Serious neglect and physical and emotional abuse of a 9-year-old boy and his siblings by their parents. Bilal (known as Billy) had not been seen by any professional since the age of 14-months and had not received education, health or social care services to meet his diagnosis of autism. Children were removed from state education and faith schools to be electively home educated. Parents believed spirit possession had caused Billy's autism and sought faith-based treatment overseas. Older sibling emailed Childline after concerns about Billy's declining health and possibility that parents would take family to Africa. Police attended and took children into police protection. Parents arrested and serving custodial sentences for child cruelty. Learning includes: the role of neighbours and local communities in recognising and responding to concerns about children and young people; areas that usefully inform practitioner learning and improvements in practice include taking a child-focused approach, cultural sensitivity and professional curiosity; contact with the family at transition from health visiting to school nursing services can help determine 'school readiness' of a child and to identify unmet needs. Billy is Black British of African heritage. Recommendations include: identify how to report and share information about children who have not been seen for a significant amount of time and triangulate whether there are further concerns across agencies; ensure that children and young people who are home educated can access help and support to meet their needs via the current children and young people section of the LA schools and learning webpage.
      
    Serious Case Review No:  2020/C8152  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    1       Serious Case Review    Bilal      Final 2019   Lead Reviewer & Independent Author Catherine Powell, Child Safeguarding Consultant   2        ‘Parents should continue to have the right to home educate their children, but stronger safeguards are required to ensure the child’s right to a decent and suitable education for life in Britain, and to protect them from harm.  The evidence we have seen in this review shows it is too easy for children to be raised in a totally secluded environment that does not provide a suitable education or sufficient protection from harm.  One case of this happening is one too many.’  Dame Louise Casey, 2016. The Casey Review: A review into opportunity and integration London: Department for Communities and Local Government. page 120.    3  Executive Summary  This serious case review concerns Bilal (known as Billy), a nine-year-old, black British child, of African heritage, who has significant developmental and communication needs.  Billy was found, together with his siblings, to be suffering from serious neglect and physical and emotional abuse.  He had not been seen by any professional since the age of 14 months, was not known to the local education authority, and was not, and never had been, in receipt of education, health or social care services to meet his additional needs and diagnosis of autism. A belief in spirit possession had led to Billy’s parents seeking faith-based treatment for him overseas.    Over time, Billy’s siblings had been variously removed from state and independent faith schools to be electively home educated (EHE).  A critical feature of this case is that the family had been ‘hidden from view’, with all the children effectively prisoners in their own home.  Frequent ‘physical chastisement’ included being jabbed, pinched or hit with cables, wooden spoons and wet cloths. Emotional abuse reflected mother ‘screaming, threatening, interrogating, accusing and insulting’ the children.  Billy was particularly vulnerable to this abuse; and this has impacted on his genetic disposition to autism.    The overarching principles that inform the review relate to the degree to which Billy and his siblings’ rights as set out in the United Nations Convention on the Rights of the Child (UNCRC)1989 (to which both the United Kingdom (UK) and his family’s country of origin are signatories) have been respected, protected and fulfilled.  There were found to be serious omissions in the parental care of these children.  At the point of rescue, all the children had multiple unmet health, educational, developmental, nutritional and social needs.  The question of whether there could be other children, like Billy, has served as an important focus for the review.  The overview report, which draws on the contribution of the family and practitioners, concludes with a number of learning points and recommendations that  seek to identify opportunities within ‘the system’1 to provide a timely response to children who may be deliberately hidden from the professional gaze.  Included here is a recommendation to be shared with the Department for Education and national panel to develop the on-line resources made available to electively home educated children in the provision of a ‘help’ button on the online learning provider landing/home page.  This would enable children to gain advice and/or easily link to other online sources, such as Childline, or advice on e-safety.  Billy and his siblings endured serious physical and emotional abuse and neglect at the hands of their parents over a period of many years. That this could happen anywhere and reflects the tensions between enabling the rights to a private and family life and taking action to safeguard and protect the welfare of children.  The key learning point from this review is that the balance should tip towards ensuring the rights of the child to education, welfare and protection.     1 Primarily mainstream health services and provision for children who are EHE.  4   Acknowledgements As lead reviewer and author of this report, I would like to acknowledge the help and support of the serious case review panel, LSCB officers and staff.  I would also like to express my appreciation for the insight of the practitioners who contributed their perspectives to the learning from this review.  Particular thanks go to the neighbourhood police officer who shared extensive knowledge of the African community and arranged visits to a number of local services.  I would like to thank Bilal’s elder sibling for making a significant contribution to the background and context for the review, and in the co-creation of the recommendations.  Thank you, and your other siblings too, for reading and commenting on the final draft of this report.  Finally, thank you to Bilal (and to your carer), for providing insight into your new life and the plans for your future. Governance I declare that I have found no conflict of interest in completing this review, and that I am independent to Local Safeguarding Children Board (LSCB) and partner agencies.  The report has been commissioned by, and written for the LSCB, and overseen by a multi-agency serious case review panel of local senior managers and practitioners. This included a cultural advisor with knowledge of the family’s faith.  In preparing this report for publication, the details of the child and their family, and the individuals providing care to them, have been anonymised in accordance with statutory guidance and best practice.   Catherine Powell Child Safeguarding Consultant 2019     5  Foreword Response from the Chair, Local Safeguarding Children Board This serious case review concerns a young disabled child who for most of his nine years was kept ‘hidden from view’ from the eyes of the community in which he lived. He was denied access to basic health services, education or any other support for his complex needs, resulting in delayed development.   The physical neglect, abuse and emotional cruelty that both he and his siblings were subjected to at the hands of their parents (both who have now received prison sentences) as they were effectively kept prisoners in their home is shocking.  The fact that the siblings were removed from state and independent faith schools and then home educated has raised some significant learning points locally about how it is possible for children to go missing not just from education, but also from universal health services, and the community. The recommendations found at the end of this review have raised some pertinent points for local practice but should also be of national interest at a time when the numbers of children who are home education are rising. The bravery of the children involved is to be commended and their willingness to share their experiences has informed this review.  Independent Chair Local Safeguarding Children Board    6    Contents 1.0 Introduction 7 2.0 Methodology 9 3.0 Family background 10 4.0 Narrative chronology 12 5.0 Discussion of key findings 14 6.0 Learning points for consideration by the LSCB 25 References 28 Glossary of abbreviations 31 Appendix One: Key lines of enquiry 32 Appendix Two: Documents accessed to inform the review 33 Appendix Three: Learning from the Practitioner Event 34      7  1.0 Introduction 1.1 This overview report sets out the findings of an independently led serious case review (SCR) commissioned by the Chair of Local Safeguarding Children Board (LSCB) in 20XX.  The review concerns Bilal, (known as Billy)2, a black British child of African heritage, who, aged nine years, was taken into police protection3 (as were his siblings), having found to be suffering from serious neglect and physical and emotional abuse.   Parents were arrested and are now serving custodial sentences for child cruelty. 1.2 Billy and his siblings’ removal from the family home and subsequent public law care proceedings followed an elder sibling’s contact with the national charity ‘Childline’.   The response by lead statutory agencies (Children’s Social Care and Police) to the concerns raised was swift and effective.   1.3 A critical feature of this case is that Billy, who has significant developmental and communication needs, was effectively ‘hidden’ from view, having apparently not been seen by any professional since the age of 14 months.  The effect of the toxic stress and maltreatment that all the children suffered has been recognised to have compounded Billy’s learning difficulties and his confirmed diagnosis of autism4.   1.4 Over time, Billy’s siblings had been removed by their parents from various state and independent faith schools to be electively home educated (a factor that forms a key line of enquiry for this review).  Whilst Billy may have had some limited early educational input at an unregistered school (run by a friend of his mother) he was not known to the local education authority and was not in receipt of education, health or social care services to meet his additional needs.  Billy had no meaningful routine in his daily life, including for mealtimes and sleeping (he did not have his own bed) and was significantly underweight. 1.5 Furthermore, neither Billy, nor his siblings, had been seen by universal or specialist health services for a period of several years.  This meant having no access to medical and dental care and a failure to receive a full programme of immunisations.  A sibling reported that Billy was frequently given medication (paracetamol suspension) when it may not have been required. Whilst there was otherwise an apparent rejection of health service provision, parents’ stated belief in spirit possession as a cause for Billy’s difficulties had led to them seeking faith-based treatment abroad. 1.6 An elder sibling described how all the children were effectively prisoners in their own home; hidden from view (blinds drawn), leaving once every three weeks or so to accompany their mother to the shops.  They were unable to socialise with peers, practice their faith outside of the home, or attend local leisure facilities.  Frequent ‘physical chastisement’ (mainly by mother) meant being jabbed, pinched or hit with cables or other items such as wooden spoons and wet cloths.  Emotional abuse reflected mother ‘screaming, threatening, interrogating, humiliating, accusing and insulting’ the children.  Billy was particularly vulnerable to this abuse.  2 Bilal/Billy is a pseudonym chosen by a sibling. 3 Section 46 Children Act 1989. 4 Paediatrician’s statement for Court hearing notes the impact of both genetic (constitutional) and environmental (traumatic) factors.  8  1.7 Opportunity to develop independence and self-reliance was virtually non-existent. At the point of rescue, all the children had multiple unmet health, education, developmental, nutritional and social needs. They were dressed in ill-fitting shared family clothing and lacked awareness of basic road safety.  Lack of daylight had impacted on their vitamin D levels and the inability to engage in outdoor exercise had seriously limited their development of gross motor skills. None of the children could swim or ride a bicycle. One sibling was described as ‘hunched and immobile’ and displaying signs of rickets. 1.8 It is a testament to the bravery and resilience of this cohesive sibling group, and the care and education that they are now receiving, that Billy and his siblings are making good progress, able to enjoy and achieve in the remaining years of their childhood, and be better prepared for their adult lives.   1.9 The commissioning brief was for a concise review that centres on the experiences of Billy and his siblings, but also asks questions of current practice and local and national policy, particularly concerning provision made for children who are electively home educated (EHE) or missing from education (CME).  At the outset of the review some key lines of enquiry (KLOE) were determined (see Appendix One).  The question of whether there could be other children, like Billy, who are invisible to services, and whose needs are currently unmet, has served as an important focus. 1.10 The review has followed the statutory guidance on the conduct for reviews as set out in Working Together to Safeguard Children (HM Government, 2015).  The report also reflects new guidance on the format for SCRs and child practice reviews, published during the review process (HM Government, 2019).5  A brief summary of the methodology, provided below, aims to provide transparency regarding data sources. 1.11 As with any review of a significant child safeguarding incident, the impact of cultural heritage and faith are considered in this report.  However, the overarching principles that inform the findings and analysis relate to the degree to which Billy and his siblings’ rights as set out in the United Nations Convention on the Rights of the Child (UNCRC)1989 (to which both the United Kingdom (UK) and the African country are signatories) have been respected, protected and fulfilled.   1.12 The UNCRC recognises that meeting the needs of children essentially rests with the nurturing roles and responsibilities of parents.  The Convention also recognises that Governments have a role in ensuring that support is offered to assist families who require help, and to make provision to ensure that children are protected from harm.  In the UK these principles inform legislation and policies for children, including (for England) the statutory guidance for inter-agency working to safeguard children. 1.13 The lived experience of Billy and his siblings reflects fundamental breaches of the UNCRC, including, but not limited to, the following: freedom of association (Article 15);  protection from all forms of violence (abuse and neglect) (Article 19);  the rights of children with disabilities to receive special care and support (Article 23); the right to good quality health care (Article 24); the right to education (Article 28) and the right to leisure, play and culture (Article 31).  The UNCRC provides the lens through which the children’s experiences,  5 Child Safeguarding Practice Review Panel: practice guidance was published by the Government in April 2019.  9  expectations of parental roles and responsibilities, and professional input to the family, may be judged.   1.14 The overview report concludes with learning points and recommendations for the LSCB.  It is important to recognise that there have already been some changes of process, either as a result of this case, or as a result of developments in practice and policy over the timeline for the review.  These include some changes regarding EHE, and in the commissioning and delivery of universal health services.  However, the possibility there are other children like Billy, withdrawn from the professional gaze, and at risk of harm, locally and indeed nationally, remains.  2.0 Methodology 2.1 Agency information and records available to inform the SCR was limited. This reflects the family’s low levels of engagement with universal health services, the withdrawal of the older siblings from school, and the fact that Billy was essentially unknown to the local authority education services.   2.2 At the outset, an integrated chronology of contacts with the family from the time of mother’s pregnancy with Billy until the children’s removal from home (Billy was nine and a half years of age at this point) was provided.  Information was also drawn from summary templates completed by agencies to inform decision-making at the LSCB’s review group and the subsequent commissioning of the SCR. 2.3 The chronology demonstrates that the following agencies, organisations and professionals had some contact with the family during the above period, albeit the health ‘contacts’ for the children (which included invitations to appointments that were not attended) ceased when Billy was three years old: • Maternity services (hospital) • Health visiting services • General practice • Education services (for elder siblings, but not for Billy) • Housing [added in course of review] • Neighbourhood services [added in course of review] 2.4 The family were not known to lead agencies (i.e. children’s social care and the police) prior to the removal of the children.  The limited case information has meant that an iterative approach has been taken, with additional searches, enquiries and wider systems analysis of policy and practice over time providing evidence to support the key learning.  Appendix Two provides a full list of the data sources. Child and Family Involvement 2.5 Billy’s significant developmental and communication difficulties were a limiting factor in gaining his contribution to the review.  However, with carer support, and the use of picture exchange communication system (PECS), a meeting was arranged, time was spent with Billy, and his progress and plans discussed.  It was also a privilege to be able to meet with Billy’s elder sibling, now a young adult, who provided vivid detail of life within the family home and the decision to contact Childline.  This young person was keen to share ideas for  10  the learning and improvement from the review and, where possible, these have been incorporated into this report.   2.6 Parents were invited to contribute to the review.  The children’s mother did not feel able to contribute.  Having agreed to meet and having travelled (with the board manager) to the location, father subsequently refused to speak to us, despite the best efforts of his offender manager.   2.7 Both parents were subsequently contacted by letter, with some questions set out, that sought to provide an opportunity for gaining their insight and contribution to the review.  No responses were received.  This is regrettable, as gaining their perspectives on what happened and why, and how services might learn and improve from this (particularly in the provision of care to families from the African communities) is a critical omission in the report. Practitioner involvement 2.8 Practitioner involvement was key to developing meaningful learning from the review.  Given the timescale from mother’s pregnancy with Billy to the children’s removal, the time frame for the commissioning of the SCR, and the fact that this was a family who had largely been hidden from view, a decision was made to hold a multi-agency practitioner event towards the end of the review process to share Billy’s story and test out the emergent learning and recommendations.   2.9 The majority of those attending the practitioner event had not had direct contact with Billy, or his family, during the timeline of the review; albeit colleagues from children’s social care who provided services after the removal of the children were present and provided a helpful input.  A full list of practitioners who attended, by job role, and a summary of the output of this event is provided in Appendix Three.   2.10 Of immense value, was an opportunity early in the process for the author to spend a day with a neighbourhood police officer in the locality.  This enabled an understanding of local provision, including housing, as well as insight into the daily lives of the African population. 2.11 In addition, the reviewer met with the lead midwife for child safeguarding to review parents’ engagement with maternity services.  This meeting incorporated a useful discussion on broader safeguarding and cultural aspects of maternity care, including provision of interpreter services.  The service has put in place improvements to meet the mental health and social and emotional care of women over the timeline.    3.0 Family Background 3.1 Billy was born in the UK. His family originate from Africa and, in common with others from the African country’s community in the local area came via Europe as economic migrants.  The parents, who are married, had been in that area, living in the same property, for nearly 20 years.  Father was in paid work and mother did not work outside of the home.   3.2 Mother’s adverse experiences in her homeland have been more recently reported to have led to a post-traumatic stress disorder.  To protect the family’s privacy, and reflect an approach taken in a recently published SCR, elsewhere, further details of these events are withheld (Hertfordshire Safeguarding Children Board, 2019).  11  3.3 The family, along with many others in their community, live where places of worship and supplementary faith schools are located within the neighbourhood.  This area is widely recognised as one of the most deprived in the UK.  3.4 The locality is a mixture of council rented, ex-local authority (private rented) and leasehold properties comprising mainly blocks of flats and maisonettes, with some shared outside space.  Community facilities such as shops, a library, sports centre and parks are in walking distance, as is the local state primary school.  The poverty of the neighbourhood is palpable. 3.5 Although there are believed to be no extended members of the family living in the UK, the parents have a network of friends and contacts locally.  The strong African tradition of sharing and supporting each other (Salad Ganey, 2007) is evident within the local community.  Opportunities for socialisation are generally enjoyed outside of the home and, in keeping with their culture, single-sex groups and clubs, abound.   3.6 Billy is the youngest sibling in this large family6.  His eldest sibling was removed from the local school by parents, at the age of seven years, to live with a grandparent in Africa.  This child had been seen by health visitors at the age of four and a half years, when their development was assessed as being normal. They were also known to the education department and attending ‘local schools’ until 20XX, when they were recognised as a child missing education (CME).   3.7 The date of the removal of the eldest sibling is believed to be 20XX and, retrospectively, concerns have been raised that the reason for their repatriation was linked to a learning disability, which featured similar symptoms to those seen in Billy.   3.8 The existence of the eldest sibling (now an adult) did not feature in some agency records; although details of the birth were present in the maternity records.  This child was not mentioned to professionals at the time of the removal of the other children from the family home.  The significance of this finding will be discussed later in the report. 3.9 Today, Billy presents as a very active child, with a happy demeanour.  He attends to his daily needs (e.g. dressing and hygiene) and has a regular pattern of eating and sleeping. Billy has his own bedroom, which is full of his favourite toys (mainly jungle animals, cars and lorries).  He is physically fit and well; has gained weight and takes part in a range of outdoor activities.  Billy enjoys swimming, rides a scooter and will shortly be learning to ride a bicycle.   3.10 Although essentially non-verbal, Billy can make his needs known, and is making progress with the use of PECS.  He has a mutually warm relationship with his main carer.  Billy attends a special school and is reported as making progress and friendships.  He sees his siblings on a regular basis. 3.11 Billy’s faith and cultural heritage needs are met within his care setting.  For example; festivals are celebrated, an appropriate diet provided, and he has access to relevant books.    He has continuing safety and wellbeing needs, and it is highly likely that he will require ongoing care and support into adulthood.  6 Details withheld to protect the family’s identity.  12  4.0 Narrative chronology 4.1 Billy is the index child in this case review.  This section seeks to provide his story from the perspective of agencies involved in his care.  Where relevant, reference is made to seminal moments in the lives of his siblings, most especially the move from state education, to (several different) independent faith schools, to elective home education.  As noted at the outset, Billy may have had some early access to an unregistered school (run by a friend of his mother), but he was essentially not known to the local education authority. None of the children attended pre-school provision (e.g. nursery).   4.2 As with her previous pregnancies within the UK, Billy’s mother attended for antenatal care and delivered her son in a hospital setting.  Her engagement with maternity services was described as ‘exemplary’ and this was reflected in a scrutiny of the records.  All the babies were noted to be ‘large for dates’ and born by normal delivery.  Mother and son were discharged home, the day following Billy’s birth, to the care of community midwives.   4.3  A home visit by the health visitor followed when Billy was 19 days of age. He was subsequently seen once more at home by a nursery nurse from the health visiting team and then at the baby clinic for weighing on four occasions; the final recorded weight was when he was two months old.  Billy’s growth pattern at this time was entirely in keeping with the expected trajectory for his birth weight. 4.4 Billy was seen by the GP, aged six weeks, for a routine developmental check.  There were no concerns about his well-being or development at this stage; he was noted to be smiling, making eye contact and was breast fed. 4.5 During the first year of life, Billy was also taken to the GP practice for immunisations, including BCG vaccination (to protect against tuberculosis).  However, as with siblings, his programme of immunisations was incomplete.  At eight months of age Billy was referred for an audiology assessment but was not brought (WNB) to the subsequent appointment.  It is unclear how these missed health appointments were followed up. 4.6 The last recorded contact that Billy had with a health professional was when he was 14 months of age.  On this occasion he was seen by a GP for viral gastroenteritis; an essentially self-limiting condition, and prescribed rehydration medicine.  At two years of age parents were sent a developmental questionnaire by the health visiting service.  It is uncertain if this was completed, or returned, and it does not appear that Billy was seen at this time.   4.7 Billy’s recorded birth order on case notes suggests that the existence of the eldest sibling (who was said to be with maternal grandmother in Africa) was not fully shared with health agencies involved at around the time of his birth (health visiting and GP). 4.8 A similar pattern of engagement with universal health services in the early years is evident for the other siblings; albeit there was a little more contact, that continued for slightly longer, for the older children.  Nevertheless, a striking feature of this case, described as ‘remarkable’ in the children’s paediatric medical assessments, was the fact that they had not been taken to a GP or any urgent care services (e.g. emergency departments) for periods ranging from four to ten years.  13  4.9 When Billy was a month old, an investigation was started by education authorities into the whereabouts of an older sibling, who was identified as a child missing education.  This investigation was reported to include enquiries made to ‘housing and other agencies’ and a home visit (doorstep) was made by an education welfare officer.  Having been at a state school, this sibling was entered onto the roll of a faith school, before once again being identified as a CME.   4.10 The sibling was subsequently recorded as electively home educated after briefly being on the roll of two other schools.  This apparently included arrangements for part-time education, although this was not known to have been provided by a LA registered school.7  Schooling of the other siblings followed a similar pattern of being ‘on-roll’ and ‘off-roll’ at different schools and eventually being withdrawn for EHE.   4.11 The Education Welfare Service have reported that they established the education provision of each known child at the various points when the children were flagged as possible CME or home educated.  Contacts included doorstep visits to enquire about the children’s education provision (these resulted in schools confirming the children were on roll).   4.12 At the point at which the children were withdrawn from school, a home-visit was undertaken by an EWO, who met with the father and two siblings to discuss their plans for home-education.  This visit took place just over a year before the children were removed into care. 4.13 In summary, the findings from this visit noted that the children were making progress in their study through an on-line provider; subjects included English, Mathematics, Science, History, Geography and Citizenship, that they visited the library ‘constantly’, attended a community college, played football with friends in the park and sports centre, and attended place of worship with their friends.  The children were spoken to in the presence of the father. 4.14 The reasons for EHE were reported by father to be cost (i.e. cheaper than the faith schools) and the quality of the resources available from the on-line provision.  There was not, and had never been, any indication of the practice of school-led ‘off-rolling’ (Children’s Commissioner, 2019; Ofsted, 2019).  No concerns were raised by the father about the previous schools indeed they were reported to be ‘excellent’.  The recall of the circumstances of this visit from the sibling’s perspective is discussed in the next section.   4.15 Information received from the neighbourhood services during the review was that there was one recorded visit, of one of the children, to the library in 20XX.  No evidence was found to support the siblings’ stated attendance at the sports centre. 4.16 Housing services, who contributed a chronology of contacts once the review was underway, were represented on the review panel.  Their contribution showed significant contact with the family; which was said to be standard for the type of housing and issues faced by tenants.  Much of the contact was office or telephone-based, but there were also  7 Flexi-schooling provides part-time education to EHE pupils, with the agreement of the Head.  These schools should be registered with the LA; in this case there was no LA record of flexi-schooling provision for the siblings.  14  home visits for repairs in 20XX and 20XX.  This included work on a kitchen appliance, central heating, light fittings and a shower repair.  4.17  In early 20XX, following a very detailed email to Childline, sent by the older sibling, police and social care attended the property, and removed the children into police protection.  The catalysts for the email included the siblings growing concern about Billy’s welfare (he had been quite unwell) and a suspicion that parents were planning to take all the siblings out of the country.  4.18 Initially parents denied Billy’s existence to the officers at this visit; he was in found in an upstairs room. Father gave Billy’s age as seven years (he was nine and a half years).  No mention was made of the eldest child.  The subsequent strategy discussion noted ‘we are dealing with a family that have been hidden from public view, stopping contact with anyone who is a professional’.   5.0 Discussion of key findings  5.1 Parents actively sought to hide Billy from professionals. In doing so, they denied him access to the specialist health and education services he required to support his special needs and to a friendship group with his peers.  He, like his eldest sibling, had become ‘invisible’. 5.2 Even, without the benefit of hindsight, this review raises potential concerns about the provision of universal services to Billy and his family, and the role of these services in recognising and responding to child safeguarding concerns.  The chronology exposes some gaps in provision and missed opportunities to intervene.  When the contributions of the sibling are also considered, the opportunities to learn and improve, are striking.  5.3 The agencies that come under the spotlight are health services (general practice, health visiting and school nursing); education (provision for children who are EHE and safeguarding practice in faith schools) and housing (safeguarding roles and responsibilities).  However, there are also important considerations regarding the role of neighbours and the local community and how they can be engaged in both supporting children and families and in reporting concerns.  5.4 In considering the context for practice, it is helpful to acknowledge the demographic pressures on the provision of services, as well as other factors that impact on workforce and service delivery.  These include issues affecting deprived communities, which are widely recognised to present significant challenges to multi-agency child safeguarding arrangements, and in protecting those children who are at risk of, or experiencing, neglect. 5.5 The area has experienced a higher than national average birth rate and a significant increase in the numbers and proportion of school-age children in the population. One in seven children have a special educational need or disability.  When these statistics are combined with high indices of deprivation, poor housing, and a greater proportion of those from black and minority ethnic groups, the pressure on the provision of health and other services for children and their families is understandable. 5.6 In seeking to find out what happened and why, it is also vital to recognise that practice and policy across agencies will have changed over the timeline for the review (10  15  years), with changes to EHE policy an ongoing feature.  Drawing on the contribution of his sibling, the discussion that follows seeks to offer a deeper understanding of what happened to Billy and to highlight the opportunities for learning and improvement from this SCR. Health 5.7 At the time of Billy’s birth, the provision of universal child health services reflected the framework provided by the ‘child health promotion programme’ set out in standard one of the National Service Framework for Children, Young People and Maternity Services (Department for Education and Skills, Department of Health, 2004).8  Health professionals delivering the programme include midwives, GPs, health visitors, school nurses and their teams.   5.8 The child health promotion programme aimed to move away from what had previously been a narrow focus on health screening and developmental reviews to a broader programme of support to children and their families that sought to address the wider determinants of health and reduce inequalities.  There was a renewed emphasis on the role of local authorities in supporting families and in early intervention.  Partnership and collaboration with parents were seen to be key. 5.9 Whilst Billy’s parents’ engaged with maternity services and attended well-baby clinics and GP appointments with Billy and his siblings in infancy (or as very young children), the review has found a marked withdrawal in accessing mainstream health services for all the children after this, with evidence that immunisation programmes were not completed, and routine and specialist appointments unattended.   5.10  Billy’s sibling told us how parents’ increasing reluctance to access services (which included dental and optical services, as well as general practice) had impacted on their own wellbeing.  They also discussed how their increasing concerns about Billy’s deteriorating health acted as a catalyst for contact with Childline.   5.11 Failing to ‘ensure access to appropriate medical care or treatment’ for children is recognised in the statutory definition of neglect (HM Government, 2015: 94).  As noted earlier, the children’s lack of contact with health services during their childhood is a ‘remarkable’ feature of this case.  All doctors have a recognised duty to safeguard and protect the welfare of children (General Medical Council, 2012). 5.12 According to professional body commissioning guidance, the majority of NHS care for children and young people is delivered by GPs, within the wider context of family care (Royal College of General Practitioners (RCGP) et al., 2013).  This guidance notes that children typically form 20% of the patient list, and account for one in four of all consultations, adding that on average children of four years and under will attend their GP six times a year, and school-age children two to three times a year.  This is a useful benchmark. 5.13 Reference to the importance of following up children’s missed appointments is made in the current LSCB procedures, and health care providers now have policies in place to  8 This framework was further developed in the Healthy Child Programme published by the Department of Health in 2009.   16  guide practice.  Whilst these set out a proportionate response based on risk-assessments; GPs are routinely informed of any child’s non-attendance at an appointment. 5.14 As the ‘hub’ for all patient information, practices may identify children who are at risk from neglect of their health care needs (for example missed immunisations). Where this is the case, liaison with other universal health services, can help to ensure timely follow-up and the identification of any other unmet needs.  5.15 The potential learning from this review reflects the importance of understanding the family and social history of child patients.  As noted in the Named GP’s contribution to this review, GPs are not necessarily aware of children on their practice lists who are home educated.  Current policies do not allow the routine centralised sharing of basic demographic data between education and health services, however, a holistic approach to the provision of health care to children should include routine questions about schooling (Sambrook, 2019).   5.16 Health visiting services are provided to all families with young children. The child health promotion programme set out a programme of contact with the service during pregnancy and the pre-school years.  This included an antenatal contact, a new-birth visit (at around 12 days of age), a one-year assessment and a health visiting contact made between the ages of two and three years. Well-baby ‘drop-in’ clinics provide a further point of contact for advice and weights. 5.17 As noted in section 4.3 above, Billy was seen at home for a new-birth visit by a health visitor and this was followed up by a home visit by one of the health visiting team. No concerns were identified at this time.  Parents also took Billy to a local clinic for weighing, with the last recorded weight being when he was two-months of age.  Contact was made at two-years of age (a posted request to complete a developmental questionnaire) but it is unclear whether this was completed or returned by parents.   5.18 The Parent-Held Child Health Record (PHCHR) has not been made available for this review; parallel paper records, held by the health visiting team, were retrieved to inform the chronology.  The PHCHR record may have contained additional information. 5.19 By the time Billy was two and half years of age, the child health promotion programme had been superseded by the Healthy Child Programme (Department of Health and Department for Education and Skills, 2009 a, b).  This programme, in common with child health promotion programme, set out an expectation of health reviews throughout the pre-school years. There is also a routine school entry review for all children, with transfer of health information from health visiting to school nursing teams.   5.20 The fact that this review did not seemingly take place is a significant finding, as it would have identified that Billy was a child whose initial developmental progress was not sustained, and who by this time had clear developmental and learning needs (as cogently described by his sibling).  It would have also identified that parents had not sought professional help for Billy’s needs or planned for his education.   5.21  Health visiting has been identified as a service that was under significant pressure at the time of Billy’s birth and in his pre-school years.  Anecdotal evidence suggests individual  17  health visitor caseloads were in excess of 600 children9.  The service was put into ‘special measures’ and one and two-year reviews were suspended.  This may explain why there is no record of contact with the health visiting service after Billy was two months old, apart from the sending of the two-year questionnaire. 5.22 The health visiting workforce crisis in the local area endured.  Data provided by health visiting service provider in the course of this review shows that in 20XX-20XX the average health visitor caseload size across the local area was 523 children.   5.23 Given there were no early indications of Billy’s vulnerability at the initial contacts, it is entirely likely that an extremely stretched service would have prioritised those children who were known to have additional needs, including those at risk of harm.  However, it is also pertinent to acknowledge that engagement with health visiting services is not compulsory; a point made in their summary.  Panel members agreed that there may be a culture of ready acceptance of parental choice in this matter; albeit the principle of best interests of the child should prevail. 5.24 The shortage of health visitors described above was not unique to the local area. A national campaign to recruit into the workforce, spearheaded by the Department of Health, led to an improved picture by 2015.  At this time, commissioning of health visiting services followed the earlier move of school nursing from the NHS to local authority public health departments, with a contractual agreement that there would be five mandated contacts with children and their families: • A health-promoting visit at 28 weeks of pregnancy • A new-baby review at 10-14 days after birth • A six to eight weeks review • A one-year assessment (now updated to a nine to twelve-month developmental review) • A two to two-and-half-year review 5.25 The critical importance of commissioning a subsequent school-entry review, as part of the Healthy Child Programme, continues to be recognised in Government guidance.  This notes the requirement for: ‘Health visiting to school nursing transition to support school readiness.  Identifying the needs of children with additional or complex needs and referring to appropriate services.’ Public Health England (PHE) (2018:29) 5.26 However, evidence suggests that local authority funding cuts are contributing to a marked reduction in the health visiting workforce nationally (Institute of Health Visiting (iHV), 2018).  The LSCB, through their partnership arrangements, should be aware of the impact  9 This is more than twice the recommended caseload size of 250 children.  18  of any reduction on the provision of services to children and families, and the potential impact on child health and wellbeing, parental support and safeguarding in the local area. 5.27 Budget cuts are also affecting school nursing services, the third of the universal services considered in this section of the report.  Billy had no contact with this service; but the service touched briefly on the needs of his sibling, whilst they were in maintained (state) education.   5.28 The commissioning guide for health visiting and school nursing services, referenced above, was first published in 2014.  Both editions state that school nurses have a role in supporting children who are electively home educated (PHE, 2018:7).  A school nursing service does not appear to have been provided to Billy’s siblings once they were home-educated.  This should be viewed as a further missed opportunity to identify both Billy’s, and his siblings’ health needs, as well as their exposure to neglect, physical and emotional abuse. 5.29 The siblings had periods of time in mainstream and faith schools.  The latter are essentially independent schools, that are not maintained by the local authority. The Health Visiting Service, in common with providers elsewhere, do not provide the full range of school nursing services to faith schools (i.e. child health surveillance, health promotion, health protection, health improvement and ‘drop-in’ sessions).  However, I have been informed that immunisations are routinely provided to faith schools and other independent schools, providing the service is aware of where these schools are, and who is on roll. 5.30 The Health Visiting Service, in collaboration with local authorities, launched a ground-breaking local programme Healthy Together that set out how the Healthy Child Programme would be delivered. This included a launch of Chat Health a secure text messaging service for parents and carers, together with a website Health for Kids10 aimed at both children and parents.   5.31 Prior to the new programme, The Health Visiting Service provided all families starting school with a health questionnaire.  These were distributed through school and return rates were consistently low in a lot of areas.  A digital version of the form was created and sent to parents for completion.  This also had a consistently low return rate from parents.  The current process (agreed by commissioners) is that parents are sent a letter with information about the Healthy Together offer (including contact and website details).  This is distributed by schools in their new starter packs. 5.32 The approach may be a pragmatic solution to the national requirement for a review at school-entry.  However, it relies on ‘opt-in’ of parents (or carers) and may fail to reach those who are not in education, EHE or attending independent schools.  Crucially, this system does not allow for the identification of children who are effectively hidden from services. 5.33 This section has sought to outline how parents initially accessed universal child health services for their children, including those provided by maternity services, general practice and health visiting.  Parents then essentially failed to ensure their children’s health  10 https://www.healthforkids.co.uk/  19  needs were met.  There were missed immunisations, non-attendance at hospital appointments and failure to seek GP advice and treatment for childhood illnesses.  Help was not sought for Billy’s developmental needs.  When the children were removed into care, outstanding dental and optical needs were also apparent. 5.34 That Billy and his siblings were found to be in poor health at the point of removal from the family reflects the impact of their maltreatment, imprisonment in the home, lack of exercise, sunshine, fresh air, poor nutrition and lack of opportunity to socialise.  Universal health services have an important role in health promotion, prevention and in child safeguarding; the missed opportunities to ensure that the children were healthy and safe (in addition to the neglect of health care needs highlighted above) are a significant finding from this review. 5.35 In their medical report for the Courts, a specialist concluded ‘parents knew how to access and use medical services in the UK.  The lack of medical care was not related to cultural issues and ignorance of how to access medical services.’  Whilst this is a critical reflection of what was happening within this family, it may belie the fact that parents’ cultural beliefs led them to seek alternative therapy for Billy by travelling abroad to visit a traditional faith healer.   Belief in spirit possession 5.36 Billy’s sibling told us that as his learning and communication needs became apparent, they were attributed by parents to an evil force that had entered their child.   As noted in the safeguarding procedures, rationalising a child’s ‘difference’ (including disability and autism) in this way reflects a belief in spirit possession; with both the belief, and the treatment, causing a child to be at risk of significant harm.   5.37 Of additional concern, and borne out in Billy’s case, is that a stigmatised child with a learning disability may be at greater risk of being subject to physical abuse (beating), emotional abuse (isolation) and serious neglect. 5.38 The alternative [traditional] treatment that Billy received comprised ‘deliverance’ (c.f. exorcism) and a treatment called ‘hijama’ (wet cupping).11 These faith-based treatments were described by Billy’s sibling as being frightening and confusing for Billy (and for the other children).   5.39 Hijama is recognised in the UK.  As with other forms of alternative therapy (e.g. acupuncture) regulation, capacity to consent, and child safeguarding duties apply.  The Code of Conduct and Standards of Proficiency for practitioners in the UK addresses these issues (Institute of Clinically Applied Hijama Therapy (ICAHT), 2013).  However, the risks to children posed by unregulated private practitioners, who may be motivated by financial gain remain, so too do the risks from taking children abroad for treatment.  This is a national issue.   5.40 As detailed in the safeguarding procedures, parents who are first- or second-generation migrants, isolated from extended family, unfulfilled by their new lives in the UK  11 Hijama is not explicitly described in the current LSCB procedures, albeit a note has been made by the LSCB Manager to ensure that it is included in the next update.  20  and/or with a sense of not belonging or being misunderstood, or suffering from PTSD, are more likely to attribute a child’s disability to spiritual forces.  Faith leaders and community groups, as well as professionals, have a role in identifying children at risk from this belief in spirit possession and in the protection from actions taken to seek a ‘cure’. 5.41 The experiences of Billy and his siblings has resonance with the high-profile case of Khyra Ishaq (Birmingham Safeguarding Children Board, 2010).  Similarities include withdrawal of (some) siblings for EHE, serious malnutrition, severe physical chastisement (beatings with an implement), humiliating punishments (including withdrawal of food), confining of children to one room (with a shared mattress), limited clothing, lack of warmth and (for those who were EHE) no access to any external contacts. 5.42 The SCR report commissioned following Khyra’s death identified that her mother’s partner’s belief in spirit possession contributed to the physical and emotional abuse and neglect experienced within this family.  No specific recommendations were made in that report as to how this issue may be identified and addressed.  5.43 A summary of learning from SCRs where culture and faith have raised specific issues, including a belief in spirit possession, is available on the NSPCC website.  This summary discusses the delivery of culturally sensitive care and could be usefully referenced in practitioner learning from the current review. Education 5.44 Education is held in high esteem within the African community (Salad Ganey, 2007).  Billy’s siblings initially attended mainstream schools and then moved to, and between, various faith schools.  At times, some of the children were identified as children missing education (CME).  Eventually all the siblings, apart from Billy, were electively home educated.  The older sibling describes their short time at a maintained primary school as ‘one of the happiest times of their life.’  School, for this sibling, was a safe place, that built resilience.  Although very young at the time, they carried the memory of ‘Childline’ from a poster at the school.  5.45 The children’s father has reported cost and quality of online provision as a rationale for choosing to EHE his older children, rather than keeping them at their (independent) faith schools.      5.46 The pattern of schooling for the older children appears disruptive and piecemeal.  It is not clear why the children were removed from, and not returned to, state provision. This may be linked to the family’s culture and faith (e.g. mixed sex classes) and this was a concern raised by the community during my visit. It is relevant to note that at the time of the review there is a groundswell of resistance to proposals regarding relationship and sex education in schools (Department for Education, 2019a).  These concerns are not unique to the local area, or those of different faiths, but there is evidence that parents may now opt to EHE their children, to avoid the compulsory elements of the new curriculum.   5.47 According to Salad Ganey, the education of a child is not a matter ‘exclusively for the education authorities’ (p.33).  The African home is said to play an important role in  21  supplementing what a child learns through homework and in developing young people’s understanding of the importance of education. 5.48 Whilst parents sought to ensure that the older children had access to some education, Billy’s educational needs were not attended to. 5.49 The siblings accessed an online learning provider for their studies.  Outside of their formal education, parents did not allow access to the internet or television.  We have already noted that the children rarely left the home and did not see friends. Much of the rest of their waking hours were, according to a sibling, spent learning and reciting religious text.  Punitive discipline was said to guide this regime. 5.50 The panel, who largely had limited prior knowledge of the regulations concerning EHE, were concerned about the ‘light touch’ and limited powers of LA, including the fact that parents do not have a duty to inform the LA of an intention to EHE a child.  Nationally, there is a strong lobby of parents who view home education of their children as a right, and who reject the notion of state intervention in family life.   5.51 The positive outcomes for many EHE children must be balanced against the pitfalls and concerns that have been raised about the vulnerability of others.  These tensions are recognised in the revisions to EHE policy published in the course of this review (Department for Education, 2019b), as well as in a new report from Ofsted that explores the movement of secondary age children from school to EHE (Ofsted, 2019).  5.52 Local policies reflect good practice in relation to EHE.  National changes following the Education (Pupil Registration) (England) (Amendment) Regulations that came into force in September 2016, have led to a system whereby all schools are required to inform the LA of all school enrolments and all cases of removal of children from the roll.  Schools are required to send details of new pupils on roll and to promptly share basic information with the LA on all children who are to be removed from roll.  This system helps to identify CME, in particular where those children were previously on the roll of an independent school (an area of weakness prior to the legislation).   5.53 Identifying children who are EHE (or who are not receiving education) is dependent on the sharing of data and information; but this is problematic when a child has not previously been on the roll of a school. 5.54 In short, education is compulsory, but schooling is not (Education Act 1996, s.7).  If a parent wishes to withdraw their child from school for EHE they must state their intention to the headteacher; local practice is for the headteacher to make a referral to the education welfare service (EWS); an education welfare officer (EWO) undertakes a visit to ensure that parents are aware of their responsibility for ensuring the education is efficient, full-time, suitable and that any public exams are paid for.   5.55 A LA home education advisor will then be allocated and visit annually.  There is no right of access to the home, or to the children.  There is no duty on the LA to monitor the quality of the education provided, but there is a duty to intervene if it appears to the LA that a child is not receiving a suitable education.   This includes cases where a parent refuses to  22  provide information to the LA.  If a child is not at school in the first place, this process may not be set in motion (see 5.49). 5.56 Procedures were followed for Billy’s siblings.  As noted earlier in the report, a visit from the home education advisor, took place just over a year before the children were removed, and the education was found to be suitable (4.12).  The older sibling has clear, and rather different, recollections of this visit. 5.57 The visit centred on two of the children, who were both of younger secondary school age.  The older sibling, who was studying part-time via an online provider, but was post-16, was not seen.  Their details were recorded on the EHE form (without a date of birth) as ‘[older sibling] at [query] college’.  This form did not include any details for Billy. 5.58 The night before the visit the family had seemingly prepared ‘evidence’ for their visitor. This included setting out timetables and placing learning materials on the walls in the living room.  The record suggests that the children were spoken to, but we are informed that this was in the presence of their parents.  The father’s assertion that the children engaged in leisure activities, including playing football with friends, and that they ‘constantly visit the library’ bears little resemblance to their daily lived experiences. 5.59 According to his older sibling, Billy was deliberately kept awake the night before the visit, to ensure that he would be asleep when the official called.  The older sibling was also instructed by the parents to go up to the bedroom and ensure that Billy was kept quiet (by this time his communication was limited to unintelligible shouts and screams).  The sibling recalls being in part relieved that Billy was asleep during the visit, and partly wanting him to make a noise so that his presence (and theirs) was identified by a professional, and that help may have been forthcoming. 5.60 In learning from this case, EWS and the home education advisor have since redesigned the home visit form to ensure that the details of all the children in the family and household are accurately collected.  They also plan to ask more searching questions about leisure activities and peer contact during visits and, if necessary, to seek proof of this.  Enquiries would also be made as to the employment, education, or training of any 16 to 19-year-olds in the household, in line with changes in national policy.  Children’s views would be sought, and, if indicated, this should be without parental presence. 5.61 The new departmental guidance recognises that one of the most significant issues for local authorities in maintaining adequate oversight is the initial identification of those who are EHE, particularly if they have never been to school (Department for Education, 2019b).  This duty reflects s.436 of the Education Act 1996 which requires an authority to establish, so far as it is possible to do so, the identities of children in its area who are not receiving a suitable education. 5.62 Unsurprisingly, a recent report from the children’s commissioner (2019) found 93% of LAs surveyed did not feel confident that they are aware of all home educated children.  Furthermore, the report notes that a LA may simply not know about those children who have never been educated, as they will hold no record for them.  Billy is one such child.  23  5.63 Sharing information between agencies may help to identify children who have ‘slipped through the net’, but, as recognised at the practitioner event, data protection concerns may prevent this from happening. In referencing the Children Act 2004 (s.10 & s.11), the new EHE guidance offers a potential solution: ‘Some local authorities already actively encourage referrals from doctors and hospitals of children whom […] may be home educated […] it is possible […] to allow sharing of data on children who appear to be home educated and […] there is a concern as to the suitability of that education which amounts to possible neglect causing significant harm. The Data Protection Act 2018 allows for such sharing of data in principle, but local authorities and their partners will […] need to ensure that their particular arrangements are fully compliant […] under the Act, the GDPR and Article 8 of the ECHR4.’  Department for Education (2019b:12-13)  5.64 The notion of ‘suitability’ of EHE is significant; but this must be incredibly difficult to assess in an annual visit that relies heavily on parental reporting.  The concept of children’s ‘happiness’ (as described by the older sibling when reflecting on their time in a mainstream school), and their wellbeing, as well as their learning is critical.  Children who are home-educated should be enabled to socialise with friends and engage in leisure pursuits.  As Foster (2019:7) has recently noted ‘education may not be suitable if it leads to excessive isolation from the children’s peers and so impedes social development.’   5.65 In her report on home-education, the children’s commissioner found that 1:200 children are now home educated; and that the number has been increasing by 20% per annum in recent years12, 13. Children spoken to for her review reported feeling isolated, lonely, depressed, left alone, living unstructured lives and missing their friends.  There are known vulnerabilities.  At 16 years of age EHE children are four times more likely than their peers in schools to be not in education, employment or training.   One in ten of all home-educated children are known to children’s social care services.  Withdrawal of children to ‘home-educate’ has been a finding in other serious case reviews; given that this allows a child to be hidden from view. 5.66 The case of Dylan Seabridge, an eight-year-old child, who died in 2011, has similarities to the experiences of Billy and his siblings.  Dylan and his brother were home-educated by their parents and Dylan had last seen a professional aged 13-months for an immunisation.  He had not been seen by a GP or any other health professional, despite emergent signs of serious illness, that included dental problems (CYSUR Mid and West Wales Safeguarding Children Board, 2016). 5.67  When he died, Dylan was found to have symptoms of vitamin C deficiency (scurvy). The independent author of the child practice review14 concluded that very little was known about Dylan’s life; in addition to being hidden from professionals, he was not accessing any sport, leisure or cultural activities.  In responding to this case, the National Independent  12  Off-rolling of children has contributed to these numbers.   13 An Ofsted (2019) report published as this review was finalised noted that between 2017 and 2018 the numbers of EHE children increased by 27% to 58,000. 14 Child practice reviews are undertaken in Wales in line with the devolved Government’s safeguarding policies.   24  Safeguarding Board (for Wales) commissioned an evidence-based report to assess the risks to children and young people who are EHE (Forrester et al., 2017).  5.68 The conclusions of the report resonate with the issues identified in the current review. This includes questioning the limited powers to monitor home-education provision and asking how the State can fulfil its obligations to protect children (as per the UNCRC) when a child is ‘hidden’, intentionally or not, and there is a lack of engagement with health, education or other statutory services.   5.69 One of the most distressing aspects of the current review is that the elder sibling carried the heavy burden about what was happening within the family over a period of many years.  This included time when they were enrolled at a faith school.  Loyalty to parents and not knowing how to share concerns within the school community was a factor that prevented earlier help-seeking.   Teaching staff at the school were perceived as friends of the parents.  This finding clearly raises questions about the provision of pastoral care, and safeguarding arrangements in the school.    Housing 5.70  Housing contacts with the family were added to the chronology in the course of the review.  We know that the service had access to the home to carry out repairs (4.16).  As noted in statutory guidance, practitioners working in these services may become aware of conditions that are harmful to children, and there would be an expectation that concerns about children’s welfare are recognised and escalated to lead agencies within the LA.   5.71 It appears entirely likely, in hindsight, that Billy and his siblings were in the home when repairs were carried out, and that there was access to upstairs for the shower repair.  The recommendations that follow will include dissemination of the learning from this review to all those who have a duty to recognise and respond to concerns about the welfare of children.  Community 5.72 This review also needs to reflect the role of neighbours and the wider community, including faith leaders.  During my visit with the neighbourhood police officer, we visited the locality in which the family lived, observed the property (from the outside) and were enabled to see inside a similar property.  The arrangements and layout of the housing is such that there are five immediate neighbours within a courtyard arrangement of other facing properties.  The family had lived in the property for close to 20 years. 5.73 We were told by the elder sibling that all the children, including Billy, would scream and shout as a result of their physical abuse.  We also know that blinds were drawn, and the children only left the house approximately once every three weeks, always accompanied by a parent.  5.74 When we met with the sibling they were interested to hear about ‘truancy patrols’; and felt that this may have provided an opportunity to help.  Brighton and Hove City Council provide an example of this initiative, which involves joint working between officers from the police and the LA.  25  5.75  We have already noted that faith leaders are well-placed to recognise and respond to concerns about children who may be at risk from beliefs in spirit possession.  However, broader child safeguarding and protection roles, in the places of worship, schools and the community, should reflect an understanding of the different, more common, forms of abuse that place children at risk, including neglect and the duties to respond. 6.0 Learning Points for consideration by the Local Safeguarding Children Board 6.1 This independent overview report concludes with learning points and recommendations for the LSCB.  Billy and his siblings endured serious physical and emotional abuse and neglect at the hands of their parents over a period of many years. They were effectively ‘hidden from view’, missing out on their right to health care, education and friendships.  That this could happen here, and indeed elsewhere, reflects the tensions between enabling the rights to a private and family life and taking action to safeguard and protect the welfare of children.  The key learning point from this review is that the balance should tip towards ensuring the rights of the child to education, welfare and protection (UNCRC, 1989).    6.2 The involvement of practitioners and their managers has been fundamental from the outset of the review, as has the support of the SCR Panel.  The practice-oriented learning points that are set out for consideration by the LSCB, reflect their collaboration and expertise.  Further dissemination of the learning from the review will follow in due course. Care has also been taken to integrate the contribution from the siblings; although parental input is regrettably absent.  The first-hand experience and bravery of the older siblings has brought humility and purpose to the review.   6.3 The learning points and recommendations that follow seek to identify opportunities within ‘the system’15 to provide a timely response to children who may be deliberately hidden from the professional gaze.  A further recommendation is made for the LSCB in raising safeguarding children awareness within the community.  Learning point one  The panel were concerned about the continuing vulnerability of a minority of EHE children and the ‘light touch’ and limited powers of LAs in providing an oversight of their education and welfare. A potential solution in reducing the risks, may lie in developing the online resources made available to EHE children16.  A suggestion is that a ‘help’ button on the online learning provider landing/home page could enable children to gain advice and/or easily link to other online sources, such as Childline, or advice on e-safety.  Resource pages for EHE children should also be developed at a local level.  Locally, this should include sign-posting children and young people to the school nurse resources offered by the Healthy Together programme. 17   15 Primarily mainstream health services and provision for children who are EHE. 16 Scrutiny of online support and advice regarding EHE appears to be exclusively for parents. 17 https://www.healthforkids.co.uk/getting-help/my-school-nurse/   26  Recommendations: • That this learning point may be of national interest, should be shared with the Department for Education and the national panel, and action taken to encourage online learning providers to develop their resources accordingly. • That the LSCB supports the education service in ensuring that children and young people who are EHE can access help and support to meet their needs via the current children and young people section of the LA schools and learning webpage and/or the parental page on EHE.  • That the commissioners of Healthy Together 0-19 public health services provide assurance to the LSCB regarding access to the school-nursing services for children who are EHE or at independent schools.    Learning point two Current policies do not allow the routine centralised sharing of basic demographic data between health and education services; such a system may provide safeguards in identifying children who are missing education/not accessing health care and in facilitating inter-agency communication.  Whilst panel recognise that there have been improvements in pathways for following up children who miss health care appointments, a ‘remarkable’ (5.11) feature of this case was the finding that the children were not seen by any health service for a considerable length of time. The absence of contact with the family at the point of transition from health visiting to school nursing services is also key.  This contact can help to determine ‘school readiness’ of a child and to identify unmet needs.  Recommendations • That the LSCB considers how, within the boundaries of current policy and legislation, basic demographic data held by health and education services can be subject to mapping exercises to identify children who are missing education/not accessing health care.  • That the LSCB ask the health community to work with partners to identify a way to report and share information about children who have not been seen for a significant amount of time and triangulate whether there are further concerns across agencies. • That the LSCB determines how the arrangements for Healthy Together school transition, meets the expectations set out in Public Health England (2018) guidance for commissioners, and that there is robust follow-up of any child whose education/education otherwise plans are unknown.     Learning point three Drawing on the contribution from the family, practitioners and the panel, this review has identified areas that can usefully inform practitioner learning and improvements in frontline practice. These include, but are not limited to, taking a child-focused approach, cultural sensitivity and professional curiosity.    27  Recommendations • That the LSCB supports the dissemination of learning through briefings and events aimed at a wide range of practitioners, ideally this should take place with mixed professional groups to support an appreciation of others’ roles and responsibilities;  • That this learning includes reference to the NSPCC briefing on risk factors and learning for improved practice around culture and faith.  Learning point four   The review brought into focus the role of neighbours and local communities in recognising and responding to concerns about children and young people.  Siblings shared their experiences of being somewhat ‘invisible’, not just when they were hidden from view, but also being seen out with a parent, when they should have been engaged in education.   Recommendation • That the new local safeguarding partnership leads a programme of public engagement in raising awareness of, and building confidence in, the child safeguarding system.  This should aim to ensure that those concerned about the wellbeing of a child or young person know how to report their concerns, and what help and support is available.      28  References Badman, G. (2009) Report to the Secretary of State on the Review of Elective Home Education in England HC 610 London: The Stationery Office.   Birmingham Safeguarding Children Board (2010) Serious Case Review Under Chapter VIII ‘Working Together to Safeguard Children’ in Respect of the Death of a Child, Case Number 14. Birmingham: Birmingham Safeguarding Children Board.  Brighton and Hove City Council https://www.brighton-hove.gov.uk/content/children-and-education/schools/truancy-patrols (accessed 17/06/19)  Casey, L. Dame (2016) The Casey Review: A review into opportunity and integration London: Department for Communities and Local Government.  Children’s Commissioner (2019) Skipping School: Invisible Children How Children Disappear from England’s Schools London: Children’s Commissioner for England CYSUR Mid and West Wales Safeguarding Children Board (2016) Concise Child Practice Review re: CYSUR 2/15 Department for Education and Skills (DfES) and Department of Health (2004) National Service Framework for Children, Young People and Maternity Services London: DfES.  Department for Education (2016) Children missing education Statutory guidance for local authorities London: DfE.  Department for Education (2019a) Relationships Education, Relationships and Sex Education (RSE) and Health Education: Draft statutory guidance for governing bodies, proprietors, head teachers, principals, senior leadership teams, teachers London: DfE.  Department for Education (2019b) Elective home education: Departmental guidance for local authorities London: DfE.  Department of Health (DH), Public Health England (2014) Maximising the school nursing team contribution to the public health of school-aged children: Guidance to support the commissioning of public health provision for school aged children 5-19 London: DH, Public Health England.  Department of Health, Department for Education and Skills (2009a) The Healthy Child Programme: Pregnancy and the First Five Years of Life London: DH  Department of Health, Department for Education and Skills (2009b) The Healthy Child Programme: From 5-19 Years Old London: DH   29  Forrester, D. Maxwell, N. Slater, T. Doughty, J. 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Sambrook, J (2019) Paediatric History https://patient.info/doctor/paediatric-history (accessed 14/06/19)  United Nations Convention on the Rights of the Child https://www.unicef.org.uk/what-we-do/un-convention-child-rights/ (accessed 17/04/19)       31  Glossary of Abbreviations CCG Clinical Commissioning Group CME Children Missing Education DfE Department for Education DH Department of Health EHE Elective Home Education EWO Education Welfare Officer EWS Education Welfare Service GP General Practitioner ICAHT Institute of Clinically Applied Hijama Therapy KLOE Key lines of enquiry LSCB Local Safeguarding Children Board PECS Picture Exchange Communication System PHCHR Parent-Held Child Health Record PTSD Post-traumatic stress disorder RCGP Royal College of General Practitioners SCR Serious Case Review UK United Kingdom WNB Was not brought (to appointments)    32  Appendix One Key Lines of Enquiry (KLOE) for the review • What was the daily lived experience of Billy and his siblings?  • What has been the impact of the emotional and physical abuse, and neglect on Billy’s health and development? • What was impact of the family’s faith and culture (including on emergent signs that Billy had a learning difficulty)? • What services were provided to Billy and his family? Why was this child/family ‘unseen’? • How do we encourage service providers to ask basic questions about family structures (who lives in the family home), language barriers, what support networks are available to the family?  • How was/is any failure to take up services followed up? • When/how should professionals challenge parents who decline the support offered? • What was/is the impact of economic migration on children, young people and families? • What provision was/is now made for children who are EHE/missing from education? (including changes to legislation or guidance). • Could there be other children, like Billy, locally, whose needs are not being met? • What evidence was/is there of good practice? • Are there any other system-based issues/additional factors that have affected service provision? • Are there lessons from other local/national reviews that resonate with this case?     33  Appendix Two Data sources (including local policies) Education Welfare Service Home Visit Reports Education Workplans (completed by parent) Family involvement - meetings with child, their carer and an elder sibling Integrated chronology of agency contacts with family Paediatric Medical Report for legal purposes Practitioner contributions Strategy discussion notes Transcript of e-mail to Childline    34  Appendix Three: Practitioner Event  Agenda  1. Introductions and welcome, outline of event (CP)  2. Group agreement (all)  3. Introduction to the SCR & emerging themes (CP)   Break  4. Learning from the case - guided group activity (all)  5. Feedback from activity (all)  6. Individual exercise: the meaning for my practice.  7. Closing comments and next steps (CP).   Attendees Independent author  Education Welfare Service  Service Manager Home Education Advisor  Children’s Social Care   Social Worker – Looked after Children  Advanced Practitioner  NHS Partnership Trust:  Clinical Team Leader x 2  Health Visitor x 3  School Nurse x 2 Police:  Two neighbourhood police officers  Serious Case Review officer  Prevent Officer  Housing:  Housing Team Leader   Housing Officer       In attendance:  35   LSCB manager LSCB Admin and business support Student Nurse  Invited, but did not attend:   General Practice  Hospital services  Guided group activity  How do we encourage service providers to ask basic questions about family structures (who lives in the family home), language barriers, what support networks are available to the family? Important to marry up information that is obtained. Information not shared between the Midwifery Service and Health Visitors, for example. A need to go back to a shared record was noted. Learning different ways of asking pertinent question. The importance to use professional curiosity was agreed by the group.  Important to speak to the children themselves, if the opportunity presents itself.  Children who are EHE should be given an opportunity to meet with professionals on a 1:1 basis.  A consultation booklet was noted as an option.  What can be done to flag up children that are slipping through the net was queried. If children do not have their immunisations, does this flag anything up? Housing hold a lot of information, including the types of properties, who lives there etc. The information is there, but it is not summarily shared. It was queried why this information is not shared. It was noted that this information is not shared as it is held on lots of different systems and areas of information; the systems are not shared and do not work together. There is effectively no joint system, which makes it difficult to check what information clashes, for example.  When/how should professionals challenge parents who decline the support offered?  Culture, faith and religion discussed. Bilal’s family were noted as very religious. They did not engage with services and were very suspicious of them. It was agreed that links within the community can offer best ways to approach a family.  It was stated that the family (particularly Bilal’s mother) engaged well during the pre-birth period and for first year of their [children’s] lives, then engagement dropped off.    36  The group were informed that drop-in baby clinics have been discontinued within the local area. This was noted as a huge barrier to health, as less and less people now attend. It was agreed that drop in clinics are opportunistic and become a social event, with families attending with friends. Due to this, drop-in clinics provide a lot of intelligence and their discontinuation is a big loss.   School Nurses are no longer commissioned to partake in hearing and sight checks when children join school.   The group agreed that it is clear that there were deliberate attempts to hide the children and Bilal’s parents used strategies to avoid contact.   Could there be other children, like Bilal, locally, whose needs are not being met?  Yes, definitely. The group were in full agreement that this is a possibility.  Practitioners invited to write up the meaning for their practice, the following points summarise the findings: Research the family structure before visit and review it after the visit. Family contact regarding concerns. Mindfulness and awareness, as a student nurse, of at-risk cultures and groups subject to possible safeguarding issues such as this case has brought up, and how that plays a part in my clinical practice and everyday life as a citizen. Professional curiosity/uncertainty – use it more!  Be alert, ask questions and challenge.  Requirement to not take things at ‘face value’ but understand the need to probe – joined up working. Access to data (all of us keep/collect data but don’t share either because of Data Protection or systems training). In Housing, we have a lot of information that would be useful.  Data and Information sharing – In respect of ‘health records’ need to share with education LAs. Review process for transition from HV to school nurse – what happens to children not educated in a setting? What happens and are we informing the LA? Ensuring groups, relationships, school nursing, faith schools attendance is up to date.  All home-schooled children should be assigned an independent advocate.  Look into consultation booklets to see if they can be adopted to inform Home Ed discussions.  Mental health concerns – Ask the question – Ask the children. What are social care and other professionals doing to engage the African community in understanding safeguarding and working together.  The need to understand the community within your area of work. 