandwell Children’s Social Care.  Her self-reported methadone use understood to be stable, her partner was in prison and she had moved to Frankley because she had not received much support from her own mother and hoped to form new relationships of friendship and support.   71. Kelly Emery’s methadone script continued to be posted out to her new address by the Dudley CRI.  DW1 was advised by his manager on the 11.07.12 to transfer the case to the Birmingham service.  The health visitor (HV3) undertook a futile home visit to the previous address on the 07.08.12 when it had been known since April that Kelly Emery and the children had moved away.  HV3 liaised with the GP practice to ascertain the new address to find that this was not on the system.  She also contacted Sandwell (not Dudley) substance misuse service to find that (unsurprisingly) Kelly Emery was not known to the agency and did not have a current address.  DW1 saw Kelly on the 21.08.12 and recorded that the methadone reduction was going well. Final Version 21.03.16 23   72. In late August the Birmingham Children Social Care (BCSC) Integrated Access team received an anonymous report of concerns from a friend of a neighbour of Kelly Emery alleging the use of heroin and crack in front of SFH, noisy parties attended by local drug dealers and an ‘old man’ encouraging SFH to take drugs.  The caller was asked to contact BCSC directly but became agitated and declined to give her (or her neighbour’s) details.  Apart from being recorded on Carefirst there was no evidence that the referral went to a team manager for assessment or any action.   73. DW1 visited Kelly Emery on the 03.09.12 and recorded that she presented well with a neat and tidy home.  She reported that the methadone programme was going well.  On or around the 07.09.12 a letter was sent by the neonatal consultant to the Sandwell GP practice reporting Fenton’s non-attendance at the arranged appointments of the 08.12.11 and 20.03.12 in relation to the ongoing monitoring of his neo-natal abstinence syndrome.  Albeit, that he was not suffering from the syndrome, the letter requested the GP to ask the health visitor to investigate and carry out a Common Assessment (CAF) if needed. Fenton was offered another appointment. No action was taken as the family had by this time moved to Frankley.  It seemed that the letter was not passed on, as the family’s whereabouts was not, at that time, known to the GP practice and the health visitor in Sandwell.   74. On the 18.09.12 Fenton was registered at Frankley Health Centre having been in the area since May.  He was given his first set of immunisations by the GP on the 25.09.12, aged fourteen months. By October, Kelly Emery’s methadone script was being sent to her mother’s address as she was not able to attend the Dudley service.  Fenton was seen by the GP on the 05.10.12 for a chesty cough.   75. A verbal telephone handover was made between HV3 and the new health visitor (WHV1) on the 09.11.12.  Only limited information was exchanged including Kelly Emery’s methadone use, the futile home visits made and that the last visit had been made in the previous April. There was no mention of the missed neo-natal appointments for Fenton although a reference was made to him being under the care of a neonatologist.  There was also no reference to the recent letter from the neo-natalist to the Sandwell GP requesting that a CAF should be considered.  The neo natal service at Hospital 1 was notified of the new address by HV3.  A letter was sent on the 16.11.12 by WHV1 to Kelly Emery arranging for a first home visit for the 28.11.12.   76. The West Midlands Police (WMP) received an anonymous call from the public on the 11.11.12 reporting concerns that a woman (Kelly Emery) had been leaving her eleven year old daughter to look after her sixteen month brother while she Final Version 21.03.16 24  'goes out to prostitute’; that the woman also had sex with men in her home.  Two officers attended the given address and found the children to be ‘safe and well’ in the care of a women who was not Kelly Emery but was ‘babysitting’.  No referral was made to the Police Public Protection Unit.   77. Kelly Emery told DW1 on the 27.11.12 that the methadone reduction was ‘going ok’.  However, she was reportedly below 30 mgs and showing signs of withdrawal.   An appointment was made for her to see the agency doctor.  It was also noted that she was ‘drug free’ although there was no test result recorded.  On the 28.11.12 Kelly Emery telephoned WHV1 to cancel the arranged home visit as apparently, a family member had had a heart attack and she was taking her mother to hospital.   78. WHV1 telephoned Kelly Emery on the 04.12.12 to arrange for her to bring Fenton to the health centre baby clinic for the 06.12.12.  He was not brought to the appointment by his mother who later told the health visitor that she had had a disturbed night with him teething.  A new appointment was arranged for the 18.12.12 which was later (12.12.12) changed to the 15.01.13.  Kelly Emery visited her GP on the 10.12.12 due to asthma; it was noted that she was a methadone user.  Fenton was also seen by the GP for vomiting and a viral illness.  Appropriate medical advice was given.  SFH was seen by the GP at the Frankley health centre on the 20.12.12 with Kelly Emery for hearing problems and was appropriately referred.  No significant concerns were raised.   79. Kelly Emery visited her GP on the 14.12.12 due to anxiety and depression which she claimed had started ‘two years ago’ in her pregnancy with Fenton.  Kelly Emery denied any suicidal thoughts although she had written a note to the GP asking for help and describing a difficult emotional situation.  The Hospital, Anxiety and Depression (HAD) scale was used and anti-depressants prescribed.  There was no evidence that any enquiries were made about the implications of Kelly Emery’s mental state for the children.  A medical review was held by Dr1 at Dudley CRI on the 17.12.12 when it was decided to continue with the methadone reduction.  Kelly Emery reported that she was ‘clean’ on reduction and stable on 27mgs of methadone.  Dr1 advised that drug testing was needed.  There was no evidence of any liaison with the GP or other services (the pharmacist) in Frankley.   2013  80. WHV1 and a student health visitor undertook the ‘New to area home visit’ on the 15.01.13.  It was recorded that Fenton’s father was in prison and the details of Kelly Emery’s drug’s worker were given.  SFH’s details were confirmed and ‘Good family support’ identified.  Kelly Emery continued to receive her methadone script during January. Final Version 21.03.16 25   81.  In January 2013 two intelligence reports were submitted by officers of the WMP suggesting that Kelly Emery was dealing drugs from her home where it was known that two children were living.  The intelligence record generated on the 17.01.13 by a Police Community Support Officer (PCSO) was almost identical to the one received on the 11.11.12.  A child abuse non-crime record was not created.  82. Kelly Emery was seen for a follow up from the consultation of the 14.12.12 by her GP on the 01.02.13 for her anxiety and depression.  She remained on a high level of symptoms similar to the previous December 2012 consultation.  Apparently she was not complying with her medication (50 mg of sertraline daily) and was advised to start correctly and review in four weeks’ time.  There was no exploration of the impact of Kelly Emery’s mental health and methadone use on her children and no liaison with other members of the primary care team such as the health visitor.  83.  Kelly Emery had cancelled an appointment with DW1 on the 28.01.13 and had re-arranged for the 08.02.13.  WHV1 had re-booked an appointment on the 06.02.13 for Fenton to be seen at the neo-natal department of Hospital1 and asked to be copied in to promote attendance.  A planned appointment at Birmingham’s Children’s Hospital (BCH) on the 07.02.13 for Fenton was re-scheduled for the 18.02.13.  Kelly Emery reported on the 08.02.13 to DW1 that she was suffering from psoriasis (not mentioned in the GP records) and wanted to delay methadone reduction until it had cleared up.   84. Fenton was not brought to BCH for his audiology appointment on the 18.02.13 and no further appointments were made.  There was no record of WHV1 or the GP being notified of this so that a follow up could happen.   85. Kelly Emery was seen by her GP on the 04.03.13 for a review of her anxiety and depression.  She reported improvements and was willing to increase her dosage of anti-depressants (up to 100 mgs of sertraline) with a review in four weeks’ time.  There was no record of any liaison with the Dudley CRI or WHV1.  An appointment was made by DW1 on the 04.03.13 for the 14.03.13 and a script posted.  86. The NSPCC Helpline received a call on the 06.03.13 from an anonymous female expressing concerns for Fenton and his sister.  She stated that drugs, cars and loud music were happening at the house all night long and was really horrendous at weekends, really rough, really bad, with shouting and screaming at the children.  It had been going on for about eight months.  The referral was sent by e-mail to Birmingham City Council (Integrated Access team) at 10pm on the Final Version 21.03.16 26  same day.  There was no record of the access team receiving the referral or of any follow up.  87.  Kelly Emery did not attend the Dudley CRI appointment on the 14.03.13 as arranged.  DW1 rebooked it for the 27.03.13.   88. Kelly Emery phoned the Police on the 16.03.13 late at night to report a criminal damage and disorder incident.  A visit was made but Kelly Emery provided minimal explanation and no offence was recorded with no mention of any children resident at the address.  The incident may have been related to a drug debt owed by Kelly Emery.  Two days later on the 18.03.13 intelligence was recorded by the West Midlands Police that Kelly Emery was, ‘a prostitute and heroin addict’ with men in attendance at all times of the day who threw rocks at her window to attract her attention.   89. WHV1 sent a letter on the 27.03.13 to Kelly Emery making arrangements for a development review for Fenton for the 19.04.13.  On the same day Kelly Emery reported to a duty worker at the Dudley CRI that she was drug free, stable on 19 mgs of methadone, wanted to stay on this dose for a while and wanted to remain with her current worker (DW1) until the reduction was completed.  90. Kelly Emery arrived late with Fenton (despite being sent a reminder of the appointment details on the 08.04.13) for the development review of the 19.04.13.  Another one was arranged for the 24.04.13.   91.  On the 22.04.13 a Police Officer from the local CID Burglary Team sent a report of his child protection concerns for Fenton and his sister to Birmingham Children Social Care.  These related to a previous stolen property enquiry and search of Kelly Emery’s house on the 18.03.13 when signs of drug misuse such as silver foil and spoons were found and where there were children living.  Additional concerns were around Kelly Emery allegedly operating as a sex worker to fund a heroin habit, various men visiting the house, loud music at all times of the day, and the children being neglected and left alone.  The Police Officer was told on the 19.04.13 by a neighbour that they had seen a child playing outside Kelly Emery’s address who looked particularly unkempt.   92. Birmingham Children Social Care received the Police report on the 22.04.13 and the referral was allocated to a senior social worker (SW1) on the same day for an initial assessment. SW1 undertook a home visit on the 23.04.13 and saw Fenton, Kelly Emery and the maternal grandmother. SFH was not seen or spoken to and was presumably at school.  Kelly Emery was noted to have grazes to her hand which she said she got from two incidents of falling over when drunk at the weekend when she binge drank when the two children were with their respective grandparents.  Kelly Emery said that the burnt silver foil and spoons were Kit- Kat Final Version 21.03.16 27  wrappers and yoghurt spoons used by the children.  She denied ever using heroin, leaving the children alone or being a sex worker.   93. SW1’s initial assessment concluded that there was no evidence of drug abuse when visited, or that the children were being neglected or exposed to inappropriate behaviour.  Kelly Emery was supporting the children appropriately with no concerns about her care of them from the professionals currently involved with her, namely, the health visitor (WHV1) and Dudley CRI.   94. However, it was the case that on the 24.04.13, SW1 telephoned Dudley CRI and spoke to the duty worker (not DW1 or his manager) stating that the Police had found possible drugs paraphernalia at Kelly Emery’s home.  The duty worker said that he would leave a message for DW1 to contact SW1.  There was no record of this happening, namely of SW1 speaking to DW1 for more information about Kelly Emery’s methadone use or possible substance abuse.  SW1 recommended case closure on the basis that there was no evidence of harm to the children with the mother engaging well with professionals.  This was endorsed by the team manager and the case was closed on the 09.05.13. CRI contacted SW1 on 29.04.13 to be told the case was closed. They did not challenge SW1’s decision.   95. On the 23.04.13 Kelly Emery was seen by her GP for anxiety and depression and was deemed to be stable on her medication.  On the 22.04.13 another worker from the Dudley CRI spoke to Kelly Emery who said that her mother was collecting her script.  This was agreed to with a four week script issued because Kelly Emery was being transferred to Birmingham.   96. The health visitor (WHV1) visited the home on the 24.04.13 for the planned development review but only managed to see Fenton and his mother on the doorstep.  Fenton was reportedly unwell with diarrhoea and vomiting and the visit was re-arranged for when he was better.  WHV1 spoke on the telephone with SW1 on the same day who fed back her conclusions of the recent home visit and Birmingham CSC’s intention of no further action given there were no concerns resulting from the lateral checks with the school and the drugs worker.  A future referral could be made if necessary.   97. On the 26.04.13 Kelly Emery telephoned the GP surgery at 17.45 regarding concerns about Fenton’s diarrhoea, vomiting and possible dehydration.  The GP advised her to take him to Birmingham Children’s Hospital (BCH) as he may have needed fluids.  The advice appeared to have been accepted by Kelly Emery.  At 18.29 hours on the same day the West Midlands Ambulance service received a 999 call from Kelly Emery who was very concerned for Fenton; he had been vomiting and suffering from diarrhoea for three days.  Two ambulances attended consecutively (at 18.42 and 19.03) and Fenton was taken to BCH with his mother.  On arrival at 19.41 at the Emergency Department he was noted to have Final Version 21.03.16 28  low blood glucose, was lethargic and with a four day history of vomiting and diarrhoea.   98. He was diagnosed as having gastroenteritis; was medicated, treated with dioralyte and discharged home with his mother at 23.40hours.  No safeguarding concerns were noted.  The GP received a letter indicating the need for follow up care.  99. SW1 telephoned a Birmingham drugs worker (BDW) on the 29.04.13 advising that Birmingham CSC was closing the case due to insufficient evidence of possible harm to Fenton and his sister.  The transfer from Dudley CRI (DW1) was still outstanding.  Kelly Emery had said that the spoons were from the children’s yoghurt and the silver foil was a Kit-Kat wrapper.  DW1from the Dudley CRI had not been spoken to as part of the social work initial assessment and it is not known how much the Birmingham drugs worker (BDW) knew about the case.  SFH’s school noted a telephone call from SW1 on the 07.05.13 about the referral.   100. Dudley CRI on the 16.05.13 recorded agreeing to post out Kelly Emery’s script and e-mailing the keyworker (DW1) to make the case transfer.  On the 24.05.13 BDW received (by fax) the transfer paperwork from the Dudley CRI.  It is recorded that ‘the referral (was) sent back via fax’.   101. On the 10.06.13 Kelly spoke to a duty worker at the Dudley substance misuse service asking for an update on the transfer to Birmingham which had not yet happened.  She was told that the transfer would take four weeks and to call back in two weeks.   102. WHV1 completed a developmental review on Fenton on the 20.06.13.  He was reported by Kelly Emery as being boisterous and destructive and was referred to the nursery nurse for support.  He had a bruised right eye which, according to Kelly Emery happened whilst at maternal grandmother’s where there were lots of other children.  Maternal grandmother returned Fenton to his mother so it was not clear how the bruise happened.  There was no follow up undertaken by WHV1 into the bruising (e.g. a referral to Birmingham CSC given the recent initial assessment by SW1) and mother’s explanation was accepted.   103. The nursery nurse spoke to Kelly Emery on the 28.06.13 by telephone to arrange an appointment for the 12.07.13 to discuss Fenton’s behaviour.   104. Fenton had spent the weekend of June 29/30 with his paternal grandparents which was a regular occurrence.  He returned home at around 17.30 on Sunday 30 June and appeared well, but tired and did not eat his food.  His mother reported that she had no concerns about his general behaviour or demeanour and he reportedly fell asleep on the sofa at around 21.15.  Kelly Emery awoke at Final Version 21.03.16 29  around 7 a.m. the next morning (1 July 2013) and found Fenton to be cold, covered him and went back to sleep.  She woke at around 11a.m. to find him not breathing, phoned an ambulance which arrived at 11.27 a.m. and took Fenton to the Emergency Department of Birmingham Children’s Hospital.   105. Fenton arrived at the hospital at 12.02 in a cardiac arrest and was pronounced dead at 12.19 after unresponsive CPR (cardiopulmonary resuscitation). Kelly Emery was arrested by West Midlands Police in the afternoon of the 1 July 2013 and a criminal investigation was started.  In September 2014 she was charged with manslaughter and found guilty as charged in March 2015, receiving a six year custodial sentence. SFH was placed by Birmingham CSC with relatives where she remains.   Analysis of Key Issues  ToR 1 What tools were used by practitioners to evaluate and assess the mother’s capacity to parent safely in the light of her alcohol and substance abuse? Was the degree to which that abuse could compromise her ability to parent safely taking into account in decision making?  106. The following seven agencies had involvement with Kelly Emery and her two children in both the ante and post-natal period whilst the family lived in Sandwell.  These were,  • The Crime Reduction Initiative (CRI) (Dudley Adult Integrated Recovery Services)  • Specialist midwifery-substance abuse and drug liaison ( Dudley Group NHS Foundation Trust) • Primary midwifery ( Sandwell and West Birmingham Hospitals Trust) • Health visiting Sandwell and West Birmingham Hospitals Trust) • General Practitioner service • Staffordshire and West Midlands Probation Trust • Sandwell Children’s Social Care   Dudley CRI  Final Version 21.03.16 30  107. Kelly Emery had been in Opioid Substitution Treatment (OST) for her substance misuse (regular heroin misuse)7 since 2007, initially with the Warehouse charity based in Dudley, and from 2009, with the Dudley CRI.  She remained with the Dudley CRI up to the death of Fenton in July 2013.  The treatment regime was twofold and consisted, firstly of being clinically prescribed methadone as a substitute to address her dependence on the above substances and work towards withdrawal.  The methadone programme was overseen by a medical lead (employed by the Dudley Hospital Group NHS Foundation Trust) who worked to the CRI under an ‘umbrella’ arrangement.  This aspect of the programme was monitored by local General Practitioners with a special interest in substance abuse.  Secondly, a non-medical key worker (DW1) from Dudley CRI whose role was to provide psycho-social support and guidance to Kelly Emery in helping her move towards recovery and withdrawal from heroin and crack cocaine.  The key worker reported to and was supervised by a Team Leader (TL1).   108. Methadone is usually prescribed in liquid form with a typical maintenance dose being between 60-120 mls daily (The Methadone Handbook).  It  is a powerful opiate in its own right with a high mortality risk associated with ‘opioid naïve’ people (as little as 10 mls can kill a young child) and is designated as a Class A drug (Adfam; 2014).  Methadone users will usually start their treatment under ‘supervised consumption’ arrangements requiring them to take their dose on a daily basis in front of a health professional such as a pharmacist for an initial period of three months.  These conditions can be relaxed by the prescriber in the event of evidence of compliance through testing (NICE; 2007).  However, the Department of Health ( 2007) guidance in relation to clinical management states that,  ‘Prescribing arrangements should aim to reduce risks to children, and these should be taken into account before any change in prescribing regime is made.’ (Adfam, 2014, 5)  109. According to the Dudley CRI IMR, both medical reviews and drug testing were supposed to happen every twelve weeks.  The prescribing aspect of the treatment was, at the time, undertaken by doctors who were not directly employed by the CRI which lead to a ‘disjointed approach to fully integrated substance misuse care’ (CRI IMR p. 7) with respect to effective collaboration with the psycho-social support worker.  Moreover, Kelly Emery was not drug tested in compliance with agency policy.  110. There were no records to show that Kelly Emery had been drug tested either before Fenton’s birth or during his lifetime.  Indeed the first recorded drug test                                                            7 It should be noted that Kelly also misused cocaine. Final Version 21.03.16 31  was on the19.07.13. sometime after his death.  There was a poorly executed and confusing change in drug screening guidance (frequency of urine screening was lessened) introduced by CRI management, which according to DW1 lacked clarity and contained mixed messages, leading to staff practising in different ways (CRI IMR, p.11).  Records indicate that there was only one medical review within the timeframe in question, namely on the 21.05.12, when Kelly Emery was not drug tested.   111. The Panel was informed that Scottish guidance suggests 8that drug testing in expectant mothers should occur more frequently as factors such as blood volume can impact on the effectiveness of the methadone.  Good practice would therefore be to test pregnant methadone programme participants much more frequently and monitor their dosage closely.  112. Kelly Emery’s attendance at appointments and general engagement with the service was sporadic and inconsistent throughout her treatment programme. She maintained telephone contact. CRI did not challenge her about her attendance at the service.  Her lack of engagement meant that the one to one psycho-social support work with DW1, a significant element of the overall treatment regime, was not effective and was not integrated with the prescribing element. Moreover, lack of attendance and engagement was not pro-actively followed up by Dudley CRI.  Despite this she continued to receive her methadone scripts by post without proper oversight and monitoring in an attempt to stop her returning to illicit drug use and try to keep her engaged with the service.  Her misuse of heroin, crack and alcohol, was known about by other agencies such as the Police.  Her lack of consistent engagement and failure to attend appointments and reviews, according to Department of Health guidance (2007), should have resulted in reverting back to a supervised consumption regime which did not happen.   113. Indeed, in relation to supervised consumption, the Methadone Handbook (at page 17) states that,  ‘Drug services would normally consider someone to be stable when they are,  • Turning up for appointments. • Picking up all their doses of methadone. • Not taking illicit heroin ( some services expect to see urine samples free of non-prescribed drugs before they will consider allowing take home doses) • Not drinking heavily.                                                            8 See NHS Lothian (2003), ‘ Substance Misuse in Pregnancy- A resource pack for professionals in Lothian’ Final Version 21.03.16 32  If things are not going well, the collection regime may go back a step or two in order to help get things back under control.’   114. There was no evidence to show that any consideration had been given by medical or non-medical practitioners associated with the Dudley CRI to the potential risks to Fenton and his sister of Kelly Emery’s inconsistent involvement with her methadone treatment.  There was no record of the use at medical reviews of any practice ‘tool’ by the CRI prescribing doctor within the treatment programme.  The ‘Parent Capacity Assessment ‘was used by DW1 during home visits but there was no recorded observations of the interaction between Kelly Emery and her two children.  Indeed, SFH had not been seen since 2010, some- time before the birth of Fenton and had been subject to a multi-agency child protection plan whilst in Sandwell in 2009, precisely because of her mother’s substance abuse.  Dudley CRI knew about this and was a member of the core group.  The focus and approach to treatment ‘did not take into account the wider needs of Kelly Emery and the impact and risks associated with substance misuse on the family unit as a whole’. (CRI IMR, p.10).   115. In conclusion, the evidence indicates that the CRI did not provide a professional view as to whether Kelly Emery was able to effectively parent and safeguard her children particularly in regard to her substance misuse and methadone treatment. (see CRI IMR, p.13).  It therefore follows that no account of Kelly Emery’s ability to parent her children safely was taken by CRI personnel in their decision making regarding her treatment.   116.  The CRI IMR identified several key organisational and cultural factors that accounted for ineffective parenting capacity assessments and the resulting lack of an awareness of risk to the children.  These included staff lacking the skills, competence, confidence and ‘Professional curiosity’ in undertaking such assessments; a belief that challenge might compromise the ‘therapeutic relationship’, an over reliance on Kelly Emery’s self-reporting, an adult focused  ‘Harm reduction’ service which did not ‘Think Family’; a lack of supervisory challenge from line management and perceived high caseloads.   117. There was no record of any liaison between the CRI prescribing doctor service and the receiving pharmacist or with Kelly Emery’s own GP in Sandwell or later in Frankley (Birmingham).  In the light of these and the previously mentioned deficiencies it was concerning that Kelly Emery continued to regularly receive her methadone script with no direct supervision or monitoring of her consumption by the pharmacist.  It was the prescribing service that had responsibility for communicating with the family GP (in Sandwell and Birmingham) and the appropriate pharmacist.  Final Version 21.03.16 33  118. In sum, the key reasons for Dudley CRI’s lack of awareness of the risks to Fenton and SFH were located within an organisational, structural and cultural context of;  •  CRI safeguarding policy was not fully implemented in the service. • A disconnect between the two key elements of the methadone service, namely the CRI prescribing doctor, oversight and monitoring; and psycho-social support. • A resulting lack of follow up regarding Kelly Emery’s poor engagement and attendance at reviews and drug testing appointments • A lack of clear guidance around frequency of drug screening. • A poorly trained and prepared workforce that was overly focussed on the adult service users and not sufficiently aware of the risks to their children. • A lack of staff challenge and professional curiosity about adult service users in the interests of maintaining a therapeutic relationship. • Poor management oversight and little focus on safeguarding children.  • High caseloads. • No liaison with the dispensing pharmacists and Kelly Emery’s GPs.   119.  The lack of awareness of risk to Fenton and his sister by the Dudley CRI resonates at a wider, national level with adult substance misuse services.  In this respect, recent research from serious case reviews on the deaths of children from opiate substitution ingestion found that,’ the evidence presented shows that practitioners do not consistently recognise the possible risks to children post by OST ( Opiate Substitute Treatment), despite NICE and the Department of Health stating this requirement explicitly’ ( Adfam, 2014, p.8).   120. Moreover, although the issue of safe storage had been discussed (albeit with no storage box provided), intentional administering of controlled substances  (including methadone) to children was not contemplated by any agency involved in the case.   121. The key learning points for Dudley CRI from this section are set out in the Key Findings and Learning section at paragraphs 338-341.  Midwifery Service  122. The midwifery service of the Dudley Group NHS Foundation Trust had a key role in early identification of any potential risk to Fenton from his mother’s methadone use and substance misuse.   123. Kelly Emery registered for her ante natal care at the late stage of twenty weeks, which in itself should have raised questions.  The specialist midwife (SPMW1) Final Version 21.03.16 34  who principally attended Kelly Emery was the named midwife for safeguarding and led on substance misuse and vulnerable women.  She was therefore an experienced and knowledgeable practitioner in this area of work, although she had not received any specific training in working with women who had misused substances, other than attending relevant courses on the subject.  Her role involved frequent and regular attendance at the CRI substance misuse service.  The second specialist midwife, (in domestic abuse and mental health-SPMW2) who had more limited involvement, was also experienced in safeguarding children and had completed advanced training in the subject.   124. Regarding practice tools the agency IMR refers to the use of a universal midwifery care pathway which contained ‘prompts’ on specific issues relating to ante-natal care, including substance misuse and vulnerability.  Moreover, there were specific guidelines for the care of substance misusing women during the ante-natal, intra-partum and post-natal periods.  However, (it would appear that) there was no available pathway at the time for the recognition of safeguarding issues regarding the children of substance misusing parents.  (See p3 of Panel minutes, 10.11.14).   125. It appears that the pathway, prior to Fenton’s birth, did not include a section on the consideration of safeguarding and potential risk issues to unborn children and neonates regarding the impact of parents who were substance abusing or on methadone programmes.  The current (Dudley Safeguarding Children Board) threshold document (Right Services, Right Time, and Right Place) was introduced in September 2011.  It contains guidance on when to request a co-ordinated multi-agency response to parental substance misuse.  126. That said, it is noted that the current Dudley Safeguarding Children Board safeguarding procedures regarding ‘Maternal Substance Misuse during Pregnancy’ ( issued in 2007 at Part C section 33, paragraphs 2.5 and 2.6 and last modified in August 2009, i.e. before Fenton’s birth) states that,   ‘Maternal substance misuse in pregnancy can have serious effects on the health and development of the child before and after birth………..all maternity services should have procedures for pregnant women who use drugs that encourage them to go to ante-natal services.  There should be liaison between Maternity and Drug Treatment services to review the management of the mother’s drug use and impact on the baby before and after pregnancy. If there is a concern about the parent’s child care abilities, a referral should be made to Children’s Social Care under these procedures’.  127. The apparent absence of a risk assessment tool regarding the potential impact on children from substance misusing parents therefore resulted in no effective assessment of the impact of Kelly Emery’s  (and her then partner, Fenton’s Final Version 21.03.16 35  father) methadone use and substance misuse on Fenton and his sister.  Indeed, the midwifery team did not record that Kelly Emery had any problem drug or alcohol use and that she had been assessed (by the CRI) as stable on her methadone programme with no safeguarding concerns.   128. This was despite the presence of numerous known risk factors such as Kelly being on a methadone treatment programme with Dudley CRI, her inconsistent involvement with the programme,  the late midwifery registration, four missed ante-natal appointments , ongoing treatment for depression, failure to provide a urine specimen, a positive test for cocaine (in addition to FFH’s  alleged cocaine use), her involvement in recent criminal activity and resulting  community order with the Probation service; and SFH’s previous (2009) child protection plan with Sandwell Safeguarding Children Board.   129. Given these numerous risk indicators it was concerning that there was no joint review held between the midwifery service and the CRI to assess Kelly Emery’s methadone (and substance misuse) use and its potential impact on the unborn child and SFH.  Indeed, the evidence suggests that there was little or no wider joint working between the two agencies in regard to Fenton.   130. In all of the circumstances and mindful of the dangers of ‘hindsight and outcome bias’, this SCR takes the view that a joint decision by the midwifery service and the CRI should have, at the very least, been taken to make a child in need and arguably, a child protection referral protection on the unborn child (and SFH) to Sandwell Children Social Care in the ante-natal period.  The absence of any formal midwifery recording has hindered this Review’s attempt at understanding the rationale for the actions and decisions taken (or not taken) by midwifery professionals.   131. In conclusion, the evidence suggests that there was no recognition by the midwifery service of the potential risks to the unborn child (Fenton) and his sister from their parents’ substance misuse and Kelly Emery’s methadone treatment.  Given the specific safeguarding role of the specialist midwife and her experience in working within the field of parental substance misuse, albeit that there was no formal risk assessment tool in place at the time; and the known existence of the above risk indictors, it would be reasonable to suggest that there were safeguarding concerns which should have; firstly been recognised and secondly, referred on to Sandwell Children’s Social Care for a pre-birth assessment, in conjunction with Dudley CRI. Such a course of action would have been consistent with existing Dudley Safeguarding Children Board Safeguarding procedures.  The reasons and analysis as to why this did not happen and resultant learning is set out in ToR 2, paragraphs 239-248.   Final Version 21.03.16 36  132. Therefore, this episode marked a missed opportunity for the Dudley CRI and the specialist midwifery service to have taken joint action to safeguard and promote the welfare of Fenton and his sister.   Staffordshire and West Midlands Probation Trust  133. Kelly Emery was subject to a twelve month community order (06.06.11 to 06.06.12) with a supervision requirement to the above agency following her conviction for shoplifting (May 2011) and a breach of a conditional discharge. She was sentenced to an additional twelve month community order with a 40 hour unpaid work requirement in September 2011 for a further shoplifting offence in late May 2011.  The evidence from the Individual Management Review (IMR) suggested that she adhered to the order and was a compliant and regular attender with her Probation Service Officer (PSO1).   134. The agency’s primary purpose was to supervise Kelly Emery in ensuring that she completed the two community orders.  However, the agency recognised its safeguarding responsibilities to Fenton and his sister who were observed with their mother on several occasions in the office and at home.  Parent and child interaction was perceived as positive with Fenton said to be thriving and well.   135. Using the OASYS offender assessment tool the Probation service classified Kelly Emery (at the pre-sentence stage on the 24.06.11)) as a medium risk to her children because of her methadone use and known substance misuse. Key parts of the sentence and OASYS risk management plans provided that Kelly Emery should adhere to her methadone treatment with the Dudley CRI and undergo voluntary drug testing.  As already noted, the evidence from the CRI was that her engagement with them was sporadic and that she did not undergo drug testing.  This information was not shared with the Probation service.  In this respect, the interagency communication and liaison between the two services was not effective and an important element of the risk to the children was not considered.  This was also a crucial piece of information that was not taken up by the specialist midwifery service.   136. However, on the basis of her medium risk status around the methadone/substance use, PSO1, following standard safeguarding practice, made a telephone referral to Sandwell Children’s Social Care on the 20.07.11.  This was some two days after being informed of Fenton’s birth by the senior nurse from the Hospital maternity ward. PSO1 correctly expressed her concerns in the referral about Kelly Emery and her partner’s (FFH) methadone use in relation to the children and felt that an assessment was needed.    Final Version 21.03.16 37  137. Two days later, on the 22.07.11 a duty social worker from Sandwell CSC made a telephone call to the Probation office and spoke to PSO2 (PSO1 was not in work) who reported that Kelly Emery was stable with her methadone script and was receiving support from a drug agency (recorded as the ‘Anchor Project’; this would seem to have been incorrect as it was in fact the Dudley CRI based at Atlantic House). Kelly Emery, the new baby, Fenton and SFH were staying with her mother (Fenton’s maternal grandmother) for a few weeks.  A duty social worker spoke to PSO2 on the 26.07.11 to state that in the light of further enquiries with other agencies there would be no further input from Sandwell Children’s Social Care at that stage.  If there were any concerns then a re-referral could be made to Children’s Social Care, or a Common Assessment could be undertaken.  138. Fenton and SFH were seen by PSO1 and the Probation Officer during a home visit made on the 02.08.11.  Kelly Emery told them that a duty social worker from Sandwell CSC had recently contacted her by telephone    and that she had said that she was receiving support from the midwife who would be handing over shortly to a health visitor.  Her mother was said to be supportive but there was a lack of clarity about the degree of support being given to Kelly Emery by her partner (FFH). PSO1 was aware that Sandwell Children’s Social Care was not taking any action in response to her previous referral. However, it was good practice when, the Probation service did make later follow up enquiries in September 2011 and February 2012 to Sandwell CSC regarding the children.  It was informed that that the family was not an open case, that Kelly Emery was getting support from family members and agencies, which, in fact was not correct.   139. It can be concluded that the Probation Service was the only agency to have assessed Kelly Emery’s risk to her children in regard to her methadone use and substance misuse whilst the family were living in Sandwell.  The assessment informed the agency’s decision to make a referral to Sandwell Children’s Social Care.   Health Visiting Service (Sandwell and West Birmingham Hospitals Trust)  140.  Fenton and his mother’s involvement with this service was from July 2011 to November 2012, although the family had moved out of the Sandwell area in February 2012 and were no longer in effective contact with the agency.  There were three health visitors deployed during this time, HV1 from 03.08.11 to 06.01.12, HV2 for one week from the 05.08.11 and HV3 from the 02.04.12 to the 09.11.12. HV1 had one contact with Fenton and Kelly Emery on the 06.01.12, HV2 had two on the 05.08.11 and 11.08.11 and HV3 had none.   Final Version 21.03.16 38  141.  The service was working to an escalation plan (i.e. a declaration that that it was struggling to respond to demand) in 2011 because of a 22% health visitor vacancy rate, 16% sickness rate and average caseloads of 1000 children per health visitor.  The escalation plan had been agreed with commissioners that Health Visitors would only monitor active child protection and Looked After Children.  In addition, new birth visits had been extended in the previous agreed timescale of 10-14 days to 10-21 days.    142. HV1 took over the care of Fenton (along with the midwifery service for a short while) on his discharge from Hospital 1’s neo natal unit on the 21.07.11.  He had been there for three days after his birth for observation regarding withdrawal from maternal methadone, of which there were no signs.  It was planned for him to have a cranial ultra sound scan (USS) and a three month neonatal follow up at the hospital in three months.  This information would have been included on the maternity liaison form and neonatal discharge summary given to HV1.   143. A primary visit was completed by HV2 to the maternal grandmother’s home on the 11.08.11, following an unplanned and uncompleted visit there on the 05.08.11.  Fenton was noted to be feeding well with good weight gain and appeared settled.  HV2 gave advice on the baby clinic and the need for an eight week check at the GP surgery.  Kelly Emery informed HV2 that she was on a methadone programme and gave details of her keyworker.  She said that her partner was an ex-methadone user and was working away in Scotland.  He was, in fact, serving a custodial sentence between the 17.07.11 to the 04.10.13 for attempted robbery.  She said that the children’s grandparents were supporting her.   144. HV2 did try and contact the substance misuse worker the next day (12.08.11) but there was no reply.  There was no record of any further attempt at contacting Dudley CRI by the service.  Thereafter, HV2 had no further involvement with Fenton and the family.  He and his mother visited the Cradley Health Sure Start clinic on the 14.09.11 when he was weighed, although there is no record of what this was.   145. HV1 resumed case responsibility and made a visit on the 06.01.12.  There had been two missed Neonatal Unit appointments notified to the service in September and December 2011.  These were not raised with Kelly Emery by HV1 as they should have been.  Advice was given about Fenton’s weaning and nappy soreness and Kelly was advised to make a GP appointment for a review on her son.  Kelly Emery mentioned that she had recently been burgled and had reported this to the Police.  Her methadone use was discussed; she said that she was monitored and supported daily by Dudley CRI.  She told HV1 that the methadone was kept on top of the cupboard.  She should have had a safe Final Version 21.03.16 39  storage box which she did not have (see CRI IMR).  This should have been queried by HV1.  A further visit was arranged in three months’ time.   146. Despite knowing about Kelly Emery’s methadone use, HV1 (an experienced health visitor) did not contact the substance misuse worker at the Dudley CRI to seek out more information about her methadone regime and any potential risks it may have presented to Fenton and SFH.  The then existing Sandwell Safeguarding Children Board guidance on the ‘Children of Drug Misusing Parents’ (Chapter 4.2.6, section 2) states that , ‘A thorough assessment by all relevant agencies is required to determine the extent of need and level of risk of harm in every case’.  Moreover, ‘Where there is concern that a parent is involved in drug use, the effect on the child needs to be considered’ and a list of ten relevant risk factors (including ‘ The impact of the parent’s drug use on the child’s development including the emotional and psychological well- being, education and friendships’)  is set out for attention.   147. HV1 no longer works for the Trust and was not able to be interviewed for the agency management review.  The reason for her not speaking to the Dudley CRI is therefore not known.  However, this important omission would tend to suggest that HV1 had an insufficient awareness and understanding of the safeguarding issues around the potential impact of substance misusing/methadone using parents on children.  148. The health care needs analysis undertaken by HV2 at the primary visit on the 11.08.11 identified, amongst other things,  Kelly Emery’s methadone use and indicated the requirement for  ‘Active intervention’ (‘Universal Plus’) with Fenton and his mother.  ‘Universal Plus’ is a service offer where the health visitor can support the child and family and is,   ‘Targeted according to assessed or expressed need.  Universal Plus gives a rapid response from the health visiting team when children, young people and families need specific expert help’. (Department of Health; 2011)   The need for a Universal plus level of intervention suggested that the family was seen as vulnerable with some concerns about parenting (see paragraph 2.2 ‘Family focused provision’, Level 3-Universal Plus Offer, page 7, National Health Visiting Service Specification 2014/15).   149. Whilst referencing Kelly Emery’s methadone use in the health care needs analysis, there was no evidence of any additional assessment or consideration by the health visiting service into the implications of this risk factor on her parenting capacity and any potential risk presented to Fenton and his sister.  Indeed, HV2, based on superficial evidence, regarded the maternal grandmother as a protective factor and recorded that she would ‘not allow any harm’ to come to the Final Version 21.03.16 40  children.  This view seemed to have been based on a ‘one off’ visit in August 2011 and seemed predicated on the erroneous assumption that there was a strong and consistent supportive relationship between Kelly Emery and her mother, which was, in fact, not the case.   150. The ‘Active intervention’ and support package of the Universal Plus care plan was not forthcoming and it is not known why not.  HV1 no longer works for the Health Trust and was therefore not able to be interviewed.  As clinical lead she should have been informed of the outcomes of all previous contacts and any actions taken.  This would have included knowledge about the intervention at Universal Plus level proposed by HV2.  151. Had there been a care plan it would likely have included the monitoring of Fenton’s health as part of a multi-agency care plan involving the health visiting service, the family GP, the Dudley CRI, Hospital 1 neonatal unit; liaison with the Probation service and if necessary, enquiries with Sandwell Children’s Social Care, when SFH’s’ previous Child Protection Plan would have come to light.  Indeed, the health visiting reference card noted that the family were known to Sandwell Children’s Social Care but there was no evidence that this information was followed up by the health visiting service.  152. There should have been multi-lateral liaison and communication with these agencies, especially with the Dudley CRI to see if Kelly Emery was appropriately engaging with the programme and a consideration of any relevant implications for her children’s safety.  Moreover, the health visitor care plan made reference to Fenton having a three monthly review that should have taken place in November 2011.  This did not happen and despite two defaulted hospital appointments a home visit by HV1 was not arranged until some five months later in January 2012.   153. It can be thus be concluded that despite the health visitor’s knowledge of Kelly Emery’s methadone use, the lack of a Universal Plus plan resulted specifically in the absence of actions to mitigate any potential risks to Fenton from this source. More generally, there was no provision of a co-ordinated multi-agency support plan to the child and his family. This practice episode was an important missed opportunity to safeguard Fenton and promote his wellbeing.  154. The key learning points from this episode are set out  at paragraphs 356-357.   Sandwell Children Social Care  155. This agency’s involvement with Fenton was confined to its response to the referral made to its Duty and Assessment service on the 20.07.11 by PSO1 of the Probation service.  Final Version 21.03.16 41   156. Given that the Probation referral was based upon its own medium risk to children assessment from Kelly Emery’s methadone use and substance misuse and the fact of SFH’s relatively recent (2009) child protection plan for, concerns around her mother’s substance misuse, it is a reasonable expectation that an initial assessment on Fenton and his sister’s wellbeing would have been carried out. However, there was no evidence that this was done.   157. What appeared to have happened was that a duty officer spoke to a probation officer (PSO2) on the 26.07.11 who reported that Kelly Emery was stable on her methadone script and was being supported by her mother and the drug agency. The duty officer spoke with Kelly Emery on the telephone who told her that she was being supported by her midwife and a drugs worker (DW1) at Atlantic House and was living with her mother for a few weeks. Kelly Emery said she had support from her family and friends and did not need any additional support from Sandwell Children’s Social Care. The duty officer spoke with a community midwife at Russells Hall Hospital (Hospital 1) who reported that she had no record of Kelly Emery but that she was being visited by midwifes from Sandwell.   158. The duty officer spoke with a community midwife on the 26.07.11 who reported that Kelly Emery was engaging with agencies and she was due to visit that week. She and the children were said to be living with the maternal grandmother (for a few weeks) and receiving adequate support from Atlantic House (Dudley CRI) who saw her at home every week regarding her methadone programme. She was also getting support from a specialist community midwife based at Atlantic House, in addition to family and friends and did not require support from Sandwell Children Social Care.  A health visitor would shortly be taking over the health care of Fenton and his mother from the midwifery service.   159. The Common Assessment Framework (CAF) process was explained to the community midwife with advice that in the event of any concerns these could be referred on to Children’s Social Care or a CAF completed if Kelly Emery needed any further support.   The Probation Service received a telephone call from a duty officer from the Children’s Services Team on the 26.07.11 confirming that there was no input from the children’s social care at that time.   160. The duty officer went on to check Children’s Social Care integrated children’s system (ICS- the electronic recording system) and noted that there were four contacts, two referrals and two core assessments. The 2007 core assessment could not be viewed and there was no record of the duty officer considering any information from the other core assessment. It was recorded that SFH was on a child protection plan in 2009 for emotional abuse and that there were concerns that Kelly Emery had been shoplifting in front of SFH who had also disclosed in a picture that her mother had been misusing substances.  Final Version 21.03.16 42   161. The duty officer (on the 26.07.11) concluded that ‘Given that mother is receiving support from health and Atlantic (the key worker wrongly stated as PSO2) House there is no current role for children’s services. PSO2 has been advised to complete a CAF (Common Assessment) and re-refer if he has any concerns’ Following the duty officer’s conclusion and recommendation the team manager made the decision that, ‘Mother has family support and there is a lot of agency monitoring. There are no current concerns around the baby and agencies will continue to monitor and complete a CAF providing mother consents. Agencies will re-refer if concerns arise’.  There was no further recording on file and no involvement with Fenton and his family from then on.   162. The response by Sandwell Children’s Services duty and assessment team to the safeguarding referral from the Probation Service was sub-standard and poor practice. The safeguarding referral should have resulted in the duty officer (DO) carrying out an initial assessment in line with existing agency and Sandwell Safeguarding Children Board safeguarding procedures. This stated (at the time) that,   ‘Where a referral is made in relation to a child where the parents have a substance dependency, Children’s Social Care Services will undertake an initial assessment and if necessary, a core assessment. The assessment should also consider and take account of whether the person concerned is hiding or denying their substance misuse, whether they are engaged in a rehabilitation programme; whether they receive support from a partner, family or friends: the impact of the drug misuse on the quality of care given to the child and the day to day environment of the child’. (Section 4- Assessment and Initial Child Protection Conference).   163. It would seem that the duty officer was reassured from the erroneously positive and superficial reports of Kelly Emery’s situation from PSO2, the midwife and Kelly Emery herself. Given Kelly Emery’s criminal history there should have been enquiries made with the Police. There was no evidence that the family’s history and the two core assessments had been effectively assessed.  SFH’s details were not noted, nor were her safety and wellbeing considered, or that any enquiries were made about her being on a child protection plan in 2009, or with her school. Had an effective initial assessment been undertaken it is likely that sufficient concerns would have emerged to have warranted a core assessment and/or safeguarding strategy discussion with the Police and other involved agencies (especially Dudley CRI), leading to a Child in Need intervention or possibly the holding of an Initial Child Protection Conference. None of these issues were raised by the team manager who did not challenge the superficial conclusions and recommendation of the duty officer.   Final Version 21.03.16 43  164. The agency’s IMR makes the point that Sandwell Children’s Service was under considerable pressure at the time of the referral in July 2011 because of insufficient staffing and ineffective partnership working. The Access service was at that time, ‘Inundated with referrals and the capacity of staff to respond to the volume of work was an issue’. The turnover of staff and acceptance of inappropriate work were additional significant factors which led to poor practice.   165. The handling of the referral from the Probation Service in July 2011 by Sandwell Children’s Social Care therefore sought to ‘cut corners’, partly in response to the existing pressures described above and needs to be set within this wider agency context.   166. Self-evidently, the lack of an initial assessment precluded the use of any assessment tool regarding Kelly Emery’s parenting capacity and her potential to provide safe parenting to her children in the light of her methadone treatment and substance misuse. It can thus be concluded that Sandwell Children’s Social Care duty team’s decision not to take any further action on the Probation safeguarding referral was not informed by an initial assessment or any understanding of the potential impact of Kelly Emery’s methadone use and substance abuse on her children. This episode was a significant missed opportunity to carry out an assessment into the potential risks to Fenton and SFH and their needs; and take appropriate multi-agency action to safeguard them and promote their wellbeing.   GP Services  167. Fenton was seen once by the GP service in Sandwell shortly after his birth for a first immunisation with nothing untoward indicated. He was seen three times by the GP service at Frankley health centre in Birmingham between September and December 2012 for routine health matters, an immunisation, a chesty cough and a viral illness. No safeguarding issues were identified.   168. On advice from the GP, Fenton attended the Birmingham Children’s Hospital on the 26.04.13 because of concerns from his mother about his diarrhoea, vomiting for three days and possible dehydration. He was treated for gastroenteritis, given appropriate medication and discharged home with his mother the same day. The GP received a letter from the hospital for follow up care. There was no evidence to suggest that this happened.   169. SFH was seen only once during the time in question, on the 20.12.12 for hearing problems and referred onwards appropriately.   170. No safeguarding issues regarding either child were identified by the GP services in Sandwell and Frankley.   Final Version 21.03.16 44  171. The children’s mother had a long standing history of episodic depression and was seen and treated by the Frankley practice in late December 2012 and the early part of 2013. The HAD (Hospital Anxiety and Depression) scale was used by the GP and indicated a high number of depressive symptoms (see IMR at page 5). Kelly Emery was prescribed anti-depressant medication (50mg of Sertraline). The HAD scale is not a holistic tool and does not include consideration of wider family dynamics or the impact of mental ill health on vulnerable family members, including children.   172. Kelly Emery was known to be on a methadone programme but there was no liaison between the GP and the specialist prescribing doctor at Dudley CRI on her progress. The GP has since acknowledged (to the IMR author) that the practice should have been proactive in seeking information from the substance misuse service. In seeking to understand why there was no communication the IMR author spoke to the GP (principal) who explained that the primary purpose of the consultation was to review Kelly Emery’s asthma and oral contraception. The mood symptoms were presented incidentally and the HAD questionnaire was used to define these more clearly. The GP had no real explanation for why there was no liaison with the substance misuse service, save that the focus of the consultation tended to be on the immediate symptoms presented by Kelly Emery. In any event, the key lesson emerging from this practice episode is for GPs and prescribing agencies to liaise effectively where patients are involved in Opium Substitute Treatment (methadone programmes), particularly where the patient is a parent.   173. Additionally, there was no discussion with other primary health staff such as the health visitor or the school nurse about the implications of Kelly Emery’s depression and methadone use for the welfare of safety of the children. Despite two out of three of the ‘toxic trio’9, and a very vivid and distressing plea from Kelly Emery to help her, there was no consideration by the GP to exploring the family dynamics and implications for the children’s wellbeing. Indeed, there was no mention in Kelly Emery’s medical record of the children.   174. The IMR revealed that despite health visitors being co-located with the GPs there were no regular meetings between the two groups to discuss safeguarding issues. Moreover, it was not normal practice to contact health visitors or school nurses unless there was the considered to be a particular risk with the actual threat of immediate harm. In Kelly Emery’s case it had been determined that she appeared not to be at risk of suicide. Thus, it would seem that safeguarding intervention thresholds (for this particular GP) were set at a relatively high level which precluded acting on the background safeguarding risks of the mother’s                                                            9 Namely, parental mental health, substance misuse and domestic abuse.  Final Version 21.03.16 45  depression and methadone use. In essence, no risks to the children were identified by the GP and therefore no action was taken.   175. Moreover, the IMR identified that there were no safeguarding protocols or guidance in use in this practice at that time. This Review would point to the duties and responsibilities of all registered doctors contained in the General Medical Council guidance, ‘Protecting Children and Young People’ (which came into effect on the 3 September 2012). Regarding the role of all doctors it states at page 11 that,  ‘You must consider the safety and welfare of children and young people, whether or not you routinely see them as patients. When you care for an adult patient, that patient must be your first concern, but you must also consider whether your patient poses a risk to children or young people. You must be aware of the risks that have been linked to abuse and neglect and look out for signs that the child or young person may be at risk. Risk factors include having parents with mental health or substance-misuse issues….’.   176. The guidance goes on to state (at page 12) that, ‘You should have a working knowledge of local procedures for protecting children and young people in your area’. This would include the Local Safeguarding Children Board safeguarding procedures, the relevant guidance in ‘Working Together’ 2013 ( and now the 2015 version) and access to named and designated doctors and nurses for advice and guidance.   177. As the IMR author (an experienced consultant community paediatrician and designated doctor in child safeguarding in Birmingham) states in his report for this SCR at page 6,   ‘Overall, these consultations would certainly have been an opportunity to make enquiries as to the state of the children whom would have been very much affected by the impaired mental health of their mother’.   178. In conclusion, apart from the specific use of the HAD tool to diagnose the extent of Kelly Emery’s depression there was no evidence to show that any consideration was given  to evaluating her parenting capacity in the light of her alcohol and substance abuse and mental health issues. It therefore follows that no account was taken of these matters by the GP in relation to the potential for abuse or neglect of Fenton and SFH. Decision making was solely confined to treating and managing Kelly Emery’s depression through medication and did not include any wider considerations for the safety and welfare of the children.   179. The key learning points are set out at paragraphs 398-400  Final Version 21.03.16 46  West Midlands Police 180. Kelly Emery came to the attention of the West Midlands Police on numerous occasions between 2002 to 2013 and was a known substance misuser (heroin, cocaine and cannabis) who funded her addiction through acquisitive crime (theft, robberies and shop lifting) and participation in the sex industry. Records also indicate that she was the victim of domestic abuse during the period.  181. Kelly Emery was visibly pregnant and known by the Police to be using drugs when she was brought into custody in May 2011 for shop lifting. In addition to being pregnant it was ascertained that she also had a ten year old daughter. She had told custody staff on the 12 May that she was a methadone user, had taken cocaine that morning and admitted occasional use of heroine. She tested positive for cocaine. None of the investigating officers or custody staff generated a child abuse non-crime number for the unborn child (Fenton) or his sister. There was no record of a referral to Sandwell CSC. A single intelligence log of the information was submitted on the 19.05.11 but was not disseminated.  182. This Review agrees with the West Midlands Police IMR that the lack of a referral to the (Police) Child Protection Unit and Sandwell Children’s Social Care in May 2011 was a very significant lost opportunity for multi-agency intervention to safeguard and promote the wellbeing of Fenton and his sister. Albeit, that there was no formal assessment tool for the evaluation of Kelly Emery’s parenting;  the impact of her substance misuse and criminal behaviour, whilst being heavily pregnant and the mother of a ten year old child, should have been considered by the Police custody officers and a referral made. Had there been a referral it is likely that a Section 47 enquiry would have been undertaken, followed by the holding of an Initial Child Protection Conference, resulting in both children made the subjects of child protection plans.   Move to Birmingham  183. The family left Sandwell in February 2012 and moved into accommodation in Birmingham in April/May of that year. They were involved with the following agencies.  • Health visiting service ( Worcestershire Health and Care NHS Trust) • Birmingham People Directorate Children’s Social Care • West Midlands Police • CRI Dudley • Secondary School • West Midlands Ambulance Service NHS Foundation Trust • Birmingham Children’s Hospital • GP service- South Central Clinical Commissioning Group Final Version 21.03.16 47  Health Visiting Service  184. Despite having lived in Birmingham since April/May 2012 the transfer from the Sandwell to the Worcestershire health visiting service did not happen until 9 November 2012. The delay was caused by the Sandwell health visitor (HV3) having difficulty in locating the family’s whereabouts. In fact it was a request for Fenton’s health records on the 18.10.12 from Birmingham that alerted HV3 to the family’s location. The verbal handover from HV3 to the new health visitor (WHV1) took place on the 23.11.12 which included information on the mother’s methadone use, the recent history of ‘futile’ visits; that Fenton had not been seen since January 2012 and that he was under the care of a neo-natal consultant at Hospital 1. It was also reported, inaccurately, that Kelly Emery did not have a drugs worker.   185. WHV1, who had completed appropriate training that included awareness of the impact of substance misuse on parenting capacity, made attempts to undertake an introductory review appointment in late November and twice in December. These were all missed by Kelly Emery who said that her mother had had a heart attack or that she had flu. A home visit was eventually made on the 15.01.13 when Fenton was seen by WHV1. Kelly Emery told her the name of her substance misuse worker whom she said she saw every two weeks. She was taking 19 mls of methadone daily. Fenton’s father was said to be in prison and the child was reported to see him every fortnight. A development review was arranged for the 19.04.13. It had been almost one year since Fenton had been seen by a health visitor.   186. WHV1 completed the ‘Health Assessment Framework’ following the visit and Fenton was identified as ‘Vulnerable’. This required medium active intervention with the child being seen every three months by the health visitor and some extra parenting support being offered to his mother. The assessment did not include any consideration of potential risk to Fenton from his mother’s methadone treatment. WHV1 did not contact the substance misuse worker at the Dudley CRI to obtain his views on how Kelly Emery was progressing with her treatment plan or what the risks from that agency’s perspective might be to Fenton. WHV1 should have contacted the substance misuse worker and this omission marked a missed opportunity to obtain a better understanding of the potential risks to Fenton from his mother’s methadone use and substance misuse.   187. WHV1’s lack of perception of risk to Fenton was informed by her observations (over three contacts) of good presentation of Fenton and interaction between mother and child, seemingly credible excuses by Kelly Emery for her absences at appointments and her reported low methadone dose, relative to other clients. This last factor was not checked out with Dudley CRI. The combination of these conditions led to WHV1 making an assumption that Kelly Emery’s methadone Final Version 21.03.16 48  use was having a minimum impact on Fenton and did not result in her making fuller enquiries into his and SFH’s  circumstances, albeit arrangements were in place for some parenting support in July 2013.   188. Worcestershire Safeguarding Children Board did at the time have a joint working protocol , ‘Safeguarding children and young people whose parents/carers use drugs/alcohol’ that was part of the ‘ Think Family’ initiative which had been signed up to by the Care Trust. However, WHV1 was not aware of the document and its encouragement of a more joined up approach between professionals. The Trust IMR noted that greater awareness of the document (which was/is available through the Trust internet) is needed which this Review would strongly endorse.   189. The relevant lessons learnt from this episode are set out at paragraph 380 below included.   Birmingham Children’s Social Care  190. This agency had two episodes of involvement with Fenton and his family, these being, the anonymous referral from neighbours in late August 2012 to the Integrated Access Team and the child protection referral from West Midlands Police on the 22.04.13. Both were missed opportunities for Birmingham Children Social Care to effectively assess the needs of Fenton and his sister and establish whether they were at risk from their mother’s methadone use, substance misuse and other aspects of her parenting.   191. On neither occasion were any assessment tools used; beyond a very superficial consideration of nominal risk and protection factors in the April 2013 referral, to produce an accurate understanding of Kelly Emery’s capacity to safely parent her children in the light of her methadone and substance misuse.    192. The referral of 30.08.12 from a neighbour taken by the Referral and Advice Officer (RAA1) in the Integrated Access Team resulted in the referrer being wrongly advised to make direct contact with Children’s Social Care. Perhaps not surprisingly, the referrer became annoyed with the response and was not inclined to contact Children’s Social Care. Apart from recording the referral on Carefirst (the local authority’s electronic social care recording platform) and some cursory health checks, there was no evidence that any additional actions or enquiries were taken to ascertain the children’s safety and wellbeing.    193. The Integrated Access Team’s screening response fell below expected standards and demonstrated inadequate practice. The safeguarding referral should have been accepted, entered on the system and been subject to one of four outcomes as set out in the agency IMR. These were,  Final Version 21.03.16 49  • Referral to Children’s Social Care First Response Team to undertake a Level 4 child protection enquiry. • Referral to an Integrated Family Support Team for a Level 2/3 response • Advise that a Common Assessment within a Level 1 universal service setting should be offered • Advice and signposting to universal services for Level 1 referrals.   194. None of these options were taken and there was no sign that the decision for no further action was discussed with and approved by a duty screening manager. Moreover, the decision was made without any reference to the safeguarding concerns of the referral regarding suggestions of mother’s substance abuse, involvement in sex working and exposure of the children to undesirable adults.   195. Given the nature of the safeguarding concerns this Review suggests that there should have been a Level 4 safeguarding response from Children’s Social Care to determine whether there were any grounds to believe that the children were suffering or likely to suffer significant harm. RAA1 and the team manager were not available to be interviewed about the reasons not to send the referral to Children’s Social Care. By way of explanation for this unsafe practice that left Fenton and his sister at risk, the agency IMR cites two recent Ofsted reports (2012, 2014) that throw some light on the situation at the time of the referral. These identified,  poor management oversight, lack of staffing capacity, the absence of qualified social workers in the Integrated Assessment and Advice teams, a lack of understanding and implementation of thresholds and a lack of focus on outcomes for children and young people, as factors.    196. In regard to the ‘ Front door’ service of the Integrated Access Team the 2012 Ofsted report commented that,  ‘ A review of contacts made to children’s services shows that some that met the threshold for services were not progressed to referrals for action, which left children at risk’. (page 9. Paragraph 25). This seemed to be the case with the August 2012 referral.    197. In the case of the April 2013 Police referral the newly introduced Integrated Advice Support Service (IASS) correctly passed it on to the Children’s Social Care ‘First Response’ team where it was allocated to a senior social worker (SW1) for an initial assessment. The initial assessment was undertaken in a very cursory manner, was significantly flawed and did not complete all of the very relevant actions set out in Carefirst by the team manager of the IASS. SFH was not seen or spoken to by SW1; there was a naïve acceptance of the mother’s denial that she was involved in substance abuse and sex working and a minimisation of the risks to the children around her admission of weekend binge drinking of alcohol.   Final Version 21.03.16 50  198. There were insufficient lateral enquiries with partner agencies, especially the Police and the drugs worker at Dudley CRI when it was known by SW1 that the mother had a long history of heroin abuse and was currently subject to a methadone programme. There were no discussions with the extended family, or neighbours, who were in receipt of a great deal of information about the wellbeing of the children.  Finally, the assessment lacked sufficient child focus as evidenced by the failure to ascertain SFH’s wishes, feelings and experiences of being parented by her mother.   199. Had all of these actions been carried out it is likely that they would have led to the convening of a strategy meeting/discussion with the Police, Dudley CRI and the health visitor, followed by an in-depth core assessment and/or section 47 child protection enquiry, when SFH’s previous episode of being on a child protection plan in Sandwell would have emerged. Given the knowledge of the full spectrum of  information it is not unreasonable to think that Fenton and SFH  would have become subject to child protection plans, or at the very least, Children in Need plans under section 17 of the Children Act 1989.   200. Instead, a decision was made by the team manager (a different one from the manager who had overseen the initial response to the referral and who had set out a number of clear tasks to be completed) to close the case. This was based on a recommendation from SW1 whose flawed initial assessment concluded that,    ‘ The mother is supporting the children appropriately and there are no concerns regarding the care provided to them by those professionals already involved with the family in respect of the five outcomes for children. I recommend closure of the case on the basis that there is no evidence of harm to the children and mother engages well with professionals’. (Birmingham CSC IMR page 15)  201. An additional contextual factor of some significance (revealed at the learning event) was the, then, agency edict, of a ten day time limit in completing and closing referrals and assessments. It may have been the case that the over-optimistic, superficial and inadequate assessment and the decision to close the case were subject to a degree of organisational pressure to close cases within the ten day target. In short, corners may have been cut at the expense of an effective consideration of Fenton and SFH’s safety and wellbeing.   202. A further factor was the well documented (Ofsted, 2014) high threshold of child protection intervention by Children’s Social Care. This was indicated  in the Le Grand, (2014) report which noted that there were 31/10,000 children on a child protection plan in Birmingham in November 2013, a much lower figure than comparative statistical neighbours and similar core cities.  Final Version 21.03.16 51  203. In conclusion, the omission by SW1 to gather all of the known intelligence and information on the family from other agencies led to a flawed risk assessment and a decision to prematurely close the case without properly considering the risks to the children from Kelly Emery’s substance abuse and methadone use. This episode was a significant missed opportunity by Birmingham Children’s Social Care to have taken steps to intervene to safeguard the children and promote their wellbeing.    204. Both SW1 and the team manager have since left the employ of Birmingham City Council. Despite enquiries as to their current whereabouts they have not been available for interviews with the agency IMR author. Therefore it has not been possible to ask them why actions were taken and decisions made that were patently not in the interests of Fenton and SFH.   205. In relation to any wider organisational and systemic factors that might have influenced the sub-standard  practice of SW1 and her manager, the agency IMR alludes to Birmingham Children’s Social Care having been served with an improvement notice in 2010 , following an Ofsted inspection which found the service to be ‘ inadequate’.   206. Following major  changes in senior management within the service, the local authority responded by introducing four Integrated Access teams in 2011 and in Birmingham South, a pilot Multi-agency Safeguarding Hub (MASH), in October 2011. The overall organisational context was therefore marked by close external scrutiny, key changes in senior personnel, the introduction of structural changes, low staff morale, poor retention and lack of staff capacity10. In short, less than favourable circumstances in which to introduce significant operational changes.   207. Despite, or perhaps because of these structural changes to contact, referral and assessment arrangements,  the Ofsted inspections of 2012 and 2014 continued to identify major weaknesses in the operation and practice of ‘Front Door’ Children’s Social Care. The Ofsted inspection report of 2014 found that,  ‘When children and young people need statutory social work intervention, they do not experience good help and support from the Information and Advice Support Service (IASS). There is a lack of clarity and understanding about the threshold for referral to children’s social care. The absence of a qualified social worker in the IASS team means that children do not benefit from a timely response from children’s services.  When children’s cases need to be progressed from the IASS to safeguarding teams, arrangements to do this are not always timely or effective. Some                                                            10 See the Le Grand (et al) report, February 2014. Final Version 21.03.16 52  contacts were closed when further action was required, and others were not acted on by safeguarding teams, because safeguarding team managers overturned original IASS decisions. There is a lack of trust and confidence between managers about thresholds and the decision making process and this means that some children do not receive a service. (Ofsted Report, 2014, paragraphs 45 and 47)  208. Other identified factors accounting for unsafe practice at the ‘Front Door’ of Children’s Social Care were the recognition by the local authority that thresholds for starting child protection enquiries were too high, due in part to a lack of staffing capacity (Ibid, paragraph 49). Moreover, there was a lack of robust management oversight in the IASS of which contacts had been screened. Thus managers were not always aware of the screening status and progress of contacts which resulted in a lack of an effective system to monitor and track the work and check that appropriate decisions had been made about referrals.   209. In sum, this analysis concludes that the actions and decisions taken by Birmingham Children Social Care staff in their handling of the two referrals, seems to have been a function, at an individual level, of inadequate practice and poor management oversight. This was set within a wider organisational context of systemic and long entrenched problems in ensuring an effective and safe delivery of services to children, particularly (but not confined to) the ‘Front Door’ (see paragraph 4.10 of Le Grande Report February 2014). In this respect, there are several parallels between this case and the earlier SCR involving Keanu Williams which criticised front-line practice and management decision making at the time of the child’s death in 2011.    Dudley CRI  210. All of the aspects of inadequate practice and service delivery to Kelly Emery and the lack of consideration around the safeguarding of Fenton and SFH identified in the earlier section (whilst the family were resident in Sandwell) continued during their time in Birmingham. The reasons for the inadequate service have already been set out previously.  211. Once it had become known that the family had moved to the Birmingham address there should have been a timely transfer of Kelly Emery’s treatment programme to the Birmingham Drug Service and the allocation of a new key worker. This did not happen because local protocols had not been developed, making information sharing and partnership working difficult.    212. Kelly Emery was allowed to continue her sporadic involvement with the Dudley CRI. She was not drug tested in accordance with agency policy and did not attend planned medical reviews. She was not given a methadone Safe Storage Final Version 21.03.16 53  Box although it was noted that she kept her prescription in a high cupboard out of the reach of the children. Her disengagement from the service meant that she was not consistently receiving the individual psycho-social support that should have underpinned the methadone programme. Moreover, there was minimal observation of her interaction with the children and oversight of the impact of her parenting on them. In short, there was no consideration given to the safeguarding and wellbeing needs of Fenton and SFH.   213. The lack of liaison between the prescribing GP at Dudley CRI and the family GP in Birmingham and the pharmacists continued the previous pattern from when Kelly Emery was in Sandwell. Given that she was being prescribed a course of anti-depressants by the family GP in the months leading up to Fenton’s death, whilst also receiving methadone, there should have been inter GP communication ( and with the pharmacist) on this matter.  214. DW1’s failure to challenge SW1 on 29.04.13 in response to her telephone enquiry of the 24.04.13 in pursuance of the initial assessment was a significant omission in safeguarding the children. It is reasonable to think that had there been some dialogue between SW1 and DW1, concerns around Kelly Emery’s poor involvement with the CRI would have come to light. This may have better informed the perception of risk by Birmingham Children Social Care leading to a form of intervention (possibly a Child in Need Plan or even a Child Protection Plan) that could have safeguarded and promoted the children’s welfare.    215. The quality of supervision of DW1 during this period was sub-standard with no evidence that there was any professional follow up of practice regarding Kelly Emery’s poor engagement; no annual review of the Parental Capacity Assessments, and minimal monitoring, factual checking and auditing of the case. No action was evident from the team leader in ensuring the timely transfer of the case to the Birmingham Drug Service.   216. In addition to the previously identified factors accounting for the inadequate safeguarding practice the CRI IMR also highlighted the tendency for the methadone treatment to over-focus on Kelly Emery as an individual rather than see her as a parent with dependent children. In essence, the treatment intervention was too adult focused and did not consider the safeguarding and welfare needs of Fenton and SFH.   217. A key learning point from this episode thus highlights the need for adult focusing agencies ( in particular, substance misusing support services) to work within a more holistic, ‘Think Family’, approach that also takes into account the impact of client behaviour on children and vulnerable others.    Final Version 21.03.16 54  West Midlands Police  218. In relation to the first two contacts with the family in January and November 2012, regarding reports that Kelly Emery was dealing in drugs from her home and engaging in prostitution whilst the children were there, no effective analysis of the intelligence was made to determine whether the children were at risk. The November episode resulted in a police visit to the home and a finding that, “All parties were safe and well, no issues”.   219. Suspicions and professional curiosity should have been aroused when the adult female left by Kelly Emery to look after the children referred to her as ‘Michelle’ and claimed not to know her surname. FLINT intelligence checks to confirm the details of the children were not completed, the identity of the babysitter was not established, no referral was made to the Police Public Protection Unit (the specialist unit that dealt with child protection cases) and a child abuse non-crime number was not generated. The episode was closed by the two police constables.   220. As the Police IMR makes clear, there was a lack of professional curiosity from the investigating officers. The family details and identification (including the babysitter) should have been ascertained and arrangements should have been made to speak directly to Kelly Emery in due course. There was no assessment done on the potential risks to the children in regard to the information received from the public. Moreover, neither child was seen or spoken with.   221. The commonplace and colloquial use of the term, ‘Safe and well’ has been criticised in the IMR and also by the SCR Panel as an imprecise and, ‘non-specific phrase which leaves it unclear what actions officers actually took to determine that a child was in fact unharmed’. What is needed is for officers to pro-actively ensure the safety of the child by physically seeing them, speaking to the parents, following up any intelligence checks and fully documenting their actions before closing a case. The IMR and a previous SCR (Khyra Ishaq; 2010) recommends that the term ‘Safe and well’ should not be used and there has, in fact, been training given to officers over the last twelve months to use more qualitative language.   222. The intelligence record of the 17 January 2013 was very similar in content and nature to the previous November 2012 referral. ‘Sanitised ‘ (i.e. the process of anonymizing and evaluating intelligence) intelligence reports were sent to the Personnel Notification List’s ( PNL) of several officers although there was no evidence that they had logged into their Intelligence Management Systems and therefore would not have received them. This dissemination system has been discontinued and since April 2014, all officers are now directly notified through e- mail of any intelligence reports which need their attention. According to the Police Final Version 21.03.16 55  IMR, this is a much more effective means of disseminating intelligence and alerting officers to the fact.   223. In any event, partly as a result of the internal communication difficulties the intelligence report was not actioned by the Police. There was no child abuse non-crime report or sharing of intelligence with other agencies or attempt at determining the safety and wellbeing of Fenton and his sister. Nor was there any evidence to suggest that the relevant officers appreciated the potential adverse effects on the children from their mother’s substance misuse and chaotic lifestyle.   224. Both this incident and the previous November 2012 episode marked missed opportunities for the Police to have directly intervened in the lives of Fenton and SFH and ascertained their safety and wellbeing.   225. The decision to make a referral on the 22.04.13 by the police officer from the local burglary team to Birmingham Children’s Social Care was correctly based on an appreciation of the possible risks (albeit not informed by a formal risk assessment tool) to the children from observations of probable drug paraphernalia (namely, silver foil and spoons) and previous known intelligence. However, the standard operating procedure within the Police was for a referral to have been directly made to the Public Protection Unit (PPU) rather than, as in this case, to Birmingham Children’s Social Care (CSC). Had this been done a child abuse non -crime number would have been generated and action taken by the PPU to hold a strategy discussion with Birmingham CSC.   226. In the event, no strategy discussion ( a joint responsibility of both CSC and the PPU)  was held and SW1 did not avail herself of the full range of Police intelligence on Kelly Emery which could have increased the perceived level of risk presented by her to the children and resulted in some form of multi-agency intervention.  School  227. SFH attended Academy 1 where she was described as a bright, articulate child; a model pupil who always presented as immaculate, hardworking, popular and outspoken. Her attendance was registered at 98% with no issues around punctuality or unauthorised absences; nor were there any concerns around parenting.  228. A teaching assistant (TA) at the school, who was a neighbour of the family, had seen several incidents concerning anti-social behaviour and problematic parenting around loud music played at night, cars regularly coming to and from the house and a suspicion that the mother was paying for drugs. These concerns, including allegations of drug and alcohol abuse, were said to have been communicated to the school’s attendance manager (AM, who was the school’s Final Version 21.03.16 56  designated safeguarding lead) at the end of April/early May 2013. Unfortunately, no records were kept by the AM of the conversation or their dates, which breached existing safeguarding procedures and practice.   229. The TA was aware of previous concerns from another neighbour about Kelly Emery’s alleged anti-social behaviour which had been reported to the Police and the Housing department. The latter agency had taken action against Kelly Emery (the Police were said to be ‘watching ‘the house) who had confronted the TA in an angry exchange and threatened her, leaving the TA feeling vulnerable.   230. AM advised the TA to make a referral to Children’s Social Care. The TA was reluctant to do so because she was fearful of being identified by Kelly Emery and suffering repercussions, given her previous experiences. The AM therefore advised that she refer to the NSPCC. This was done on an informal basis and none of the conversations were recorded or dated. Being ‘petrified’ of making a referral to the NSPCC herself, the TA asked a friend to do so anonymously. The NSPCC had no record of any referral in late April/early May 2013 on the children or their mother.   231. The School’s and Settings Improvement Service IMR highlighted a number of deficiencies and significant breaches of basic safeguarding procedures and practice. Firstly, the AM’s advice to the TA was not compliant with the school’s (and Birmingham Safeguarding Children Board) existing safeguarding procedures and practice. The AM, as the school’s designated safeguarding lead should have made a referral to Birmingham Children Social Care. Secondly, SFH’s file was not checked. Had it been, it would have revealed that she had been subject to a child protection plan in Sandwell in 2009 (for concerns around her mother’s substance misuse), in addition to previous records from her primary school of drawings made by her of Kelly Emery’s drug use. Knowledge of the previous episode of being on a child protection plan could have been passed to SW1 at Birmingham Children’s Social Care and informed the initial assessment. The AM made some checks with SFH’s head of year and from tutor regarding the concerns but none were identified.   232. Thirdly, SFH was never spoken with about her experiences at home by any school staff. Thus, her voice was not heard in the process and there was a general lack of a child focus in this case. Finally, the recordings of the episode and decision making were minimal and sub-standard.  233. The agency IMR identifies several reasons why safeguarding procedures were not followed. These included,   Final Version 21.03.16 57  • Capacity issues of the AM having a very high case load of over ninety cases where she was ‘fire- fighting’, in addition to having responsibility for addressing issues around school attendance. • An increase in workload resulting from reduction in the Education Social Work service.  • Over reliance on the actions of other agencies such as the Police and Birmingham Children Social Care, where the latter agency had told the school that the case was closed after having done an assessment. The Police had stated that they were going to challenge this decision.  • Over-optimism and a lack of professional curiosity about SFH’s safety and wellbeing given reports she was a ‘model’ pupil with an excellent attendance record. The TA’s concerns were rationalised and reframed as being about anti-social behaviour and ‘neighbour nuisance’ rather than the possible impact of the concerns on the children and issues around appropriate parenting.  • A lack of any basic assessment that included looking at SFH’s school file and speaking to her.  • Concerns for the TA about possible repercussions from Kelly Emery.  • Lack of any regular and structured line management supervision for the AM and others with designated safeguarding responsibilities.   234. Overall, this analysis suggests that sub-standard safeguarding practice and poor decision making happened within an organisational context of insufficient resources and lack of line management oversight and supervision. These conditions led to corners being cut and non-compliance with basic safeguarding practice which did not promote the safety and welfare of SFH or Fenton. Moreover, there was minimal recognition or awareness of the potential risks of Kelly Emery’s substance misuse and lifestyle on the children and no evidence of any reference to the existing Birmingham Safeguarding Children Board substance misuse guidance.   235. See paragraph 403 for lessons learnt. South Central Birmingham Clinical Commissioning Group (GP Service)  236. See paragraphs 167-178 above.    ToR 2 To what extent did practitioners understand and investigate the risks to the children and act on them, in particular considering maternal alcohol and substance misuse and the presence of males in the home?  Final Version 21.03.16 58  237. Many aspects of this question have already been addressed in the previous term of reference and paragraphs from that part of the report will be cited to inform the ensuing analysis of this section.   238. The analysis and supporting evidence of ToR 1 have shown that, with the exception of the Probation Service and to some extent the West Midlands Police in regard to the April 2013 referral by the burglary team; practitioners did not understand and investigate the risks to the children from their mother’s behaviour in general and substance and alcohol misuse in particular. Nor was there sufficient appreciation of the presence of males in the home and its implications for the children. Consequently, no effective action was taken by any of the relevant agencies (save those already mentioned above) to safeguard and promote the welfare of Fenton and his sister.  239. This Review has identified that there should have been a pre-birth review undertaken jointly by the Dudley CRI and the specialist midwife in line with Dudley Safeguarding Children Board guidance (see above at paragraph 126). Indeed, this was one of the Key Practice Episodes (KPE1) analysed at the Learning Event. Why was not a pre-birth assessment held?    240. The process leading up to a review should have started with Dudley CRI undertaking an effective Parent Capacity Assessment. This should have accurately identified any risks to the unborn child and SFH from Kelly Emery’s methadone use and substance misuse. The known risk factors (i.e. SFH’s  child protection plan of 2009, Kelly’s sporadic engagement with CRI, evidence of ongoing substance abuse when arrested by the Police in May 2011, no drug tests, Kelly Emery’s community order with the Probation Service) should have raised questions and prompted,  ‘professional curiosity’, for the safety and wellbeing of the unborn child and SFH.  These should have been shared with the specialist substance misuse midwife who attended Dudley CRI for a fortnightly ante-natal clinic which at the time did not involve a joint meeting with the CRI prescribing doctor and allocated drugs worker.  241. Formal channels of communication in 2011 between the specialist substance misuse midwifery service and Dudley CRI professionals were thus not in place. Currently, the Specialist Midwife conducts a fortnightly antenatal clinic for women accessing services at Atlantic house (Dudley CRI). Joint substance misuse/antenatal clinics are also conducted by the Specialist Midwife and Consultant in Specialist Addictions on a six weekly basis at Atlantic House. The woman’s drug worker is also present at this appointment.  242. Regarding Dudley CRI, the reasons for the lack of an effective Parenting Capacity Assessment have been previously set out above at paragraphs 116 and 118. A key factor was the ‘silo’ approach on ‘harm reduction’ intervention that Final Version 21.03.16 59  was entirely adult focused on Kelly Emery. This was not holistic and did not ‘Think Family’ and consider the safeguarding needs of and risks to the children of Kelly Emery’s methadone use and substance misuse.   243. The inaccurate view communicated to the specialist midwife by CRI Dudley was that Kelly Emery was stable on her methadone programme with no current safeguarding concerns. A drug test on Kelly Emery done by the hospital on the 21.06.11 indicated that she was positive for methadone and did not detect any banned substances. This may have reinforced the midwife’s thinking that there were minimal concerns around evidence of any substance misuse by Kelly Emery. Moreover, there was no evidence of Fenton suffering from neo-natal abstinence syndrome on discharge from hospital. The specialist midwife’s positive perception developed into a mind-set and dominant narrative of Kelly Emery who claimed to be co-operating with Dudley CRI and receiving support from her mother and male partner, neither of which were true. This narrative described Kelly Emery as adequately managing the care of Fenton and SFH. Arguably, there was a degree of naivety on the part of the specialist midwife in not seeking any third party corroboration of Kelly Emery’s self-reported accounts of her drug use and lifestyle.   244. A Review of cases (Adfam, 2014) involving intentional administration of Opiate Substitutes (methadone) to children by their parents has identified a common feature to be the omission or minimisation of risk factors by professionals. Professionals working with adults, understandably, often adopt a ‘Positive regard’ attitude towards their clients/patients/service users which rules out the ‘unthinkable’ of deliberate administration of methadone as a pacifier to children by their parents.   245. This SCR agrees with the observations in the Adfam Review that a ‘cultural shift’ by agencies and practitioners is needed towards adopting a more robust and challenging approach to substance misusing parents. Whilst respecting the adult, practitioners should have an open mind on circumstances and maintain a degree of ‘healthy scepticism and respectful uncertainty’ in their work with parental substance misusers. 11 In short, practitioners should not automatically take the word of clients who substance misuse. Rather, in the interests of children’s welfare they need to seek corroboration from other professional sources. The approach would be applicable to all practitioners (both adult and children’s services) working with substance misusing parents and not just specialist substance misuse midwifes.                                                              11 These terms are taken from the Victoria Climbie Inquiry Report authored by Lord Laming in 2003. See also ‘Medications in Drug Treatment: Tackling the Risks to Children’ (Adfam: 2014, pp54-55).  Final Version 21.03.16 60  246. In any event, informed by an overly optimistic understanding of Fenton’s family situation no assessment of need/risk was undertaken by the specialist midwife; nor were any safeguarding issues identified. Moreover, even if any concerns had been recognised, the specialist was not aware of a formal threshold document (The ‘Right Services, Right Time, Right Place’ threshold document was only introduced in September 2011), or a risk assessment tool that considered the impact of parental substance misuse on children. There was also no structured ‘pathway’ process for adult substance misuse services working with parents in place at the time. One was subsequently later produced by Public Health England in 2013 (see appendix 7) which this Review would commend the use of to all of the agencies involved in this Serious Case Review. This Review submits that the presence of these systems and processes in 2011 would have greatly facilitated a joint review by the Dudley CRI and the specialist midwife into the needs and risks of the children.   247. However, notwithstanding the lack of the above guidance, the overly optimistic narrative needed to be set against the known evidence of a number of significant risk factors as set out above in paragraph 128. On this basis, the lead reviewer and Panel are of the opinion that there were sufficient grounds for the specialist midwife to have requested a joint review with Dudley CRI of Fenton, SFH and Kelly Emery’s circumstances. Such action would have been consistent with both the Dudley and Sandwell SCBs extant guidance on maternal substance misuse as set out in paragraphs 126 and 146 above.  Had this happened it is probable that a decision to make a referral to Sandwell Children’s Social Care for a pre-birth assessment on Fenton would have followed. At the very least a Common Assessment/Early Help offer may have resulted or, depending on the circumstances at the time, perhaps a child in need plan or even recourse to child protection measures might have ensued.   248. In any event, this was a missed, early opportunity for a pre-birth, multi-agency intervention to have been started which could have sought to safeguard and promote the children’s welfare and got them on the Sandwell Children’s Services ‘radar’.   249. The key learning points are set out at paragraph 345.    Post Birth Assessments in Sandwell   250. As previously mentioned, Staffordshire and West Midlands Probation Trust understood the risks to Fenton and SFH from Kelly Emery’s methadone use and substance misuse by classifying her as a ‘medium risk to children’, following the OASYS offender assessment. In the lead reviewer’s opinion the risk classification Final Version 21.03.16 61  would have been increased to ‘high risk’ had the Probation Service Officer (PSO1) spoken with the drugs worker from Dudley CRI and learnt that Kelly Emery’s engagement with the agency for her methadone treatment was sporadic and that she was not being drug tested. Adherence to the methadone programme and regular drug testing were two key conditions of the twelve month community order and risk management plan.  251. As pointed out in the agency IMR, action should have been taken to identify Kelly Emery’s partner (FFH) and establish whether he was known to the Probation Service. The agency had evidence suggesting that FFH was misusing substances and enquiries should have been done to ascertain any potential risk to Kelly Emery and the children. Whilst acknowledging the concerning omission PSO1 was not able to explain why she had missed this matter, save that there had been an overreliance on information given by Kelly Emery. This was a feature in all agency contacts throughout this case.   252. The IMR identified that although the risk to the children was identified as medium which resulted in a late referral to Sandwell Children Social Care, the case should have been flagged as a, ‘Child concern’, on the agency’s internal recording system. The absence of flagging meant that the case was not identified as one needing escalation to management oversight by a senior probation officer. This gap in practice, according to the IMR, was not unique to this case and an implementation circular was issued to clarify the practice in December 2012.   253. See paragraph 355 for the key learning point.  254. In relation to the Sandwell and West Birmingham Hospital’s Trust health visiting service the evidence suggests that the risks to the children from Kelly Emery’s substance misuse were not well understood or investigated. Although the proposed Universal Plus/Active Intervention support package recognised Kelly Emery’s methadone use there was no effective consideration of the potential risks to Fenton and SFH.    255. Reasons for this included the health visitor’s untested assumptions, based, partly on Kelly Emery’s self-reporting that her methadone and substance abuse risks were being mitigated by positive engagement with the Dudley CRI and that consistent support was being given by the maternal grandmother. Both of these accounts were untrue.   256. HV2 should have spoken directly with the drugs worker at Dudley CRI to find out the extent to which Kelly Emery was co-operating in her methadone treatment. Moreover, there should have been a phone call to Sandwell Children’s Social Care to enquire about that agency’s previous involvement with the family in relation to SFH’s child protection plan of 2009, given the reference to the agency Final Version 21.03.16 62  in the health visiting card. Fenton’s defaulted hospital neo-natal appointments should also have been followed up in a timely way and given rise to some concerns.   257. Here, the rule of optimism, untested assumptions based on untruthful accounts from Kelly Emery; and a lack of lateral enquiries with other involved agencies, seemed to have contributed to a health visiting perception that Kelly Emery was adequately managing the care of Fenton. His development was therefore not identified as requiring further follow up.   258. Also, there was no appreciation of the presence of males in the household and the potential risks presented to the children. The ‘invisibility’ of males would appear to be a common phenomenon amongst child welfare practitioners.   259. See paragraph 357 for key learning points.   260. The child protection referral and request for an assessment made by the Probation service to Sandwell Children’s Social Care on the 20.07.11, some two days after Fenton’s birth and whilst he and Kelly Emery were in Russells Hall Hospital, was responded to in a very inadequate manner. It breached the Sandwell Safeguarding Children Board procedures which stated very clearly that, “Where a referral is made in relation to a child where the parents have a substance dependency, Children’s Social Care Services will undertake an Initial Assessment and if necessary a Core Assessment’.   261. As previously analysed and concluded in ToR 1 at paragraphs 162-166, there should have been an Initial Assessment informed by rigorous lateral enquiries with all of the agencies involved with Kelly Emery and both children. Instead, only limited and partial checks were made with the Probation Service (and not with PSO1) and the community midwife, who, “appeared to reassure the duty worker that there was sufficient support from professionals and family not to warrant a further assessment”, (Agency IMR, page 6). Indeed, given the array of risk factors present at the time, it is reasonable to suppose that a core assessment would have followed, resulting in a Child in Need Plan or possibly a Child Protection Plan.   262. In addition, no reference was made to the presence of males in the home or any associated potential risks to the children.  263. In conclusion, the inadequate enquiry by Sandwell Children’s Social Care into the concerns for the children by the Probation service, the lack of an Initial Assessment and poor management challenge and oversight, evidenced minimal Final Version 21.03.16 63  understanding of the risks to them and marked a very significant lost opportunity to safeguard and promote their welfare.   264. The poor practice response and inadequate management challenge and oversight can be seen as a function of the wider organisational context of systemic problems within Sandwell Children’s Services and in particular the referral and assessment team in July 2011, as referenced by the agency’s IMR.   265. Additional contextual insight into organisational issues has been provided by the 2010 Ofsted inspection report of safeguarding and looked after children services. Then, Sandwell Children’s Services were subject to an improvement notice which was overseen by an Improvement Board. The inspection found the overall effectiveness of safeguarding services in Sandwell to be ‘Inadequate’. Of some significance in regard to this practice episode, the report noted that the Referral and Assessment team had,   266. “Been under considerable staffing pressures and several posts have been filled by a succession of short term agency staff. As a result, thresholds for intervention remain too high and assessments are not routinely completed and lack detailed analyses of risk and need. Assessment and planning processes are inadequate. The use of CAF (Common Assessment Framework) is not yet fully embedded across the borough”. (page 7, paragraph 18)  267. The local authority was required within three months to,  “Review staff workloads and pressures in referral and assessment services and take action to ensure these are consistently delivered to the required standards and are supported by regular supervision and managerial oversight”. (paragraph 16)  268. Three years on, things had not improved. The Ofsted Inspection report of 2013 judged the overall effectiveness of child protection in Sandwell to be inadequate and that,  “Significant, systemic failures in arrangements for the protection of children mean that the council and its partners cannot be assured that all children and young people in Sandwell are being appropriately protected from harm”. (Page 6, paragraph 14)  269. Ofsted required that the local authority,   • “Ensure that all Section 47 enquiries are compliant with child protection procedures and statutory guidance.  Final Version 21.03.16 64  • Introduce a formal risk assessment process to improve management oversight of child protection work and ensure that decisions are based on robust written evaluations of risk.   • Improve the quality and consistency of assessments so that full account is taken of risks, protective factors and historical information and that where appropriate, fathers are fully engaged in the process”   270. See paragraphs 361-362 for learning points.  Assessments in Birmingham  271. In regard to the Worcestershire Health and Care NHS Trust health visiting service, WHV1 knew of the risks associated with parental substance misuse and possible accidental ingestion of methadone by children. WHV1 said in interview that normally she covered these aspects with substance misusing parents and could not explain why she had not done so with Kelly Emery.  272. By way of partial explanation, WHV1 said that Kelly Emery was ‘very welcoming’ and seemed very open with her. In these circumstances when faced with a welcoming and likable mother it was difficult to ‘Think the unthinkable’. Hence, she had not considered the possibility that a mother might purposely administer the substance to a child to keep them quiet. There may have been an element of ‘false or disguised compliance’ from Kelly Emery.   273. For further analysis, reference has previously been made (at paragraphs 188-190) to WHV1’s lack of consideration of potential risk to Fenton from Kelly Emery’s substance and alcohol misuse and the reasons for this.  274. WHV1 was aware that Fenton’s father was in prison; she said that there had been discussions with Kelly Emery about contact with the father and where he planned to live on release.    275. As observed by the agency IMR, the bruise noted on Fenton at the final visit should have been referred onto Birmingham Children’s Social Care, particularly given the earlier assessment completed in late April 2013 and the discussion had between WHV1 and the duty social worker.  276. Key lessons are set out at paragraph 380.   Final Version 21.03.16 65  277. Regarding Birmingham Children’s Social Care the evidence and analyses presented in ToR 1 at paragraphs 190-209 have shown that the practitioners involved in the two referrals of August 2012 and April 2013 did not sufficiently understand or adequately investigate the risks to the children from their mother’s substance misuse and methadone use. The reasons for this are set out in the above mentioned paragraphs of this report and it is not intended to repeat them here.   278. These episodes were very significant missed opportunities to intervene in the lives of Fenton and his sister and promote their safety and welfare.  279. See paragraph 385 for key learning points.    280. Regarding the West Midlands Police, its IMR found that all (save one) of the officers who had involvement with the family between 2011 and July 2013 did not recognise the risks to the two children. Hence, no referral was made to the Public Protection Unit/Child Abuse Investigation Unit for an assessment and possible investigation. This included the custody staff who dealt with Kelly Emery in May 2011. Moreover, even when the risk was recognised by DC2 in March 2013, staff did not follow proper procedure and make an internal referral to the Police Protection Unit (PPU).   281. In the event, the referral to Children’s Social Care on the 22 April 2013 by DC2 was a month after the episode and should have been made contemporaneously to the PPU. The reason for the delay was that DC2 was unclear of the correct pathway for making a referral, which as noted below (at paragraph 221) is not uncommon amongst front line (non PPU) officers. If the referral had been made in March, standard practice should have resulted in the generation of a child abuse non-crime number and the probability of a strategy discussion between the PPU and SW1 from Birmingham Children’s Social Care. The very significant intelligence held on Kelly Emery by the Police could have been shared with SW1 and her manager and a section 47 enquiry duly initiated. Moreover, according to the Police IMR, (at page 19), a strategy discussion would have ‘afforded the opportunity for suitably trained officers to make a joint visit with the assessing social worker’, possibly leading to a more rigorous and fuller initial assessment and follow up child protection response.  282. A further issue was the inter-agency escalation process not being used by the police in response to SW1 and her manager’s decision to take no further action and close the case on the 26.04.13. DC2 was uncomfortable with this response and discussed his concerns with a PPU officer (DC1) who directly challenged SW1’s assessment that there were no safeguarding concerns. The lack of Final Version 21.03.16 66  recording by DC1 and her supervisor (ADS) not to formally escalate a challenge to Birmingham CSC was not compliant with agency practice. Police standard operating procedure provides that a decision and rationale, not to challenge (or conversely, to challenge) another agency’s actions would be recorded on the CRIMES (crime recording system) portal. The result in this case was that the decision went unchallenged despite the legitimate reservations of the two DCs.   283. Clearly, DC1 and ADS should have recorded any discussions held regarding challenging Birmingham CSC’s decision to close the case, along with a rationale for any decisions (entered on the CRIMES portal) relating to accepting, or not, the course of action.   284. Passing reference only was made in a Police log in May 2011 to FFH as being the temporary partner to Kelly Emery. There was no effort made to find out more about him and any potential risk implications for the children.  285. The above findings need to be set within the wider context of the Police role in safeguarding children. This can be found in the October 2014 HMIC12 inspection report of the West Midlands Police Child Protection service; the specific police roles as set out in the guidance13are:  • The identification of children who might be at risk from abuse and neglect. • The investigation of alleged offences against children • Their work with other agencies, particularly the requirement to share information that is relevant to child protection issues  286. Moreover,   ‘Every officer and member of police staff should understand their duty to protect children as part of their day-to-day business. It is essential that officers going into people’s homes regarding any policing matter recognise the needs of children they may encounter’ (HMIC, October 2014, 9)   287. As previously mentioned, there were several missed occasions when the Police could have intervened in the children’s lives and liaised with Sandwell and Birmingham Children’s Social Care, respectively; to safeguard and promote their welfare. These included the four times she was in custody between May to July 2011 (see paragraphs 183-184 above) and the two occasions in November 2012 and January 2013 (see paragraphs 220-226) regarding the allegations of drug                                                            12 Her Majesty’s Inspectorate of Constabulary 13 Working Together To Safeguard Children: HM Government, March 2013. Final Version 21.03.16 67  taking and sex working. Non-abuse crime reports/numbers should have been submitted and referrals made to the Public Protection Unit/Child Abuse Investigation Units (CAIU). Why were risks not recognised, interventions not made and non-abuse crime reports not submitted?  288. Several reasons have been identified both in the IMR and from the learning event. These include;  • Officers being too ‘crime focused’ and not sufficiently attuned to the circumstances of the children.  • Intelligence officers not always being conversant with their responsibilities regarding safeguarding and child protection. • Confusion with front line officers around correct referral pathways to the PPU. • Not seeing and speaking to the children (SFH). • A tendency towards ‘Silo’ department working. • Interoperability difficulties around internal Police IT systems. • Internal and external information sharing/inconsistent use of flags on IT systems.  • General lack of awareness by some front line officers of the risks to the children from their mother’s substance misuse.  • Lack of a risk analysis. • Lack of building intelligence and joining ‘The jigsaw’ to see the ‘bigger picture’ of the children’s situation. • Lack of supervision • Over-reliance on ‘Safe and Well’ checks when investigatory follow up actions should have been undertaken.   289. Several of these factors are reflected in the HMIC inspection report, which whilst not confined just to practice in Birmingham, did identify (at page 20) ‘a lack of understanding (from officers) about, and guidance for recording information that had come to the attention of the police……..they should initiate an electronic non-crime incident form’. The report highlights the importance of the form, which outlines an incident, risks to the children and any action taken; and crucially, its use. In the case of any further incidents with a child, a cumulative record of a pattern of abuse can be identified leading to a much richer and more comprehensive intelligence picture that can be shared with other agencies when needed.    290. There was also a general lack of awareness of child protection issues and inconsistent supervisory oversight in some frontline teams which may have accounted for the poor recording and quality of information in some cases. These observations in the HMIC report (at page 20) resonated with the findings of this SCR.   Final Version 21.03.16 68  291. See paragraphs 365-373 for key lessons.  292. The contacts with the GP services in Sandwell and Birmingham have already been set out previously in paragraphs 167-178 above. The evidence and analysis of these paragraphs demonstrates that the GP services in Sandwell and in particular, Birmingham (Frankley) did not recognise any safeguarding issues in respect of Fenton and SFH, when, patently, there were. Kelly Emery’s methadone programme and mental health issues were not seen by the Frankley GP in a wider context as presenting a possible risk to the children’s welfare and safety. This included no discussion of safe methadone storage. The absence of a holistic, ‘Think Family’ approach to Kelly Emery precluded any exploration of the presence of males in the home.   293. As identified by the IMR, a good opportunity to have made some enquiries about the impact of Kelly Emery’s parenting on the children was during the consultations in December 2012 and early 2013 when she was being treated for depression. In particular, her written ‘cry for help’ to the GP at the December consultation should have prompted action to seek to understand and investigate the risks to the children. As previously mentioned there were no lateral communications with the Dudley CRI or the practice health visitor. The reasons for this have been previously set out in paragraphs 172 to 174 above.   294. Reasons for the lack of action by the GP practice to make some enquiries on the children included the absence of a holistic approach with an overly narrow professional adult focus on Kelly Emery’s depression. This medical model approach confined itself to diagnosis and medication with no wider reference to liaison with the Dudley CRI or the relevant practice health visitor. This was an example of ‘Silo’ practice which is a recurrent theme amongst other agencies in this review. The GP should have followed the GMC and Birmingham Safeguarding Children Board guidance in regard to parental substance misuse and mental health and considered the impact of Kelly Emery’s parenting on the children.  Analysis as to why this did not happen is provided in paragraphs 172-178.  295. Key lessons and current practice are set out at paragraphs 398-400.  296. Regarding SFH’s school (Academy 1), the previous analysis in Term of Reference One (see paragraphs 231-233) concluded that there was minimal recognition or awareness of the potential risks of Kelly Emery’s substance/alcohol misuse on the children and no evidence of any reference to the existing Birmingham Safeguarding Children Board substance misuse guidance. Final Version 21.03.16 69  Moreover, there was also no awareness of the potential dangers presence of males in the home.   297. The principal reason for these deficiencies was the lack of adherence by the school safeguarding lead to the Birmingham Safeguarding Children Board to the published guidance and the absence of senior staff oversight. The contributory causal factors for this are set out in paragraphs 233-234.   298. Key lessons can be found at paragraph 403 below.  ToR 3 To what degree were both children’s wishes and feelings, the voice of the child and needs for protection recognised and acted upon by practitioners?  299. The foregoing analyses and accompanying underpinning evidence, set out in the preceding ToRs, suggests that there were very few occasions when the voices of Fenton and his sister were heard by practitioners and their wishes and feelings noted and acknowledged. Exceptions, to some extent, were those occasions when the Probation service PSO1 and the local burglary team police officer recognised the children’s needs for protection and made referrals to Sandwell and Birmingham Children’s Services respectively.   300. However, apart from these two instances, none of the other involved practitioners or their managers; in particular those from Sandwell and Birmingham Children’s Social Care and SFH’s  secondary school, sought to talk with SFH in an attempt to understand her experience of living with and being parented by Kelly Emery. Regarding Fenton, none of the relevant child care agencies, GP services and Dudley CRI effectively documented the interaction with his mother, considered his lived experience with her or attempted to get a sense of his ‘voice’. Significant emphasis is given in Government guidance (‘Working Together’ 2013, 2015 and previous editions) and in the Children Act 1989 to establishing the wishes and feelings of children and young people. Why was this not done in this case?  301. Likely reasons include;  • Silo working within agencies and within agency departments such as the West Midlands Police (crime focused and offence specific) which omitted consideration of the welfare of the children.  • An overly adult focus on Kelly Emery by adult services such as GPs (patient and symptom focus), Dudley CRI (methadone programme, harm reduction focus) which did not recognise the presence of the children Final Version 21.03.16 70  • Professional assumptions and an unchallenged  ‘narrative’  that the mother was being supported by her extended family and other agencies, leading to a low perception of risk for the children.  • Lack of a holistic,’ Think Family, Whole Family’, 14interactional approach by adult service providers that considered the impact of Kelly Emery’s behaviour and actions on her children and vice versa.15   • Pressure on Birmingham Children’s Social Care practitioners to close assessments in ten working days and ‘cut corners’ by not seeing the child.  • In the case of Sandwell Children Social Care, the workload demand and its effect on staff and over reliance on agency staff, and pressures to address a significant workload.  302. Ofsted (2010),  in a study of the importance of professionals listening to the voice of the child and learning lessons from Serious Case Reviews,  found that,  • “The child was not seen frequently enough by the professionals involved, or was not asked about their view and feelings. • Agencies did not listen to adults who tried to speak on behalf of the child and who had important information to contribute • Parents and carers prevented professionals from seeing and listening to the child • Practitioners focused too much on the needs of the parents, especially on vulnerable parents, and overlooked the implications for the child. • Agencies did not interpret their findings well enough to protect the child.”   All five of these findings resonate with this case and can be identified as factors in how the agencies interacted with Fenton, his sister and Kelly Emery. The key lessons are set out at paragraphs 412-414.    ToR 4                                                            14 See the ‘Think Family Protocol’ (based on original work by the Social Care Institute for Excellence in 2009) from Warwickshire Safeguarding Children Board for principles.   15 This approach is not the same as the ‘Think Family’ initiative (which comes under the ‘Troubled Families’ programme of the Department for Communities and Local Government (DCLG)) currently being implemented by Birmingham City Council. See the Birmingham Safeguarding Children Board website for more information.  Final Version 21.03.16 71  Did agencies undertake formal interventions to safeguard the children appropriately? If they did, were they effective? If not, why did they not happen?  303. As previously noted, there were several missed opportunities for agencies to have taken action, both before and after Fenton’s birth whilst he was living in Sandwell; and then after the family’s move to Birmingham, which could have contributed towards safeguarding and promoting the welfare of the two children. The reasons and analyses why this did not happen have been set out in the earlier sections of this report.   304. In regard to formal interventions to safeguard the children there were three occasions when this should have taken place. Firstly, following the referral from the Probation service to Sandwell Children’s Social Care consequent to Fenton’s birth in July 2011. Secondly, in August 2012 consequent to the anonymous referral to Birmingham Integrated access team and thirdly, in April 2013 when Birmingham Children’s Social Care received a referral from the West Midlands Police. The referral from the TA at SFH’s school to the Attendance Manager/Safeguarding Lead was not passed to Birmingham Children’s Services, as Child Protection Procedures required.  Had it been, Children’s Services would have been alerted to the serious situation in which Fenton and his sister were living.  The failure to deal properly with this was a significant lost opportunity to protect the children. Possibly the last one before Fentons’ death.  305. On no occasion did these referrals lead to the instigation of formal safeguarding interventions by way of strategy discussions, Section 47 enquiries, initial child protection conferences and possible formal child protection plans or child in need plans.    306. As previously noted, the referral to Sandwell Children’s Social Care led to no further action, rather than the completion of an initial assessment and if necessary a core assessment, in line with existing standard safeguarding procedures. An analysis and reasoning for this has been provided above at paragraphs 260-269..  307. Regarding the two Birmingham referrals and why they did not result in action to safeguard Fenton and his sister, the analytical reasoning is given at paragraphs 190-209 above.       Final Version 21.03.16 72  Family Views  308. Both sets of grandparents and Fenton’s father were seen in separate meetings by the SCR Panel Chair and the lead reviewer in July 2015. The purpose of the meetings was to hear their views about the way that agencies handled the situation with Fenton, his sister and Kelly Emery. All family members were aware of what had happened from their attendance at Kelly Emery’s trial in March 2015. SFH declined to be interviewed. The accounts below are summaries from the written notes of the Panel Chair which have been seen by the family members and agreed as being an accurate version of what was said.   Fenton’s Paternal Grandparents and Father  309. Fenton’s father (FFH) had been in prison during the lifetime of his son but had seen him on prison visits and had formed a deep attachment with him. FFH was aware of Kelly Emery’s drug use and was very concerned about the response to it from the drug agency based at Atlantic House. He considered it unacceptable and a dangerous practice that Kelly Emery’s methadone script was posted out to her when she had not been drug tested. He felt that there were clear indications that Kelly Emery was using other none prescribed drugs and to presume that she was not using, in the absence of proof by drug testing, was an unsafe response.   310. The paternal grandparents (PGFH) had the care of Fenton on most weekends. They said that they were not welcome by Kelly Emery to collect Fenton and there was an arrangement whereby the maternal grandmother would bring him to them. Alternatively, Kelly Emery would meet them away from the home and pass Fenton to them. They now consider this was to prevent them seeing the unacceptable home conditions, which were described during the trial.   311. The PGFH and FFH felt that the referrals to Birmingham Children Social Care had not been thoroughly investigated. FFH stated that SFH’s teacher had phoned Social Care several times about concerns around lack of parental care. They understood that a social work visit had taken place some ten days before the death of Fenton and questioned why no action on the children’s situation had been taken.  They had a copy of a section 47 report giving details which would be sent to the lead reviewer.   312. FFH also highlighted concerns that the Police saw unsatisfactory home conditions and felt that they could have removed the children on an emergency basis to ensure their safety. FFH and PGFH understood that Social Care had carried out a home visit in June 2013 when home conditions were alleged to be poor. They considered that (Birmingham) Social Care had failed to assess the risk to the children and act appropriately. They also felt that the incidents at Kelly Emery’s home involving parties and disturbances were well known. Agencies did Final Version 21.03.16 73  not consider the risks to the children, in particular Fenton being so young and vulnerable. They felt if appropriate action had been taken his life could have been saved.  The Maternal Grandparents  313. The maternal grandparents described many years of trying to support their daughter Kelly Emery in numerous difficult situations caused by her drug misuse. In 1999 they had sold their home to move to another area, in an attempt to separate Kelly Emery from the drug dealing/using fraternity she was involved with. These problems predated SFH’s birth but had progressively become more serious and worrying for the maternal grandparents once SFH and then Fenton were born.   314. They complained of a lack of support from Children’s Social Care both from Sandwell and Birmingham. When SFH had been subject to a CP Plan the maternal grandmother  (MGM) had initiated the intervention by reporting concerns relating to SFH’s safety and wellbeing due to neglect on the part of Kelly Emery. MGM felt that throughout the intervention Kelly Emery “managed” the social workers, complaining about any who challenged her and having them replaced.  MGM tried to tell the social workers how manipulative Kelly Emery was but felt she was not listened to.  Both maternal grandparents felt all social workers involved should have made unannounced visits.  They then would have gained a more accurate picture of the lifestyle of Kelly Emery and the neglect the children were suffering.  As a result of MGM’s referral Kelly Emery refused her access to SFH for a year. This caused great distress to MGM resulting in her feeling unable to report further concerns regarding SFH and later Fenton, as she feared losing her contact with them again. In effect Kelly Emery was controlling her mother by this threat.  315. The maternal grandparents described a deteriorating series of events in the lives of Kelly Emery and her children. These included frequent house moves, damage to her homes windows being smashed and a car, being used by Kelly Emery, being “petrol bombed’. These events they understood to be related to drug use and dealing. The MGPs frequently heard of the noisy parties and frequency of male visitors to Kelly Emery’s home from her neighbours and friends who had witnessed or heard accounts of these. They were aware Kelly Emery was involved in prostitution and had tried to dissuade her from this. They described Kelly Emery’s care of Fenton to be good during his first year, however once she moved to Rednal in Birmingham, the situation deteriorated markedly. The lack of any unannounced visits to Kelly Emery’s home by social workers and other professionals was again a feature of concern. They felt this contrasted keenly with the frequent inspections of their home prior to SFH’s permanent placement with them being agreed.  Final Version 21.03.16 74   316. SFH’s life experience was described as living with the home conditions described above; in addition Kelly Emery sold SFH’s possessions to purchase drugs. Her grandparents tried to keep any valuable items owned by SFH at their home but often Kelly Emery would insist on taking these to her home, she would then sell them. MGM described trying to improve Kelly Emery’s home for the sake of the children, buying replacement carpet and furniture and decorating the houses. SFH spent almost all weekends with her grandparents. MGM described both of them being in tears when the time came for SFH to be taken home. On one occasion a friend witnessed their distress and had made an anonymous call to Social Care giving information about the concerns, including concerns that the children were inadequately fed. MGM believes the Social Care did not check their records fully when evaluating this referral.   317. The MGPs were also concerned that the drug agencies were not sufficiently robust in monitoring Kelly Emery’s drug use while issuing her with prescriptions for methadone. Kelly Emery was able to obtain prescriptions through the post so avoiding clinic appointments and any testing for her use of other drugs. On occasions SFH told her grandparents Kelly Emery had used SFH’s urine to submit as a sample in place of her own, in order that her use of non-prescribed drugs would not be identified. The MGPs felt Kelly Emery manipulated her key drugs worker DW1 and had him,  “wrapped around her little finger”.  Both Grandparents said methadone containers were everywhere in the house. They had not considered Kelly Emery would administer drugs to her children. Following Fenton’s death, a neighbour of Kelly’s, told of a conversation she had with Kelly Emery in 2013 prior to Fenton’s death in which Kelly Emery had spoken of the dangers of methadone and she would not give it to a child. The MGM had reported this to the police investigating the circumstances of Fenton’s death.16  Kelly Emery  318. Kelly Emery agreed to be interviewed as she hoped the Serious Case Review Reports findings would contribute to a safer environment for children whose parents abuse substances. She felt that overall the professionals who visited her were too trusting and accepted her assurances regarding her situation and her ability to care for her children. Kelly Emery felt they placed too much weight on the good appearance of her home and the fact that FH’s sister attended school regularly and without problems. She was untruthful about her drug use and those visiting her accepted what she said without question. She thought professionals should be aware that drug users may be untruthful.                                                             16 This information was passed on to the West Midlands Police by the lead reviewer shortly after the interview in July 2015.  Final Version 21.03.16 75  319. Specifically she highlighted;   • The repeated issuing of prescriptions for her methadone, by the agency, without drug testing her, this allowed her on occasion to store the methadone, as she was additionally using other drugs. • The professionals visiting accepted her account of her compliance with the methadone programme, without seeking any verification.  320. Kelly Emery said as she was using other drugs in addition to the methadone she was able to store quantities of the methadone in the house. She was not supplied with a secure box to store the methadone. She was not told in detail about the dangers of methadone to children or that a small amount could kill a child.  321. She would have expected professionals to seek some verification, of her accounts of her drug taking and lifestyle; she knew that her mother was concerned and would have voiced those concerns had she been seen without Kelly Emery being present. One worker who called to assess home circumstances following a Police referral stayed no longer than 10 minutes.   Key Learning and Findings from Similar Serious Case Reviews  322. All but one of the SCRs have involved the deaths of young children from methadone ingestion whilst in the care of their parents/carers. The Child Daniel, Wolverhampton SCR concerned the death of a young child (23 months) from heroin ingestion.  Birmingham SCB; Child 2007-8/3  323. The child (2 years and 5 months) died in 2008 as a result of drinking methadone. His older sibling also drank methadone but survived. The SCR Overview Report was completed in June 2009. Key relevant findings and learning points were,  • Professionals were overly focused on the needs of the adults and not sufficiently aware of the neglect suffered by the two children. • The mother’s drug abuse was not fully recognised and the impact of two drug abusing parents on the children was missed.  • The BSCB and Birmingham Drug and Alcohol Action Team to commission training for professionals in recognising drug abuse by parents and the impact on their children • Agencies were working in isolation with poor information sharing between them. Final Version 21.03.16 76  • A general lack of professional curiosity and failure to challenge the parents who showed apparent compliance • A willingness for professionals to accept the reassurances and excuses of the parents despite chronic neglect and inadequate parenting • A lack of  a holistic view of the family • Professionals did not follow basic procedures, failed to intervene appropriately and did not respond to the obvious risks to the children.  Wolverhampton Safeguarding Children Board; Child Daniel 324. Daniel (aged 23 months) died after ingesting heroin in May 2011 whilst in the care of his parents who were on methadone programmes. The SCR report was published in 2013. Key relevant findings and learning points were,   • Insufficient child focus; practitioners did not understand the day to day experience of the child. • Missed opportunities to address safety issues with the parents around safe storage and use of substances. • Missed opportunities to undertake effective assessments around the impact on the child of parental substance misuse.  • Lack of challenging but supportive management oversight • The need to guard against professional ‘ over-optimism’ and fixed thinking and maintain a child focus.  • WSCB to develop an inter-agency pathway and protocol for assessing the needs of unborn babies in all circumstances where there is the likelihood of compromised parenting. • The need for professionals to have in mind the ‘Think Family’ approach when working with adults who have children.  Derbyshire Safeguarding Children Board; Child BDS (Published   November 2013) 325. BDS, a two year old boy died in March 2012 from ingesting his mother’s methadone from his beaker. Key relevant findings and learning points were;  • The failure of drug treatment professionals to prioritise the safety of the child over the needs of the mother. • Robustly risk assess the mother regarding her suitability for having methadone in the home where she had the care of her young son and to review this as circumstances changed and incidents occurred, sharing information with other professionals as necessary.  • An over-reliance on mother’s ‘ Engagement’ with services as evidence of compliance and a lack of professional challenge and cynicism Final Version 21.03.16 77  • Lack of a referral to Children’s Social Care which could have led to a comprehensive assessment being made and the likelihood of the child being subject to a child protection plan.  • The need for a ‘Think Family’ approach.  Blackpool Safeguarding Children Board; Child BT (Published May 2015) 326. The young child BT died in 2014 from methadone poisoning after drinking the substance from a feeding cup whilst in the care of both parents. Key findings and relevant learning points were,  • A whole-family approach was lacking which did not include the father. There were no parenting assessments done.  • Despite knowing about the mother’s illicit drug use the substance misuse service did not make a referral to Children’s Social Care.  • Specialist drug services were aware of the child’s mother not complying with OST treatment by using illicit drugs whilst on a methadone prescription and providing ‘false’ urine samples.  • Non-compliance should result in immediate action to bring multi-agency professionals together to discuss the case. • It was recommended that all drug using parents are tested via swab tests if this provides a more accurate and reliable test result.    Key Findings, Learning and Desired Outcomes  327. Formerly, it has been accepted practice for Birmingham Safeguarding Children Board (BSCB) to be presented with a set of SMART17 recommendations resulting from the conclusions and key learning points from commissioned Serious Case Reviews. The agreed recommendations would be operationalised into an action plan and duly implemented. However, recent thinking on achieving effective change in safeguarding policy and practice has challenged this practice. Arguably, there has been a tendency to focus on relatively minor changes such as revisions to policies and procedures whose outcomes (or more accurately, outputs) can be easily measured; and which rarely produce effective improvements to safeguarding practice and substantive positive outcomes for children.   328. After consultation with the Board, through the Business Manager, it has been agreed not to produce a list of recommendations but rather to set out the key findings, identified learning and desired outcomes for children. These will aim to offer challenge and reflection to a ‘Strategic Panel’ from the BSCB that is familiar with the current complexities and context of the local safeguarding scene. The                                                            17 Specific, Measurable, Attainable, Relevant, Timely (SMART) Final Version 21.03.16 78  lead reviewer will converse with the Strategic Panel with the aim of converting the findings and learning into relevant and tangible actions, through an Action Plan that complements and informs the current on-going development of services (‘the Birmingham improvement journey’). The Action Plan will be implemented by the BSCB to ensure that the required changes are widely disseminated and embedded across the full spectrum of front line practice in Birmingham (and elsewhere).   Finding 1-Fenton’s Death  329. Fenton died on the 01.07.13 after being given a lethal dose of methadone by Kelly Emery in the belief that it would pacify him so that she could take illicit drugs.  The finding of manslaughter at the trial of Kelly Emery by definition established that she did not intend to kill her son. The evidence of this SCR and the criminal trial suggests that his death was not predictable.      Finding 2-Was the Death Preventable? 330.  There were many agencies and professionals involved with Fenton and his family during his short life that between them could and should have taken steps to have better promoted him and his sister’s (SFH) safety and wellbeing. Tragically, this was not done. There were significant shortcomings in the way that agencies, both individually and collectively, responded to the safeguarding needs of Fenton and his sister.  331. It was not possible to conclude with any causal certainty that Fenton’s tragic death could have definitely been prevented had there been effective multi-agency intervention, given his death was manslaughter and that Kelly Emery did not intend to kill him. However, the Review concludes  that the likelihood of his death could have been reduced had effective inter-agency action been taken to recognise and assess the known risks to him and his sister from Kelly Emery’s substance misuse, methadone use and lifestyle;  and based upon this recognition, implement an effective inter-agency response.   Finding 3  Pre-Birth Recognition and Risk Assessment of Parental Substance Misuse/Methadone Use regarding Fenton and his sister.   332. There was no evidence to show that any consideration had been given by medical or non-medical practitioners associated with Kelly Emery’s drug support agency (Dudley CRI) to the potential risks to Fenton and his sister of Kelly Emery’s inconsistent involvement with her methadone treatment. The focus and Final Version 21.03.16 79  approach to treatment ‘did not take into account the wider needs of Kelly Emery and the impact and risks associated with substance misuse on the family unit as a whole’. (CRI IMR, p.10). No account was taken by CRI personnel in their decision-making regarding Kelly Emery’s treatment, of her ability or motivation to parent her children safely.    333. The lack of awareness of risk to Fenton and his sister by the Dudley CRI resonates at a wider, national level with adult substance misuse services. Recent research from serious case reviews on the deaths of children from opiate substitution ingestion found that,’ the evidence presented shows that practitioners do not consistently recognise the possible risks to children post by OST ( Opiate Substitute Treatment), despite NICE and the Department of Health stating this requirement explicitly’ ( Adfam, 2014, p.8).   334. There was no recognition or assessment by the midwifery service to the potential risks of Kelly Emery’s methadone use to the unborn child (Fenton) and his sister. The midwifery service did not liaise with the drug support agency despite the known risk factors; Kelly Emery’s inconsistent engagement with her treatment regime, and the lack of any drug testing.  335. There should have been a joint review of risk to the unborn child (Fenton) by the Dudley CRI and the specialist midwife and a referral on to Sandwell Children’s Social Care for an assessment of risk and need. The omission was an early missed opportunity for a pre-birth multi-agency assessment that could have informed a plan to have safeguarded the children’s safety and welfare and placed them at an early stage on the Sandwell Children’s Services ‘Radar’.   336. A factor in the lack of a pre-birth joint review of risk to the unborn child  (Fenton) was the lack of a structured ‘pathway’ for midwifery and adult drug support services to use in consideration of whether to refer onto Social Care for a pre-birth assessment. This SCR would suggest that the pathway developed by Public Health England (2013) should be incorporated into local multi-agency policy and practice (see appendix 7).   Key Lessons and Learning  337. Knowing what went wrong and why, what now would be done differently and what are the key learning points?   338. Firstly, Dudley CRI (and indeed, all substance misuse support services) needs to be working within an effective safeguarding policy. This should contain a set of effective safeguarding systems and processes informed by a holistic, ‘Think Final Version 21.03.16 80  Family’ approach18; where practitioners (both medical and non- medical) routinely consider any potential safeguarding issues, especially in relation to the potential impact of a client’s methadone use and substance misuse on any children and vulnerable adults in the service user’s family. In this regard, this Review would urge the CRI to adopt ‘The Protocol for Provider Services Working with Parents who misuse substances, HM Government, 2013 (see Appendix 7).    339. Secondly, practitioners and their supervisors need be trained and confident in competently carrying out Parenting/Risk assessments that are compliant with Local Safeguarding Children Board guidance. Thirdly, practitioners require manageable caseloads and the opportunity for regular, reflective and challenging supervision. Fourthly, there needs to be a rigorous quality assurance and audit framework that, amongst other things, ensures that agency practice keeps children (and vulnerable adults) safe.     340. Thirdly, there needs to be a fully integrated service delivery system with prescribing GPs working within the CRI structure and liaising closely with the drug support workers, dispensing pharmacists, midwifes, health visitors and social workers, in addition to also communicating with clients’ own GPs. Sixthly, sporadic client engagement and failure to attend medical reviews needs to be followed up and addressed robustly, especially with those service users who have children. Lack of engagement should be seen as a significant risk factor in regard to children; and serious consideration should be given to the suspension of prescribing and a return to supervised consumption of methadone.  Seventhly, there should be regular drug testing of clients and where appropriate (and with the client’s consent) the sharing of results with other relevant professionals such as midwifes health visitors, GPs and social workers. Eighthly, there should be a quick and timely transfer of service to the new district when a client moves into a different catchment area.   341. Fourthly, methadone needs to be kept in safe storage by the client with a record of this by the agency. The risks to children of ingesting even small amounts of illegal substances, including methadone, should be clearly explained, as should the absolute requirement that children are never to be given these substances as a sedative or pain reliever.  Documented rationale should be made as to why prescribed supervised consumption is not used for parents whose engagement or compliance to treatment is poor.  Finally, CRI professionals need to work co-operatively and effectively communicate with other professionals; particularly, as in this case, specialist midwifes, who should be present at all client reviews held by the CRI agency.                                                              18 Not to be confused with the ‘Troubled Families’ initiative which in some areas (such as Birmingham) is referred to as ‘Think Family’.   Final Version 21.03.16 81   Changes Made since 2013 and Current Practice  342. The CRI’s Individual Management Review (IMR) states that the key lessons from the case have been identified and are being addressed through an action plan that purports to remedy the previous deficiencies. However, it was the view of the lead reviewer and the Overview Panel that the IMR lacked sufficient rigour in its analysis of why the risks to Fenton (and his sister) were not recognised and acted upon by a referral to Sandwell Children Social Care. The action plan was thought to be reactive, vague and a reflection of the weak analysis.   343. Indeed, the evidence of serious systemic and structural flaws accounting for the causes of a lack of recognition of the risks to Fenton and his sister  raised wider concerns for the Panel and the lead reviewer about the current effectiveness of Dudley CRI practice regarding the safeguarding of children (and for that matter, all vulnerable individuals). The Panel was also aware that as of the 1 March 2015 the CRI is the current sole supplier of drug and alcohol services to Birmingham City Council.   344.  Such were the concerns about the safeguarding processes and practice of Dudley CRI that the Panel took the view (in October 2014) that Dudley Safeguarding Children Board should undertake an audit of the effectiveness of the agency’s safeguarding practice. This was done. No concerns were identified by Dudley in terms of safeguarding or clinical practice. CRI Dudley now conduct a rigorous annual S11 self assessment and report it to the Dudley LSCB. The Panel also requested (in February and July 2015) that the Birmingham Safeguarding Children Board (BSCB) be assured by the CRI that its current practice is safe. A letter was received from the Chair of the BSCB on the 26 August 2015 informing the SCR Panel Chair that the concerns regarding the local substance misuse service had been passed on to the service commissioners to look into to the issues raised. Consideration was to be given to an audit of safeguarding practice by the BSCB multi-agency audit pool if necessary. 19  345. Regarding the midwifery service (Dudley Group NHS Foundation Trust), changes in practice and procedures are required based upon the following identified learning, namely;                                                              19 The Chair of the Birmingham Safeguarding Children Board, in a letter from the Birmingham Director of Public Health (dated 11 September 2015), has been informed that the CRI designated Quality and Governance Lead has completed an internal safeguarding governance audit. There is also to be a Section 11 audit focusing on the specific issues identified in this SCR. Birmingham has also put itself forward as a pilot site for Adfam’s Year +Project.  Final Version 21.03.16 82  • That the service should comply with the current Local Safeguarding Children Board guidance on ‘Maternal substance abuse during pregnancy’. • That the service should adopt a ‘Think Family’ approach that includes working within a structured pathway (e.g. the ‘Protocol for Provider Services Working with Parents who misuse substances’, see Public Health England, HM Government, 2013). • The adoption, effective implementation and embedding into practice of the threshold document ‘ Right Service, Right Time, Right Place’ and a specific risk assessment tool regarding the potential impact of substance misusing  (and methadone using) parenting on children.  • Close joint working between the specialist midwifery service and the CRI (both the CRI prescribing doctor and the drugs support worker) that would include regular attendance at joint reviews on service users with children. 20 • Recording of all discussions and contacts to be made in hospital clinical notes in addition to the women’s handheld notes. • Where drug testing (with informed consent of the mother) is not done by the substance misuse service (i.e. Dudley CRI) this should be done by the specialist midwifery service/Hospital. • The need for Professional curiosity (‘Healthy scepticism’ and Respectful uncertainty’) and not to take everything on face value from the parent’s self-reporting. 21 • Regarding the above learning point, agencies should provide staff learning and development opportunities that build confidence and competencies around child safety, whilst maintaining an open, direct and positive relationship with the client.  • Effective liaison and communication with the community midwife, allocated health visitor, family GP service, maternity service and (where appropriate), local authority Children Social Care service.   Changes Made since July 2013 and Current Practice  346. The Head of Midwifery services for the Dudley Group Foundation Trust (Russells Hall Hospital) reported to the Panel in March 2015 the following changes to practice.                                                            20 ‘There should be liaison between maternity and drug treatment services to review the management of the mother’s drug use and impact on the baby before and after pregnancy. If there is a concern about the parent’s child care abilities , a referral should be made to Children’s Social Care  under these procedures’ ( Current Dudley Safeguarding Children Board safeguarding procedures; Maternal Substance Misuse during Pregnancy’)  21 This learning point and the one immediately below would apply to all agencies and practitioners working with parents who substance misuse.  Final Version 21.03.16 83   347. Regarding closer joint working with the CRI, the specialist midwife holds a fortnightly clinic for women accessing services at Atlantic House (Dudley CRI). Joint substance misuse/ antenatal clinics are also held by the specialist midwife and consultant in specialist addictions every six weeks at Atlantic House, with the woman’s substance misuse worker also present.   348. All non-face to face contact is recorded in the hospital held clinical notes and if the woman brings her handheld pregnancy/postnatal notes a record is also documented in these. If any information, gained by face to face contact, is needed to be shared in writing, this will be by secure email. Notes are taken at the joint clinics and the Consultant management plan is shared with the Specialist Midwife who files this in the woman’s hospital held clinical notes on receipt (this comes by secure email). A copy is also provided by the Consultant to the GP. Following birth the Specialist Midwife also documents in the parent held record (red book), as a form of communication with all other care providers.  349.  In relation to drug testing, at each antenatal contact attendance at the hospital a urine sample is requested and drug testing performed with consent. The results are sent from the Path Lab to the Specialist Midwife via internal post within 7-10 days. If the result was of ‘immediate concern’ the Path Lab contacts the Specialist via phone or secure email. The Specialist Midwife would then communicate with the Drug Team at Atlantic House to review/revise the woman’s management plan as required. This is documented in the woman’s hospital held clinical notes; the same applies post -natally.  350. Regarding shared care with the woman’s GP, The Drug Worker’s role is to meet with the GP and liaise regarding the monitoring of the prescription. Pregnant women who are prescribed by their GP are requested to attend the Joint substance misuse/antenatal clinics conducted by the Specialist Midwife and Consultant in Specialist Addictions in the presence of the woman’s drug worker, to review the woman’s management plan including the prescribed medication. The GP is informed of outcomes by the Consultant Outcomes as detailed above.    351. The points above describe the expected communication/ involvement of the GP. The Specialist Midwife role does not have any expected regular communication with GPs, this is performed by the woman’s named community midwife, however, if the woman’s care has multiple complexities, ante-natally or post-natally, the Specialist Midwife would ensure direct communication with the GP as required, completing documentation as described above.  352. Regarding liaison with other relevant professionals, all women who are substance misusers are notified to the Health Visitor/Family Nurse Practitioner directly by the Specialist Midwife via phone and discussed at the monthly unborn baby Final Version 21.03.16 84  network meetings. All women who require a CAF have the involvement of the Health Visitor/Family Nurse Practitioner as part of this process and these professionals are also invited to attend any ‘core group’/safeguarding meetings by Children’s Social Care which are also attended by the Specialist Midwife. Any additional ‘ad hoc’ communication is recorded and documented as described above. Desired Outcome for Children 353. The desired outcome from the learning  aims to ensure that, when appropriate, a timely pre-birth assessment of risk to unborn children of parents who misuse substances/ are subject to methadone programmes, is undertaken to safeguard and promote the unborn child’s welfare.    Finding 4  Post Birth Recognition and Risk Assessment of Parental Substance Misuse/Methadone Use regarding Fenton and his sister and intervention whilst in Sandwell  354.  The Probation Service was the only agency to have assessed Kelly Emery’s risk to her children in regard to her methadone use and substance misuse whilst the family were living in Sandwell.  The assessment of ‘Medium Risk’ informed the agency’s decision to make a referral to Sandwell Children’s Social Care.   Lessons  355. The key lessons are firstly for the Probation Service to communicate directly with substance misuse services to clarify and confirm that clients are actually adhering to treatment programmes and undergoing drug testing when stipulated.   Secondly for there to be an accurate recording of all family members of probation clients, especially children and partners, so as to obtain an accurate and full assessment of risk to relevant vulnerable individuals. The Probation Trust states in its IMR that this omission has been remedied through the implementation of a circular issued in December 2012.   356. The Health Visiting service of Sandwell and West Birmingham Hospitals’ Trust did not understand and investigate the risks to the children from Kelly Emery’s substance misuse/methadone use. Although the proposed Universal Plus/Active Intervention support package recognised Kelly Emery’s methadone use there was no effective consideration of the potential risks to Fenton and SFH.  Final Version 21.03.16 85  357. The rule of optimism, untested assumptions based on untruthful accounts from Kelly Emery; and a lack of lateral enquiries with other involved agencies, seemed to have contributed to a health visiting perception that Kelly Emery was adequately managing the care of Fenton. His development was therefore not identified as requiring further follow up.  Lessons  • Health visitors should adopt a ‘Professional curiosity’ approach to parents who substance misuse/ are on OST programmes. • There should be direct lateral follow up enquiries with substance misuse services, Children’s social care and other involved agencies when it is known that parents are substance misusers/ methadone users. • There should be adherence to the defaulted appointments procedures. • There should be inclusion of all significant household members, including relevant males, in health visiting assessments.  358. The response by Sandwell Children’s Services duty and assessment team to the safeguarding referral from the Probation Service was sub-standard and poor practice. The safeguarding referral should have resulted in the duty officer carrying out an initial assessment in line with existing agency and Sandwell Safeguarding Children Board safeguarding procedures.  359. The handling of the referral sought to ‘cut corners’, partly in response to existing organisational pressures (see paragraphs 164-165) and needs to be set within this wider agency context.   360. Sandwell Children’s Social Care duty team’s decision not to take any further action on the referral was not informed by an initial assessment or any understanding of the potential impact of Kelly Emery’s methadone use and substance abuse on her children. There was also poor management challenge and oversight of the case. This episode was a significant missed opportunity to carry out an assessment into the potential risks to Fenton and Robyn and their needs; and take appropriate multi-agency action to safeguard them and promote their wellbeing.   Lessons   361. Sandwell Children’s Services were inspected in January 2015 and were given a rating of ‘Inadequate’ by Ofsted. In regard to children who need help and protection the Ofsted report noted that, ‘Management oversight of frontline practice is failing to ensure that children and families are receiving services at the Final Version 21.03.16 86  right level based on need and risk and taking account of the requirements of ‘Working Together to safeguard children’ (Ofsted report, June 2015, page3). The Report ( at page 4) required the agency to, ‘Improve the management oversight of social work practice to ensure that assessments, plans and interventions are at the right level to address need and risk and that appropriate action is taken to safeguard children’.    362. The findings of inadequate and superficial assessments and poor management oversight from this practice episode would reflect, emphasise and support the recent (2013 and 2015) Ofsted findings and improvement requirements regarding the referral and assessment team.    West Midlands Police  363.  The lack of a referral to the (Police) Child Protection Unit and Sandwell Children’s Social Care from police custody staff in May 2011(following Kelly Emery’s arrest for shoplifting offences in May 2011prior to Fenton’s birth) was a very significant lost opportunity for multi-agency intervention to safeguard and promote the wellbeing of Fenton and his sister.   364. The impact of Kelly Emery’s substance misuse and criminal behaviour, whilst being heavily pregnant and the mother of a ten year old child should have been considered by the Police custody officers and a referral made. Had there been a referral it is likely that a Section 47 enquiry would have been undertaken, followed by the holding of an Initial Child Protection Conference, resulting in both children made the subjects of child protection plans.   Lessons  365. Front line officers, custody personnel, intelligence analysts and supervisors, whilst necessarily having a crime focus to their work, also need to develop a more holistic, less, ‘Silo’, approach to recognising the potential impact of individual’s (alleged or actual) criminal behaviour on children, young people and vulnerable adults within the household.  366. In this regard, as identified by the Police IMR (at page 29), a duty of care was owed towards the unborn child (Fenton) by the Police when Kelly Emery was in custody in May 2011 for the shoplifting offences. In addition to compromising her unborn child’s welfare through her criminal activities she was also known to be misusing cocaine and heroin whilst pregnant. This Review agrees with the Police IMR view (at page 29/30) that, ‘It would have been appropriate for (the) custody Final Version 21.03.16 87  sergeant to instruct investigating officers to make a child protection referral by way of generating a child abuse non-crime number’.   367. Had this been done, Fenton and SFH’s  circumstances would have been considered by specialist safeguarding officers in the PPU, resulting in a greater likelihood of West Midlands Police gaining an effective appreciation of the family dynamics and risks that their mother’s criminal behaviour presented to the children. Moreover, as stated in the IMR, the procedures would have led to a strategy discussion with Sandwell Children’s Social Care and in all probability, a pre-birth child protection plan for Fenton; in addition to SFH also being subject to formal child protection measures. In short, the children would likely have been placed on the inter-agency ‘radar’ in the summer of 2011.   368. In addressing the matter of a more holistic, child focused approach, the IMR identifies that safeguarding issues may exist in regard to the unborn child where there are concerns for a pregnant woman in relation to domestic abuse.22 In this eventuality, the Police policy is very clear; namely for a child abuse non-crime report to be filed to both the domestic abuse and child abuse investigation teams respectively. The IMR therefore correctly identifies that there is a need to widen out the recognition amongst the Police service of the potential risks to the unborn child (and existing children) in pregnancy, other than in domestic abuse contexts.  369. Thus the lesson here is for the production of clear guidance where pregnant women (and their partners) are engaging in lifestyle behaviours (such as acquisitive criminality, substance misuse) that place the safety and wellbeing of children (including the unborn) at risk of harm. This is addressed by Recommendation One and the ensuing actions of the IMR Action Plan which addresses the need for both custody staff and front line officers to recognise the risk and make an internal referral to specialist officers or third party agencies.   370. All front line staff, intelligence analysts and supervisors need to be knowledgeable about the signs of child abuse, recognise and consider risk in child protection and take appropriate action to address risks; including recording, referring on to specialist sections and clarity around initiating non-crime (child abuse) reports. This learning is partially covered by Recommendation Two of the Police Action Plan contained in the IMR which takes steps to train intelligence officers to analyse risk to children and know the appropriate referral pathway to specialist officers in the PPU/CAIT. The wider aspects of this lesson, including recording and, where appropriate, initiating a non-crime incident form, are included in the HMIC ( 2014) recommendation to the West Midlands Police at page 21, namely to;                                                            22 West Midlands Police Child Abuse Policy and Guidance ( September 2012)  Final Version 21.03.16 88   • “Ensure that police officers and staff understand the significance of drawing together all available information from police systems to improve their risk assessments; • Ensure that all relevant information is properly recorded and readily accessible  in all cases where there are concerns about the welfare of children and, as a minimum, provide guidance to staff on:  � What information (and in what form) should be recorded on systems to enable good quality decisions;  � The importance of sending the information to the correct police department and/or relevant partner agency;  � The value and relevance of ensuring that records are made promptly and kept up to date; and    • Ensure that managers carry out quality assurance checks on records and provide feedback to police officers and staff. “   371. An obvious lesson was that officers should always (as far as possible) see and speak to any child or young person who is a subject of concern. If not already in existing procedures this learning point should be included in the agency action plan.   372. Two further lessons of note were;  • The need for effective, high quality supervision of front line officers in regard to decision making around child protection practice. • Adherence to Police policies around the use of challenge (that is recorded) to other agencies’ decision making, the recording of the rationale for any outcomes and the use of intra and inter-agency (LSCB) escalation measures when appropriate.    373. This SCR would suggest that the Police IMR action plan includes and operationalise these lessons in order to disseminate them widely and embed thoroughly into practice.    Reported Improvements made since 2014  374. This SCR notes that the HMIC inspection required the West Midlands Police to take immediate steps ( as of the published date of October 2014)  to implement the recommendation at paragraph 318 and would therefore anticipate and expect  that the above actions have been completed, or are at least well on the way to Final Version 21.03.16 89  completion. Some evidence of this has been provided by West Midlands Police and can be found at appendix 6.  375. The SCR Panel was encouraged to see the developmental progress made by the West Midlands Police as set out in its commentary. It looks forward to clear and tangible evidence of improved outcomes for children as a result of the ongoing work and would suggest that the Birmingham Safeguarding Children Board receives regular audit data that demonstrates the improvements.  Desired Outcome for Children 376. The desired outcome of the above lessons aims to ensure that timely recognition and assessment by professionals of risk to children of parents who misuse substances/ are subject to methadone programmes, is undertaken to safeguard and promote the child’s welfare.   Finding 5 Post Birth Recognition and Risk Assessment of Parental Substance Misuse/Methadone Use regarding Fenton and his sister; and intervention whilst in Birmingham  377. None of the agencies in Birmingham, either individually or collectively, sufficiently recognised or assessed the potential risks to Fenton and his sister from Kelly Emery’s methadone use and substance misuse. This resulted in there being no effective agency intervention to safeguard and promote the children’s welfare.    378. The ‘Health Assessment Framework’ completed by the Worcestershire Health and Care NHS Trust, health visiting service, identified Fenton as being ‘Vulnerable’. This required medium active intervention with the child being seen every three months by the health visitor and some extra parenting support being offered to his mother.   379. The assessment did not include any contact with Kelly Emery’s drug misuse support service or consideration of potential risk to Fenton from his mother’s methadone treatment. This omission marked a missed opportunity to obtain a better understanding of the potential risks to Fenton from his mother’s methadone use and substance misuse.      Final Version 21.03.16 90  Lessons 380. These include;  • Health visitors (and all other practitioners) should adopt an attitude of respectful uncertainty and healthy scepticism in taking at face value what they are told by parental substance misusers. • Professionals should consider whether parents are engaging in ‘false and /or disguised compliance’.  • Professionals should not work on the basis of untested assumptions. Information should be checked out directly with other agencies and professionals, particularly substance misuse agencies (including GPs) to ascertain the facts.  • Parents should be informed of the dangers of children ingesting methadone or being given it in a misguided attempt to pacify them.  • Health visitors (and other practitioners) should work within an agreed pathway of risk (see appendix 7 parental substance misuse pathway protocol)), be child focused and ‘Think Family’. The IMR reference to considering adopting a risk assessment tool such as the ‘Substance Misuse Family Matrix ‘would seem a sensible move.  • That the service should comply with the current Local Safeguarding Children Board guidance on ‘Maternal substance abuse during pregnancy’.   381. Birmingham Children’s Social Care in its handling of the two referrals of August 2012 and April 2013 did not sufficiently understand or adequately investigate the risks to the children from Kelly Emery’s substance misuse and methadone use.   382.  The omission by the social worker to gather all of the known intelligence and information on the family from other agencies led to a flawed risk assessment and a decision to prematurely close the case without properly considering the risks to the children from their mother’s substance abuse and methadone use.  383. These episodes were very significant missed opportunities to intervene in the lives of Fenton and his sister and promote their safety and welfare.   384. The actions and decisions taken by Birmingham Children Social Care staff in their handling of the two referrals, seems to have been a function, at an individual level, of inadequate practice and poor management oversight. This was set within a wider organisational context of systemic and long entrenched problems in ensuring an effective and safe delivery of services to children, particularly (but not exclusively confined to) the ‘Front Door’ service.     Final Version 21.03.16 91  Lessons  385. Key lessons include;  • Birmingham Children’s Social Care need to complete and successfully embed the structural changes regarding the development of the locality Hubs (co-located Multi-Agency Safeguarding Hubs) with the child protection and family support teams all co-located, ensuring consistency of practice city-wide. 23  • Evidence of sustained improvement in the effectiveness and safety of the agency’s, ‘Front Door’, service needs to be provided, with particular reference to child protection enquiries, quality of assessment and inclusion of the voice of the child, in compliance with the Birmingham City Council Children Social Care Improvement Plan 2014-2017.   • In compliance with the Ofsted 2014 report, priority action 31; ensure that the system to manage contacts and referrals is secure and provides the professional basis to support social workers in keeping children and young people safe and protected.  • In compliance with the Ofsted 2014 report, priority actions 29 and 30, ensure that the delayed Early Help strategy is implemented urgently and that partners are fully engaged in the work to achieve this; and, for the local authority and partners to re-launch the threshold document, ‘Right Service, Right Time’.   • In compliance with the Ofsted 2014 report, priority action 25, to ensure that strategic and operational oversight is effective, including supervision and that case file audit arrangements are robust in order for workers to deliver services of consistently high standards.   • Develop the confidence and practice competencies of social workers in the referral and assessment teams to undertake child focused risk assessments that include, properly analysed impact assessments on children of parents who substance misuse and/or use methadone.  • Adopt a more ‘Professionally curious’ approach to assessing parental substance abuse which respectfully challenges what parents say and conducts the full range of robust lateral enquiries, especially with adult substance misuse services. In short, be aware of the rule of optimism, parental disguised compliance and be prepared to ‘Think the unthinkable’.                                                            23 See ‘Integrated Transformation; Our Strategy for Improving Services for Children and Young People in Birmingham’. ( Birmingham City Council:2013) Final Version 21.03.16 92   • Maintain a child focused approach and speak to all of the siblings and extended family members in conducting the assessment.  Such an approach should seek to understand the ‘lived experience’ of children and young people.   Reported Improvements made since 2014  386. Birmingham Children Social Care has been operating to an Improvement Plan (2014-2017) since June 2014 which includes many of the above issues. The following commentary has been provided regarding progress being made with the ‘Front Door’ services. The reader is referred to Appendix 5    387. The SCR Panel was encouraged to note the extensive work that has been undertaken by Birmingham Children’s Social Care over the last eighteen months, particularly in respect of the ‘Front Door’ services. However, clear and tangible quality assurance and audit evidence of high quality outcomes for children, in relation to high quality risk and need single assessments, child protection enquiries and the inclusion of the voice of the child are needed to demonstrate consistent and sustained service improvement. The SCR Panel would expect the Birmingham Safeguarding Children Board (in addition to the Improvement Board and Ofsted) to be assured of outcome improvements for children through the provision of regular audit data as part of its learning and improvement agenda.    388. Regarding Dudley CRI the previous inadequate and unsafe service with respect to Kelly Emery’s methadone programme and the lack of any consideration of potential risk to her children, whilst in Sandwell, continued during the family’s time in Birmingham and up to Fenton’s death.  389. There was a tendency for the methadone treatment to over-focus on Kelly Emery as an individual rather than see her as a parent with dependent children. In essence, the treatment intervention was too adult focused and did not consider the safeguarding and welfare needs of Fenton and SFH.   390. The quality of supervision of the drugs worker (DW1) during this period was sub-standard with no evidence that there was any professional challenge regarding Kelly Emery’s poor engagement; no annual review of the Parental Capacity Assessments, and minimal monitoring, factual checking and auditing of the case. No action was evident from the team leader in ensuring the timely transfer of the case to the Birmingham CRI.    Final Version 21.03.16 93  Lessons  391. Drug support agencies should work within a more holistic,’ Think Family’ approach that considers the impact of adult client behaviour on children and vulnerable others.   392. There needs to be a challenging and rigorous approach to management supervision and oversight that includes case auditing both of the effectiveness of the OST treatment and any safeguarding risks to children.   393. West Midlands Police in its involvement with the family between 2011 and July 2013 did not recognise the risks to the two children. Hence, no referral was made to the (Police) Public Protection Unit/Child Abuse Investigation Unit for an assessment and possible investigation. This included the custody staff who dealt with Kelly Emery in May 2011. Moreover, even when the risk was recognised by DC2 in March 2013, staff did not follow proper procedure and make an internal referral to the Police Protection Unit (PPU).  Lessons  394. See paragraphs 365-373  395. Regarding the GP service; apart from the specific use of the HAD tool to diagnose the extent of Kelly Emery’s depression there was no evidence to show that any consideration was given  to evaluating her parenting capacity in the light of her alcohol and substance abuse and mental health issues. Thus, no account was taken of these matters by the GP in relation to the potential for abuse or neglect of Fenton and SFH.   396. Decision making was solely confined to treating and managing Kelly Emery’s depression through medication and did not include any wider considerations for the safety and welfare of the children. The absence of a holistic, ‘Think Family’ approach to Kelly Emery precluded any exploration of the presence of males in the home.   397.  There was no liaison with the prescribing doctor or drugs worker at the Dudley CRI or any discussion of safe methadone storage.   Lessons  398. The learning from this episode highlights the need for GPs to firstly, be knowledgeable about their duties and responsibilities regarding the safeguarding Final Version 21.03.16 94  of children and young people. Secondly, to think about the children of parents who may present risks, in this case in relation to mental health and substance misuse issues. Thirdly, to discuss any concerns about the children of parents in the context of the ‘toxic trio’ (or any wider safeguarding concerns) with their practice safeguarding group/ safeguarding lead, which needs to meet regularly. Fourthly, the imperative for effective communication between GPs and drug support agency professionals.   399. The IMR states that the Frankley practice has since, ‘embedded’ the discussion of parents with mental health and substance misuse issues at practice safeguarding meetings. These mechanisms need to be a systemic feature of all GP practices in the four areas (Birmingham, Sandwell, Dudley and Worcestershire) subject to this Review and should be monitored by the respective LSCBs and Clinical Commissioning Groups.    400. Key learning points are,  • That GPs and prescribing substance misuse agencies must communicate with each other regarding progress of the patient with the OST programme, medication from the GP and consideration of any risks to children.  • GPs must take a holistic (‘Think Family’) view and consider the impact on children, by the use of their Local Safeguarding Children Board guidance, when treating parents for mental health and substance misuse issues. •  GPs must discuss any concerns about children with their primary care colleagues, including health visitors and school nurses. • GP Safeguarding leads must regularly participate in their safeguarding practice team meetings.    401.  In regard to SFH’s school, no referral was made to Birmingham Children’s Social Care in April/May 2013 regarding concerns of drug and alcohol misuse in the family home. This was a serious breach of local authority and Birmingham Safeguarding Children Board safeguarding procedures.   402. There was minimal recognition or awareness of the potential risks of Kelly Emery’s substance/alcohol misuse on the children and no evidence of any reference to the existing Birmingham Safeguarding Children Board substance misuse guidance. Moreover, there was also no awareness of the potential dangers of males in the home.  Final Version 21.03.16 95  Lessons  403. These include, • The school safeguarding lead having sufficient capacity to discharge their duties effectively and not having to ‘cut corners’. • Compliance to the Birmingham Safeguarding Children Board safeguarding guidance including referral on to the Children Social Care when appropriate and not other agencies such as the Police or the NSPCC. • Adherence to strict recording policies, including written reasons for decision making.  • Not putting the responsibility on to the TA to make a referral.  • Speaking to the child.   • Not assuming that because a child is a ‘Model pupil’ all is necessarily well at home. Sometimes school can be a ‘safe haven’ for abused and neglected children and young people.  •  Effective senior line management and oversight of the safeguarding lead by the head teacher; and regular scrutiny from a safeguarding governor lead and sub-group.   404. Both the lead reviewer and the Overview Panel were very concerned in regard to the evidence from the IMR of such poor safeguarding practice from the school. The Panel requested that a safeguarding review of the school under section 175 of the Education Act 2002 be carried out in order to assure itself that children were safe in the school. This was done in July 2014 although the Panel has (of August 2015) not yet seen the report to the Schools and Settings Improvement team. It is therefore not yet reassured that safeguarding practice has improved. It is suggested that the Panel is provided with the report.   405. Regarding GP intervention, apart from the specific use of the HAD tool to diagnose the extent of Kelly Emery’s depression there was no evidence to show that any consideration was given  to evaluating her parenting capacity in the light of her alcohol and substance abuse and mental health issues. It therefore follows that no account was taken of these matters by the GP in relation to the potential for abuse or neglect of Fenton and his sister. Decision making was solely confined to treating and managing Kelly Emery’s depression through medication and did not include any wider considerations for the safety and welfare of the children.   406. The learning from this episode highlights the need for GPs to firstly, be knowledgeable about their duties and responsibilities regarding the safeguarding of children and young people. Secondly, to think about the children of parents who may present risks, in this case in relation to mental health and substance Final Version 21.03.16 96  misuse issues. Thirdly, to discuss any concerns about the children of parents in the context of the ‘toxic trio’ (or any wider safeguarding concerns) with their practice safeguarding group/ safeguarding lead, which needs to meet regularly.   407. The IMR states that this is now done (and ‘embedded’) within the Frankley practice. This begs the question as to whether practice safeguarding team meetings involving GPs are systemically embedded and operating effectively within the practices overseen by the Clinical Commissioning Groups in Birmingham, Sandwell, Dudley and Worcestershire?  408. Key learning points are,  • That GPs and prescribing substance misuse agencies must communicate with each other regarding progress of the patient with the OST programme, medication from the GP and consideration of any risks to children.  • GPs must take a holistic (‘Think Family’) view and consider the impact on children, by the use of their Local Safeguarding Children Board guidance, when treating parents for mental health and substance misuse issues. •  GPs must discuss any concerns about children with their primary care colleagues, including health visitors and school nurses. • GP Safeguarding leads must regularly participate in their safeguarding practice team meetings.   Desired Outcome for Children 409. The desired outcome of the above lessons aims to ensure that timely recognition and assessment by professionals of risk to children of parents who misuse substances/ are subject to methadone programmes, is undertaken to safeguard and promote the child’s welfare.   Finding 6 The Wishes and Feelings and Voices of the Children 410. There were very few occasions when the voices of Fenton and his sister were heard by practitioners and their wishes and feelings noted and acknowledged. Exceptions, to some extent, were those occasions when the Probation service and the local burglary team police officer recognised the children’s needs for protection and made referrals to Sandwell and Birmingham Children’s Services respectively.   Final Version 21.03.16 97  411. Apart from these two instances, none of the other involved practitioners or their managers; in particular those from Sandwell and Birmingham Children’s Social Care and SFH’s  secondary school, sought to talk with SFH in an attempt to understand her experience of living with and being parented by her mother. Regarding Fenton, none of the relevant child care agencies, GP services and Dudley CRI effectively documented the interaction with his mother, considered his lived experience with her or attempted to get a sense of his ‘voice’.  Lessons  412. All agencies, in particular those delivering services to adults, need to be aware of the potential dangers of ‘Silo working’ where there may be an overly narrow focus on specific aspects of an adult’s behaviour or condition. Agencies should adopt a holistic, ‘Think Family’ approach which includes appropriate consideration of the impact of parenting on children. This is especially the case when children are living in a family environment where parental mental ill health, substance misuse and/or domestic abuse are present.   413. In compliance with law and statutory guidance, subject children and their siblings must be seen and when developmentally mature enough, their views elicited and recorded. In this case SFH had spoken back in 2009 to social workers of her Kelly Emery’s drug use and its impact on her. Evidence from the Birmingham Children Social Care IMR stated that SFH, after Fenton’s death, spoke about him being left unattended by Kelly Emery until 2 pm whilst she slept. Babies and young children’s interaction with their carers should be observed and recorded. Observations need to be made sense of in the context of any risk factors such as substance misuse, adult behaviour and poor parenting.   414. When appropriate, practitioners must speak to and elicit the views of significant figures in the child’s life such as, in this case, grandparents and adult males. According to the Birmingham Children’s Social Care IMR, the maternal grandmother had several very significant concerns about aspects of her daughter’s parenting of Fenton and SFH. Arguably, had she been spoken to  on her own in April 2013 by the social worker the emerging evidence of concern could have been assessed (e.g. SFH allegedly being forced by Kelly Emery to shoplift, intending to be used as a drugs mule on a forthcoming holiday, Kelly Emery being an active sex worker and having sex with ‘clients’ whilst SFH babysat Fenton downstairs). This may have led to formal child protection intervention such as a Section 47 enquiry, an Initial Child Protection Conference and a child protection plan.      Final Version 21.03.16 98  Desired Outcome for Children  415. For the voice of vulnerable children to be heard by professionals in order to better understand their lived experience and include their wishes and feelings in all planning aimed at safeguarding and promoting their welfare.   Finding 7 Formal Safeguarding Interventions and Their Effectiveness  416. There were three occasions when formal agency safeguarding interventions should have happened, namely, the Probation Service referral to Sandwell Children’s Social Care on the 20 July 2011, the anonymous referral in August 2012 to Birmingham Children’s Service and the Police referral in April 2013 to Birmingham Children’s Service.   417. On no occasion did these referrals lead to the instigation of formal safeguarding interventions by way of strategy discussions, Section 47 enquiries, initial child protection conferences and possible formal child protection plans or child in need plans.    Lessons  418. See previous sections   Finding 8 The Six Key Findings from the Similar SCRs  419. These are,  • Professionals need to ‘Think Family’, be aware of the needs and risks to children from parental substance misuse, not be overly adult focused and beware of ‘Silo’ working.  • Professionals should beware of accepting at face value the accounts of substance misusing parents and avoid adopting a fixed over-optimistic view of parenting in the face of evidence to the contrary. Parental non- compliance with treatment plan should result in immediate action to arrange  a multi-agency meeting to discuss case Final Version 21.03.16 99  • Professionals should adopt a ‘Respectful uncertainty/Professional curiosity’ approach to parental substance misuse which, when necessary, challenges parents’ behaviour.  •  Agencies not referring to Children’s Social Care for assessment.  • Lack of challenging but supportive management oversight • The need for an inter-agency pathway and protocol for assessing the needs of unborn children in all cases where there is the likelihood of compromised (including parental substance misuse) parenting.    Seven Overarching Lessons  420. Finally, many lessons and learning points have been identified by this SCR. Here are seven key overarching lessons.  1. Agencies, particularly adult service providers, need to think holistically ('Think Family') and consider the effects of parental substance misuse on children.   2. In families where there is parental substance misuse there needs to be early intervention, including an initial assessment of need/risk by substance misuse and midwifery services, and where indicated, early help or child protection measures when necessary.   3. Agencies, especially adult service providers, should be aware of the dangers of 'Silo' working in relation to being too crime focused (Police), symptom focused (GPs), treatment focused (drug support agencies).   4. When working with parental substance misusers Professionals should maintain a degree of 'Respectful uncertainty' and not accept at face value what they are told; seek corroboration. Beware of parental disguised compliance.    5. When working with parental substance misusers Professionals should always make wider lateral enquiries with other agencies and not make assumptions about the support given to parents and how they are coping. Where possible, always speak to the wider family to gain a fuller picture of what is going on for the child.   6. The voice of the child must be included in all interventions with parental substance misusers.  7. 'Stick to the knitting'. Do the basics well and follow agreed procedures and practice.  Final Version 21.03.16 100  Glossary of Terms  Family Members FFH - Father of Fenton SFH - Sister of Fenton Kelly Emery - Fenton’s mother MGP-Maternal Grandparents MGM-Maternal Grandmother PGP-Paternal Grandparents Terms  IMR - Individual Management Reviews SCR - Serious Case Review Hospital 1 - Russells Hall Hospital Dudley CRI - Crime Reduction Initiative WMP - West Midlands Police BCSC - Birmingham Children’s Social Care SCSC - Sandwell Children’s Social Care CM1 - Community Midwife1 DW1 – Kelly Emery’s Drugs Worker from Dudley CRI BDW - Birmingham Drugs Worker HV1 - Health Visitor 1(Sandwell) HV2 - Health Visitor 2 (Sandwell) HV3 - Health Visitor 3 (Sandwell) WHV1 - Worcestershire Health Visitor Dr1 - The Prescribing Doctor   PSO1 - Probation Service Officer 1 PSO2 - Probation Service Officer 2 PPU - West Midlands Police Public Protection Unit Final Version 21.03.16 101  USS - Ultra sound scan PCSO - Police Community Support Officer TL1 - Team Leader (Dudley CRI) GP - General Practitioner  CAF - Common Assessment Framework HAD: Hospital, Anxiety and Depression Scale BCH – Birmingham Children’s Hospital NSPCC - National Society for the Prevention of Cruelty to Children SW1 - Birmingham Social Worker (senior) OST - Opioid Substitution Treatment NICE - National Institute for Clinical Excellence SPMW1 - Specialist Midwife 1 SPMW2 - Specialist Midwife2  OASYS - Offender Assessment System (Probation) ICS - Integrated Children’s System (electronic social care system)  (RAA1): Referral and Advice Officer; (Birmingham) IASS: Integrated Advice Support Service (Birmingham) MASH – Multi Agency Safeguarding Hub (Birmingham) Academy 1-SFH’s school TA –Teaching Assistant (at Academy 1) AM - Attendance Manager (at Academy 1) DC2 - Detective Constable 2 (West Midlands Police, burglary squad) DC1 - Detective Constable 1(West Midlands Police, Public Protection Unit) ADS - Acting Detective Sergeant (West Midlands Police, Public Protection Unit) CAIU - Child Abuse Investigation Unit (West Midlands Police) HMIC: Her Majesty’s Inspectorate of Constabulary  SMART - Specific, Measurable, Achievable, Relevant, Timely Final Version 21.03.16 102  References Department for Education (2013) : ‘Working Together to Safeguard Children’ Department for Education (2015) : ‘Working Together to Safeguard Children’ Advisory Council on the Misuse of Drugs (2003): ‘Hidden Harm’ Adfam (2014): ‘Medications in Drug Treatment-Tackling the Risks to Children’  Social Care Institute for Excellence (SCIE): (2008): ‘Learning together to safeguard children, developing a multi-agency systems approach for case reviews’. A Preston: ‘The Methadone Handbook’ (11th Edition); Exchange Supplies.org NHS Lothian (2003): ‘Substance Misuse in Pregnancy: A Resource Pack for Professionals in Lothian’ Dudley Safeguarding Children Board: (2007): Maternal Substance Misuse During Pregnancy  Sandwell Safeguarding Children Board: Guidance: ‘Children of Drug Misusing Parents Department of Health; (2007): Drug Misuse and Dependence; UK guidelines on clinical management General Medical Council (2012): ‘Protecting Children and Young People’ Ofsted (2012): Birmingham City Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’  Ofsted (2014): Birmingham City Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’  Ofsted (2010): Sandwell Metropolitan Borough Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’.  Ofsted (2013): Sandwell Metropolitan Borough Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’.  Ofsted (2015): Sandwell Metropolitan Borough Council, ‘Inspection of services for children in need of help and protection, children looked after and care leavers’.  Ofsted (2010): ‘The Voice of the Child: Learning Lessons From Serious Case Reviews’ Le Grand. J et al: (2014): ‘Report to the Secretary of State for Education and the Minister for Children and Families on Ways Forward for Children’s Social Care Services in Birmingham’. Final Version 21.03.16 103  Birmingham City Council; Children Social Care Improvement Plan 2014-2017.  Birmingham City Council (2013): ‘Integrated Transformation; Our Strategy for Improving Services for Children and Young People in Birmingham’.    HMIC (2014): ‘National Child Protection Inspections: West Midlands Police 2-13 June 2014’                           Final Version 21.03.16 104  Appendix 1  Scope of the SCR and Terms of Reference Key Issues  1. The Review will consider each agency’s contact with Subject Child, half sibling, Mother, Father, Maternal and Paternal Grandparents and any other known adults living in the household and the nature of that contact in terms of how well FH’s needs were identified and recognised  2. The Overview Report will consider relevant research and previous Serious Case Reviews, based on a West Midlands wide learning event and the outcomes of previous West Midlands SCRs related to the ingestion of methadone where circumstances were similar and make recommendations if appropriate in relation to this for Birmingham and the Region.  3. The Panel will consider how and when the most appropriate method of securing family members involvement with the SCR process whilst adhering to BSCB’s guidance on the involvement of family members and being mindful of the criminal investigation.  The Panel Chair will be responsible for arranging liaison with the family with the support of West Midlands Police Family Liaison Officer. Consideration should be given to whether it is possible to talk in particular the Subject child’s half-sister taking into account the potentially traumatic nature of such a conversation.  4. Consideration has been give to the racial, cultural, linguistic and religious background to this case and there does not appear at this stage to be any factors that impact on immigration status.     5. BSCB will obtain legal advice as necessary. Current BSCB legal advice relating to SCRs and other publication will be adhered to.  6. The CCG will notify the Local Area Team of NHS England of the Serious Case Review through the Sudden Untoward Incident system.    7. Relevant information to emerge from criminal proceedings will be taken into account by SCR Panel.  The police representative on the panel will be responsible for liaising with the CPS.  8. The social care representative will be responsible for provision of information from family proceedings.  9. Public and media enquiries will be handled by the Chair of BSCB.  10.  Agencies will implement the learning from this case prior to publication  11. Health Forum to review emerging findings for Health Organisations and advise on the most effective way the learning can be taken forward.  Final Version 21.03.16 105    At the conclusion of the Serious Case Review agencies will debrief those staff involved in the case, BSCB will disseminate the key learning from the case through a series of targeted seminars and Senior Managers in each agency will be asked to audit the impact of applying relevant learning within a year of finalising the draft report.  Learning Events Following the panel’s deliberations and draft hypotheses and the production of a draft overview report the panel should organise two learning events, to   1. Work with middle managers in each agency to consider the implications of the overview report for their services   2. Work with representatives of each West Midlands regional LSCB’s to look at the learning from similar SCR’s over a 5 year period in the region and identify regional learning and recommendations  Case Specific Terms of Reference (ToR)  ToR 1 What tools were used by practitioners to evaluate and assess the mother’s capacity to parent safely in the light of her alcohol and substance abuse? Was the degree to which that abuse could compromise her ability to parent safely taking into account in decision making?  ToR 2  To what extent did practitioners understand and investigate the risks to the children and act on them, in particular considering maternal alcohol and substance misuse and the presence of males in the home?  ToR 3 To what degree were both children’s wishes and feelings, the voice of the child and needs for protection recognised and acted upon by practitioners?  ToR4  Did agencies undertake formal interventions to safeguard the children appropriately? If they did, were they effective? If not, why did they not happen?     Final Version 21.03.16 106  Appendix 2- SCR Panel Membership  This comprised of senior representatives from the following agencies,   • The Independent SCR Panel Chair • Birmingham Children’s Social Care • Birmingham South Central Clinical Commissioning Group (CCG) • Birmingham and Solihull Mental Health Trust • Birmingham Clinical Commissioning- Public Health-Substance Abuse Service • Birmingham General Practice Service • West Midlands Police • Consultant Paediatrician • Birmingham Early Years’ Service • Dudley Safeguarding Children Board  Representatives from Sandwell and Worcestershire Safeguarding Children Boards were invited to be part of the SCR Panel but declined. Administrative support was provided by the Birmingham Safeguarding Children Board business unit.                                Final Version 21.03.16 107  Appendix 3  List of Agency Individual Management Reviews  1. Crime Reduction Initiative (Substance Misuse Service) - CRI-Dudley Adult Integrated Recovery Services 2. Dudley Group NHS Foundation Trust-Specialist Midwifery - Substance Abuse and Drug Liaison service 3. Sandwell and West Birmingham Hospitals Trust (Primary midwifery) 4. Sandwell and West Birmingham Hospitals Trust (Health Visiting) 5. South Central Birmingham Clinical Commissioning Group (GP services) 6. Staffordshire and West Midlands Probation Trust 7. Sandwell Children’s Social Care 8. Worcestershire Health and Care NHS Trust (Health visiting)  9. Birmingham People Directorate-Children’s Social Care 10. West Midlands Police 11. Academy 1 (Secondary school)                                  Final Version 21.03.16 108  Appendix 4- Key Practice Episodes  1. Why was there no pre-birth assessment of risk and need undertaken on FH (and SFH) during the ante-natal period, given Kelly Emery’s methadone use and substance abuse?  (Kelly Emery, during the ante-natal period, was in contact with the specialist midwifery service, the GP, the Probation service, the Police, Russells Hall Hospital and Atlantic House: SFH had been on a child protection plan to Sandwell CSC in 2009 and this agency was aware of his birth to Kelly Emery). Analyse this KPE from a multi-agency perspective in terms of what individual agencies knew about Kelly Emery and family and what they could have done.   2. Why was there no post-birth assessment of risk and need undertaken on FH (and SFH), given Kelly Emery’s methadone use and substance abuse? (The family had involvement with the Probation service, Sandwell CSC, the health visitor, community midwifery, Atlantic House, School. Probation made a referral to Sandwell CSC on 20.07.11 regarding concerns about Kelly Emery and her partner’s methadone use.) Analyse this KPE from a multi-agency perspective.  3. Why was the referral to Birmingham CSC in August 2012 not followed through for action to an assessment? Why was the second referral of the 22.04.13 and the subsequent Initial Assessment unsatisfactory and prematurely closed? Why was it not effective? (Were these missed opportunities to safeguard and promote the children’s welfare? Why wasn’t SFH seen and her voice heard? Why weren’t other sources of corroboration of concerns explored-neighbours, family? Why wasn’t the professional making the referral (the Police officer) spoken to? The need for professional curiosity and the danger of an overly adult focused approach despite knowledge of Kelly Emery’s parenting status. Also, consider the earlier NSPCC referral in March to Birmingham CSC.)  4. Why did Fenton’s GP not share information about Kelly Emery’s methadone use when referring the child to BCH on the 26.04.13?  5. Why wasn’t a holistic and up to date awareness of Kelly Emery’s overall progress in addressing her substance misuse (drug addiction) maintained?  (Maintaining timely reviews of Kelly Emery’s engagement with the drug services-including her voluntary drug testing, via the drugs agency rather than solely dependent on her self-reporting. Ensuring the right questions are being asked of other key professionals. For example, is the mother undertaking voluntary drug testing? How often is this taking place, what are the results? Are there any particular issues that can be addressed by agencies jointly? The need to ‘Think Family’.) Final Version 21.03.16 109   6. Why did the police intelligence reports of January and November 2012 and January 2013 on Kelly Emery not generate child abuse non-crime numbers and referrals to the Public Protection Unit and Birmingham CSC?          (Analyse what happened and why? What systems changes have been made to assess intelligence and communicate it back to police officers to take action to protect vulnerable children? Issue of ‘Safe and Well’ checks?)                                        Final Version 21.03.16 110  Appendix 5   Birmingham Children’s Social Care Improvements made to the ‘Front Door’ Services ‘Since the introduction of MASH (Multi-agency Safeguarding Hub) in July 2014 there has been a marked increase in partner confidence that the local authority will  respond to safeguarding concerns as expressed by partners. This is evidenced by a 60% increase in contacts and increased referrals. Children on Child Protection Plans have increased and are now comparable to National and statistical neighbour averages.  Work has been undertaken internally and with partners agencies in understanding thresholds by holding MASH/Right Service RightTime roadshows.   Monthly Independent multi-agency auditing of the front door takes place which report consecutive improvements.   Threshold consistency is a constant theme for practitioner workshops and the service proclaims that Birmingham is “Safer but not yet safe”   The voice of the child is well understood by practitioners and a recent Ofsted improvement visit reported that the voice of the child is evident in our work.   A new quality assurance framework has been introduced which has the voice of the child as a measure in every audit undertaken. Quality of assessments have improved in some large part by reducing and capping caseloads, currently at 23 children to reduce to 21.  We have implemented Voice of the Child Project which includes (that) managers will not sign off assessments unless the voice of the child is evident, this includes tools of observation and behaviours of parents with pre-birth and none verbal children.  Dip sampling would suggest performance is much better although still not evident in all cases.  Managers undertake five audits a week and we are currently producing learning themes.  We have also developed an audit for monitoring outcomes from strategy meetings’.                    Final Version 21.03.16 111  Appendix 6  West Midlands Police –Practice Improvement Actions   The agency states that,  ‘A substantial amount of improvement work has already taken place within WMP, since the death of Fenton and following on from the requirements, following the HMIC inspection in June 2014.   .     1.   Improving West Midlands Police Service to Children (See paragraphs 298-305 in SCR Report)  WMP Public Protection Unit (PPU) have delivered a presentation entitled ‘Improving our services to children’, to all officers and staff across all departments within WMP.  This presentation has been complimented by the issuing of an Aide Memoire, which reinforces the referral steps that all employees should take if they encounter a scenario where a vulnerable child is apparent.     Current additional developments include significant work with colleagues in ensuring WMP have a definition of vulnerability against which the service can operate and be held accountable for. Linking to this has been significant work regarding developing the THRIVE model for dissemination into WMP and staff psyche.  This model is aimed at encouraging officers and staff, regardless of rank or role, to consider what additional and wider Threat, Harm and Risk may be apparent to help Identify Vulnerabilities that necessitate partnership intervention and Engagement, aside from the job that they are actually faced with.  (Clearly in this case WMP had a pregnant mother coming in and out of custody with a drug dependency, who was shoplifting and turning to prostitution, with children in her care that the service failed to pick up).  This then all links with the flowchart that the author has discovered, which was referred to at the last panel, which the NHS National Treatment Agency have developed.  This could be adapted to incorporate the THRIVE approach?  WMP currently have key leads in force under the prevention strands of work and partners have been consulted regarding the approach THRIVE brings and currently a unanimous agreement in utilising this approach has been recorded. The force Learning and Development department has then been consulted and subsequently commissioned to develop and design a THRIVE approach in all training – focussing especially on  courses around Sentinel (See explanatory notes attached) and the key themes identified within this scope. This was  trialled initially in  June 2015 and it has been identified that there needs to be some further development of the material to influence behaviours/thinking as well as how WMP influence partnerships in terms of early intervention, referral and any intervention/engagement.  Final Version 21.03.16 112  This work is also factored into a key development and training approach in Force Contact, the department that handles all calls/face-to-face contact with the  public at the police stations along with our control room staff.  The WMP approach to ‘risk frameworks’ is a key part of the 60 day accelerator programme under WMP’s 2020 programme with Accenture.  Therefore whilst work will continue to be developed around the THRIVE model it has to blend into the structured delivery under the 2020 work streams. It is recognised that there is a need for cultural and behavioural changes in our approach to, recognition of and action to mitigate prevent, reduce risk/vulnerability and potentially for THRIVE becoming part of WMP psyche in this approach.   The work to formally bring THRIVE (or an appropriate alternative framework) into WMP actually starts Mon 6 July and will gather momentum.   2.       Early Help (EH) & MASH  In essence, most local authorities across the West Midlands now seem to be moving towards a MASH/EH approach within social care change programmes.  The “PVVP” document attached contains current assessments of where each LA area is currently at.    An Assistant Chief Constable (WMP) now chairs an internal governance group covering WMP responses to both concepts. A Chief Inspector has been asked to co-Chair the Birmingham Early Help Partnership which meets for the first time on the 20th July and he will work through developing a city wide offer across the partnership.  It is anticipated that this approach, once agreed for Birmingham will be shared with the other 6 local authorities across the Midlands for consideration and possible adoption     3. Criminal Justice /Safer Custodial Detention    A substantial amount of work around Safer Detention and vulnerability has been completed over the past 12 months within WMP focusing on the detention and treatment of juveniles whilst they themselves are in custody.  In this instance, Kelly Emery was in and out of police custody both during and post her pregnancy for drugs/shoplifting offences.  As an organisation, WMP dealt with her for the matters in hand but failed to notice the child suffering from harm in the background.    Final Version 21.03.16 113  In the below scenario the emphasis very much currently sits with the Officer in Charge (OIC) to ensure that there were no issues with dependents whilst the detainee was in custody, although the question would be asked of the detainee by the custody staff whilst delivering their rights and entitlements and conducting the risk assessment/necessity test.  As part of the risk assessment process any detainee with a Class A substance abuse problem should also have been referred to the Drug Intervention programme.  However, I believe that there is a necessity for the force to strengthen its approach and learn lessons from the Fenton Hogan case in this regard.    4.    Encourage officers and staff to have the confidence to escalate a challenge when a partnership response to a concern does not feel right (as per paragraph 305)  The West Midlands regional escalation process is currently out for consultation across all seven local safeguarding children’s boards   5.     Requirement to further strengthen National Intelligence Model (NIM) processes and the knowledge management side of things (capturing/developing/sharing/disseminating to ensure effective use of organisational knowledge and engender a multi-disciplined approach.  WMP have been on this journey around CSE but I think that there is still opportunity for WMP to develop capturing the wider risk implications around vulnerability that is not overtly obvious and subject of a crime/non-crime number.i.e. the custody scenario surrounding Fenton’s mother with Fenton slipping through the cracks in the background.  Clearly one of the issues highlighted within the SCR is the interoperability difficulties around internal IT systems (see paragraph 295).  Although there is no overnight fix for this, work is already in hand to bring wholesale change in enhancing WMP’s approach towards protecting children in the guise of the WMP2020 project, a fundamental change programme delivered in partnership between WMP and Accenture, which was launched in early 2015.  A Blueprint has been developed which is a target for how West Midlands Police will operate by 2020. The Blueprint gives an indication of what policing within the West Midlands will look and feel like. It also describes how the organisation, services, processes and technology will all work together.  The development of the Blueprint has involved extensive internal and external consultation and has drawn upon Accenture’s experience with other police services as well as with other public and private sector organisations.     Final Version 21.03.16 114  Three main areas WMP2020 is focusing on are:  1. A programme of work to deliver wholesale change.  2. Business change – preparing the workforce to get ready for the changes coming over the next five years  3. ICT – ensuring WMP have the right technological infrastructure to be able to deliver a new service Underpinning all of this is a communications and engagement plan’.                                      Final Version 21.03.16 115  Appendix 7  Protocol for Adult Substance Misuse Services Working with Parents Adapted from Public Health England, 2013        Final Version 21.03.16 116       