Death of a 6-week-3-day-old baby boy and neglect of his older half-siblings (13 and 15-years-old). Ambulance service was called by parents on 29 November 2015. Baby V was not breathing and was judged to have been dead for some time. Parents had been drinking heavily. Coroner returned a verdict on the cause of death as "unascertained". Both parents pleaded guilty to child neglect and received a custodial sentence. All three children were subject at that time to child protection plans for neglect and physical abuse. The parents of Baby V and father of U and B, who was still involved with the children, all had histories of alcohol misuse, mental health problems and domestic abuse. U and B had poor school attendance and B had disclosed her struggles with self-harm and suicide-ideation. Issues identified include: the overwhelming needs of the adults dominated the work undertaken; increasing concerns about the children's wellbeing failed to trigger intervention via the Common Assessment Framework (CAF); and adults' accounts were accepted without reference to other available information. Lessons learned include: the need for better use of early help; the importance of good reflective supervision and management scrutiny; and the need for all agencies to consider information on fathers and other significant males during assessments. Recommendations include the local safeguarding children board to review and report on the effectiveness of early intervention; and to ensure commissioning arrangements for assessing substance misusing parents/carers are in place and there is a clear pathway to accessing services for families.
      
    Serious Case Review No:  2016-C5807  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.               Children U,B and V Overview Report ANONYMISED OVERVIEW REPORT Child U Child B and Baby V            2    TABLE OF CONTENTS       Page  FOREWARD 3 1 INTRODUCTION 4 2 ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 5 3 FAMILY INVOLVEMENT  7 4 METHODOLOGY USED TO DRAW UP THIS REPORT 8 5 FACTUAL NARRATIVE CHRONOLOGY  9 6 KEY THEMES IDENTIFIED BY THE REVIEW PROCES 25 7 ANALYSIS FROM IMRS 36 8 CONTRIBUTION FROM THE FAMILY 44 9    LESSONS LEARNED  47 10 RECOMMENDATIONS 49  APPENDIX 1: RECOMMENDATIONS FROM IMRS 50  APPENDIX 2: ACRONYMS REFERENCES 55                             3    FOREWARD   A Local Safeguarding Children Board (LSCB) commissioned this Serious Case Review (SCR) in December 2014 and the final version was presented to the LSCB In September 2015. Many of the themes arising from the review had been identified elsewhere in work undertaken by the Board and in other areas of Children’s Services, including previous SCRs. In short many of the lessons and related recommendations were already subject to scrutiny by the Board and monitored closely by the Independent Chair via the sub groups.     At the time this review was underway LSCB commissioned two separate pieces of work. One was a multi-agency audit, the subject of which was safeguarding pre-birth cases and children under one year old. This was conducted by an Independent Safeguarding Consultant on behalf of the LSCB. The focus of the audit was domestic abuse, parental mental health and substance misuse – themes which are replicated in this report. The second piece of work was a review of the Multi Agency Safeguarding Hub (MASH) also undertaken by an external consultant. The findings from these separate pieces of work largely echoed those in this report and so it is important to note that the LSCB were already aware of many of the practice issues and had included them in their business planning priorities in 2014-15.   Since 2013 the government’s publication Working Together to Safeguard Children has placed an increasing emphasis on recognising the complex and difficult circumstances in which safeguarding professionals work and that these should be reflected in the lessons identified by SCRs. This local authority has been facing some obstacles which have been acknowledged by the LSCB over recent years. Of significance, it has been noted that the child population is predicted to continue to increase. Also, the prevalence of poverty, domestic abuse, substance misuse and parental mental health - factors that compromise safe parenting - are expected to rise.  This coupled with the difficulties in the recruitment and retention of permanent staff across key areas adds to the overall picture of a service with significant challenges to overcome. These factors should be taken into account whilst reading this report.       4  1 INTRODUCTION   1.1 This is the overview report from a Serious Case Review (SCR) conducted by Local Authority 1(LA1) Safeguarding Children Board (LSCB). The matter under review is the death of a baby aged 6 weeks and 3 days in November 2014. The exact date and cause of the baby’s death are uncertain and the coroner returned a verdict of ‘unascertained’. At the time of writing this report both parents had pleaded guilty to Child Neglect and had received a short custodial sentence.    1.2 The case pertains to and highlights the following issues:   The sad and untimely death of Baby V aged 6 weeks and 3 days old due to abuse and neglect  Neglect of his two older half siblings born to a different father aged 13 and 15 at the time of the incident   The extreme vulnerability of the three adults involved in the children’s care including chronic alcohol misuse, associated mental health difficulties and domestic abuse  The father of Baby V having been deemed unsuitable by a neighbouring LA (LA2) to care for a son from a previous relationship   The middle child experiencing mental health difficulties in the form of hearing voices and suffering from anxiety   Chronic poor school attendance for the older two children  The difficulties that arise when families span a number of boroughs and different Clinical Commissioning Groups (CCGs) over a number of years.   1.3 The following is a summary of the basic circumstances leading up to Baby V’s death.   1.4 The three children of this LA1 family were made subject to Child Protection Plans (CPP) for Neglect and Physical Abuse on 11 November 2014.    1.5 On 27 October 2014, the mother, Ms X and the three children were moved to temporary accommodation in LA3 following eviction from their LA1 property.   1.6 Ms X left the family home with Baby V on Thursday 27 November 2014 to go to his father’s (Mr W’s) home in another borough (LA4) leaving the older two children alone overnight.  On Saturday 29 November the parents called the Ambulance Service (AS) and they attended Mr W’s address. The baby was not breathing and was judged to have been dead for some time. Both parents admitted that they had been drinking heavily.  There was confusion at the scene which was further exacerbated by the adults’ differing accounts of events over the previous 48 hours.   5  2 ARRANGEMENTS FOR THE SERIOUS CASE REVIEW   2.1 After the death of Baby V LSCB took the view that the criteria for an SCR had been met which is entirely consistent with the guidance in ‘Working Together’1 (WT) 2013.   2.2 The case meets the two criteria below set out in Working Together,   5(2)(a) Abuse or neglect of a child is known or suspected  and  5(2)(b) (ii)The child has died.  2.3 Working Together (2013) Chapter 4 Para 10 states a Serious Case Review should be conducted in a way which;   recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings.     The purpose of the review is to;    Look at what happened in the case and why and what action will be taken to learn from the review findings;  Identify actions that result in lasting improvements to those services working to safeguard and promote the welfare of children;  Provide a useful insight into the way organisations are working together to safeguard and protect the welfare of children.  2.4 Arrangements were made to appoint the independent people who are required to contribute to the conduct of SCRs. An independent professional was appointed as the Chair of the SCR panel. This person has had a lengthy career in local authority social work, in adult mental health and children and families services. As an independent consultant, the person acts as both Chair and author of Serious Case Reviews, and is accredited as a reviewer using the Social Care Institute of Excellence (SCIE) Learning Together model.  A second independent professional was appointed to produce this overview report. This person is an Independent Social Work Consultant with a considerable background in child protection and quality assurance. As an independent consultant the person specialises in multi-agency learning reviews including partnership reviews and SCRs.                                                          1Working Together to Safeguard Children (Working Together) is the government’s overarching guidance on safeguarding. It has recently been revised but the terms of reference for this review were in place before the publication of Working Together 2015  6   2.5 LSCB arranged a Review Panel to manage and oversee the review. The membership of the panel is set out below;  Name/Designation Organisation Role  Independent N/A Chair of the panel  Independent N/A Overview author Designated Doctor  NHS Trust and CCG Panel member  Designated Nurse  CCG Panel member Head of Housing Need and Assessment Housing  Panel member Head of School Standards Education Panel member Acting Assistant Director of Nursing Trust, Named Nurse Safeguarding Mental Health Service 1 (MHS1) Panel member Associate Director for Safeguarding Children Mental Health Service 3 (MHS3) Panel member Head of Service  Children’s Social Care Panel member Review Officer Specialist Crime Review Group Police Service Panel member Board Manager  LSCB Panel member  2.6 It was determined through the emerging facts of the case that the following agencies had had contact with the family and should therefore contribute to the review:    Agency  Nature of contribution Children’s Social Care, Local Authority 1  Chronology and IMR Education (covering School, educational psychologists and education welfare) Chronology and IMR Local Health Services (Covering Health Visiting, Hospital 6 and School Nurses) Chronology and IMR  MHS1 Chronology and IMR MHS3 Chronology and IMR Hospital 2 NHS Trust (including the Health Visiting service)  Chronology and IMR Police Service Chronology and IMR NHS England (including GPs) Chronology and IMR Community Drug and Alcohol Service 1 (CDAS1) Chronology and Background Summary Report   Hospital 1 Chronology and Background Summary Report  Housing Service 1 Chronology and Background Summary Report LA2 Chronology only  Ambulance Service  Chronology only   7  2.7 The Terms of Reference (ToR) agreed by the Panel were that the period under detailed review would be from 1st January 2014 to the 1st December 2014, with the proviso that agencies would summarise any other relevant information to add context and background to their report. In line with this some background information about events prior to January 2014 and the current position of the siblings is also included in the report.   2.8 The methodology used by the LSCB in this review is a hybrid model, in that each agency was asked to complete a chronology, and undertake an Independent Management Review (IMR).  Those agencies who have had minimal contact were asked to complete an Agency Summary report (see table at 2.5)  2.9 The LSCB held a series of SCR Panel meetings, chaired by the Independent Chair, where all the agencies and the overview author contributed to the process.   2.10 A consultation and learning event was held in April 2015 to enable those practitioners who worked with the family to contribute to the overall findings and lessons from the review. Where relevant their views have been incorporated throughout the report.   2.11 LSCB plan to hold further learning events at the conclusion of the review     both for practitioners and other staff from Children’s Services and Adults Services as well as other board partners.   3     FAMILY INVOLVEMENT   3.1 Consideration was given to involving the family in the review process and family members were advised early on that the review was underway. The maternal grandparents and both Baby V’s parents accepted the invitation to contribute and their views are included in the body of the report  3.2 Child U and Child B were encouraged by their grandparents to contribute their views but they felt too overwhelmed by the events of recent months.  During the course of the care proceedings they had spoken to many different professionals and, understandably, declined the offer to speak yet more.   3.3 Mr R was contacted and invited to contribute his views but also declined as he wanted himself and his family to be left alone and did not consent to his personal records being used to inform the review.   3.4 The panel discussed the issue of consent carefully and at length, giving due consideration to the views of the family members involved, current guidance and legislation and the proportionality of the information used in the review.    8  3.5 The LSCB notified each parent that the SCR was taking place and asked whether they would be willing to participate in the process.  They were advised that their relevant medical records would be accessed for the purpose of the review and were additionally asked if they gave their specific consent.    3.6 Contact with Mr W and Ms X was via their legal representatives as they were in custody at the time and direct contact was made with Mr R.   3.7 Mr R advised that he was not the carer of his children during the review time period and as such felt that his records were irrelevant.  The SCR Review Panel took legal advice and made the decision that information from Mr R’s mental health records was needed in order to understand the family context and the decision-making undertaken by professionals.  Mr R was informed accordingly.   3.8 In recognition of his explicit denial the only medical records of Mr R’s that were considered were those at MHS1 and only matters which were relevant, proportionate and necessary to the SCR were commented upon by the report authors.  Those records were not accessed by anyone outside of the MH Trust.   4     METHODOLOGY USED TO DRAW UP THIS REPORT   4.1     This report is informed by    The agency chronologies, IMRs and summary reports   Background information from agencies involved in the review  Panel discussions and analysis  Dialogue with IMR authors   Input from family members   Input from practitioners via the consultation and learning event held on the 15th April 2015  Research findings.   4.2   The report consists of   A factual context  Analysis of how the agencies worked together from the information provided in their IMRs   Commentary on the family situation and their input into the SCR  Analysis of the specific issues identified in the ToR  Findings and lessons learned  Recommendations   4.3 The review has been conducted and written with the benefit of hindsight which often distorts the reader’s view of the predictability of events which may not have been evident at the time.    It is important to  9  be aware as Munro (2011)2 states just how much hindsight distorts our judgement about the predictability of an adverse outcome. Once an outcome is known we can look back and believe we can see where practice, actions or assessments were critical in leading to that outcome. This is not necessarily the case, and information often becomes much clearer after an event has occurred. The review is therefore sensitive to this ‘bias’.   4.4 The review is also sensitive to pressures on agencies and the demands of the work which are sometimes overwhelming for even the most capable of workers. The pressures are felt more keenly in the face of a tragedy such as the death of a baby; therefore it is important to disseminate the learning and reflect on how the lessons can help change practice rather than apportion blame to agencies or individuals.    5     FACTUAL NARRATIVE CHRONOLOGY     The Family Structure   Name  Relationship Age at time of incident  Ethnicity  Baby V Subject 6 weeks and 3 days White British Ms X Mother  40 White British Mr W  Father to Baby V 47 White British Child U Subject (half sibling to Baby V - same mother) 15 years and 7 months White British Child B  Subject (half sibling to Baby V - same mother) 13 years and 8 months White British Mr P Half sibling to Baby V (same mother) 20 years and 10 months White British Mr N Half sibling to Baby V (same mother) 22 years and 7 months White British Child S Half sibling to Baby V (same father) 8 years and 1 week White British Ms J  Mother to Child S N/K White British  Mr R Father to Children U and B 58 White British Grandfather Maternal grandfather to 62 White British                                                          2 Munro review of child protection: final report - a child-centred system. Department of Education, May 2011   10  Children U and B Grandmother Maternal grandmother to Children U and B 63 White British    5.1.   Introduction   5.1.1   Each of the agencies involved in this review submitted a detailed chronology of their involvement with the family members in the period under review. Those submissions have been co-ordinated into an integrated chronology which is summarised here. Further factual information is provided in some subsequent sections where relevant.  The Family background    5.1.2   The family in question consists of Ms X who is mother to all three children, Mr W (father to Baby V), child U (aged 15 years and 7 months at the time of Baby V’s death), Child B (aged 13 years and 8 months at the time) and Mr R who is the ex-partner of Ms X and father to children U and B. Ms X has two adult sons from her first marriage, the eldest of whom does not reside in the family home.  The other son stays in the family home during visits and holidays from university. Mr W also has a son from a previous relationship who resides in another area.     5.1.3. The members of the family are all White British and their first language is English. Little information is provided in the IMRs about their socio-economic background and there was no knowledge of either of the adult men’s current employment status. Ms X was said to run her own business. There was no evidence that any member of the family followed any established religion and there was minimal information provided about their cultural identity.   5.1.4. It would appear from the records that Ms X met her first husband in 1990 when she was 16 years old. She described this relationship as controlling and her husband drank alcohol to excess.  They separated in 1997 having had two children.   5.1.5. Ms X met Mr R in the same year and they were together until 2012. Child U and Child B are the result of this relationship. The two adults along with Children U and B lived together until January 2012 when there was a serious episode of DV. This led to an assessment by CSC and Mr. R pleaded guilty to, and was convicted of, Common Assault on Ms X. Ms X was encouraged to take an injunction out against him, which she did and he left the family home. CSC was notified by Probation that Mr R had returned to the family home in August 2012. It is not clear when he obtained his most recent address but what is now known is that he continued to have frequent contact with Ms X and their two children despite the agreement with CSC that he would not.    11  5.1.6. There are two accounts of how Ms X met Mr W. According to Ms X whilst being interviewed for this review they met in 2013 through a family friend and this version of events was corroborated by the MGF. However, according to CSC records Ms X disclosed to the SW that they had met through a counselling group for recovering alcoholics.  5.1.7. The family friend in question had met Mr W through this route (Alcoholics Anonymous) so it is possible that this was misunderstood or misinterpreted by the SW. In any event Ms X does not dispute that the relationship began in 2013 and she became pregnant with Baby V in early 2014.   5.1.8. At the time covered by the review period Ms X, Child U and Child B lived in privately rented accommodation, her older two children having left home by this time (one was at university). It would seem that although both Mr R and Mr W had their own accommodation they were frequent visitors and lived in the family home on and off throughout the period under review.  In October 2013 the family were notified that they were to be evicted although this was did not take place until  the end of October 2014 and as a result were provided with emergency accommodation in LA3.   5.1.9. At the time of the review Mr W was living in LA4 having lived in a series of hostels for the homeless. He has a son from a previous relationship who lives in another local authority and more detailed information from the LA2 is contained in section 5.2.  5.1.10. Information to this review suggests that Mr W had a formal diagnosis of Asperger’s Syndrome (a form of autism). Asperger’s Syndrome is a lifelong disability that affects how a person makes sense of the world, processes information and relates to other people. This is likely to have added to his vulnerability especially in combination with his other significant problems - e.g. problematic alcohol misuse and associated physical and mental health difficulties.   5.1.11. The relationship between all three adults is complex and not completely understood at this stage but it is known that they spent time in each other’s company and their contact was characterised by their mutual long standing abuse of alcohol.   5.2.     Agencies’ Involvement with family Members – LA2  5.2.1.    As part of the review information obtained from the LA2, Children’s Social Care (CSC), confirmed that Mr W’s son (Child S) was subject to involvement from them between 2006 and 2010. The involvement started in 2006 when soon after he was born Child S’s mother (Ms J) - rang her local hospital stating that she was unable to cope with her son.    12  5.2.2.   Over a period spanning approximately four years CSC’s involvement consisted of conducting Initial and Core assessments and later in 2007 s47 (CP) enquiries were undertaken. The concerns were due to domestic violence between the parents and excessive alcohol misuse.      13  5.2.3. In June 2007 Mr W received a police caution for Common Assault against Ms J following heavy drinking sessions by both parties. In August 2007 he was found ‘not guilty’ of an offence of Common Assault again against Ms J.    5.2.4. In the same year due to a growing number of incidents Child S was made subject to a Child Protection Plan (CPP) under the category of neglect.  Child S was also taken into Police Protection, again in 2007, due to Ms J and Mr W breaking a written agreement that Mr W would not have sole care of his son. Child S was accommodated in foster care under s20 of the Children Act 1989 for a short period.   5.2.5. Child S was subsequently moved to the care of his maternal grandparents and the couple were required to live at Ms J’s parents’ house with the baby.  It is not clear if Mr W joined them there but in any event it would appear from the information provided that the relationship with Ms J ended around 2008. The CPP ended in September 2008 and Mr W was having no contact at that time.   5.2.6. It is significant to this review that the couple’s relationship was categorised by incidents of domestic violence, which appeared to be fuelled by Mr W’s excessive alcohol misuse and associated mental health difficulties. During this period LA2 reported that Mr W was admitted to hospital on at least four occasions due to mental ill health including having taken overdoses of various medications and feeling suicidal. He was also an in-patient in at least two detox units but relapsed on both occasions. Mr W is also reported to have made threats to CSC staff stating that he would ‘bomb’ anybody he felt was working against him.   5.2.7. The case was closed to LA2 in September 2010 with no contact offered between Child S and Mr W.   5.3.   Agencies’ Involvement with family members – LA1   Relevant events prior to 2014  5.3.1. In July 2011 Ms X reported to her GP that she was suffering from insomnia and excessive alcohol intake which she stated was as much as 75 units per week.   5.3.2. In 2012 Children’s Social Care in LA1 conducted an assessment of the family due to concerns around domestic violence – Mr R was said to have held a Samurai sword to Ms X’s neck and threatened to kill her. The assessment concluded that Mr R was not to have contact with Ms X or the children. This was agreed by Ms X and as a consequence of this Mr R left the family home   14  5.3.3. The outcome of this was No Further Action (NFA) to CSC as Ms X co-operated with the assessment and sought an injunction against Mr R.  Mr R pleaded guilty to Common Assault in relation to the incident.   5.3.4. In November 2013 Ms X made an appointment with a Housing Needs Officer (HNO) saying that she had been threatened with eviction due to the landlord wanting the property back. Mr W attended the appointment but was not included in the application. Mr R was listed as a tenant on the privately rented property and Ms X was open about the fact that there had been DV between them, which led to CSC involvement. She cited the DV for the reason Mr R no longer lived in the family home. Her application was followed up in February 2014 when she provided written documentation from her landlord that he intended to evict her. At this point Ms X also requested that Mr W be added to her housing application.   Events from January 2014 onwards  5.3.5. In January 2014 Child B disclosed to a school teacher that she had been hearing voices and could describe the characters that were speaking to her in detail. Child B said that she had not attended the GP as she feared she would be seen as ‘mad’. The school staff were concerned about this and as a result the teacher spoke to Ms X who said that she was aware of Child B’s disclosure re voices. Ms X was advised by the school to take Child B to the GP which she did, and the GP made the referral to Mental Health Service 2 (MHS2) for Child B to be assessed. The referral was accepted by MHS2 and after the information had been assessed in line with their usual process Child B was placed on their standard waiting list.3   5.3.6. It is significant also to note during this period that the children’s school attendance was very poor and between January to July of 2014 it was as low as 50%.      February 2014  5.3.7. In February 2014 Mr W presented to A&E in the LA5 and was assessed by a psychiatrist which led to a hospital admission for approximately one week.  Mr W presented as very distressed and said that he felt suicidal and would ‘jump into the river’ if discharged from A&E. He reported that this was as a result of his girlfriend who had ‘kicked him out of her house’ the day before as he did not get on with her children. He further informed the doctor that the previous day he had taken an overdose of 25-30 painkillers. Mr W also disclosed that after abstaining from alcohol for a period of three years he had started drinking again in January. He disclosed the reason for his relapse was due to his girlfriend drinking with him and that they consumed 3 - 5 cans of cider (7.5%) a day.                                                          3 The national standard waiting time for MHS2 is currently 18 weeks  15   5.3.8. The staff at A&E took a detailed history from Mr W and his previous presentation in terms of hospital admissions, previous diagnoses (including Asperger’s Syndrome and alcohol dependence) and self-reported overdoses.  Mr W was assessed as being depressed and suicidal in the context of alcohol misuse further complicated by the fact that he had spontaneously stopped his medication for depression about 6 months previously making his depression worse. The doctor assessed that he had active suicidal thoughts and intent and plans to commit suicide were present.    5.3.9. A risk assessment concluded that at that time he was moderate/ high risk to self and low risk to others. By the time he was discharged seven days later the risk to himself was said to have reduced and he and Ms X were reported to have agreed to work ‘as a team’ in regards to the children. He was discharged and informed members of staff that he was going to an address in LA1 to stay with his girlfriend but no discharge address was elicited.     March 2014  5.3.10. Less than three weeks later in early March Mr W was again admitted to hospital under similar circumstances. He had reportedly taken an overdose of medication and had drunk heavily. Mr W complained about his girlfriend’s children (Children B and U) and said that they were trying to sabotage his attempts to get himself organised. He was worried about housing and said that he had wanted to commit suicide for a long time, claiming that it was always in the back of his mind. He also disclosed that he believed his girlfriend was pregnant.  5.3.11. Mr W was discharged six days later and Hospital 5 offered an outpatient appointment and encouraged him to register with a GP in LA4 so that his mental health care could be transferred over to them. A Mental Health Project (Rehab2) was to assist him in receiving counselling for his alcohol use, help with housing and registering with a GP in LA4.  5.3.12. It would appear he was discharged to accommodation in LA4 who were assessing Mr W’s housing situation to see if they would accept responsibility for this as he had spent some time there in a hostel for homeless people.   5.3.13. Mr W received some aftercare services from GP Practice 1 (based in LA4) and he eventually registered with a regular GP practice later in the year. He was however reluctant to engage further and declined most services offered to him. Within the paperwork transferred by Hospital 5 there was a mention of his girlfriend’s pregnancy but this was not picked up.    16  5.3.14. After several attempts to make contact with him after his discharge from hospital, Rehab2 closed Mr W’s case in June 2014. It is not clear what MH services he received (if any) between March and September as he was not registered with the GP in LA4 until September 2014.   5.3.15. Around a similar time to Mr W’s hospital admissions Mr R also presented to an A&E on the 18/03/2014. He presented as drunk and was experiencing chest pains. It is documented that he reported that this was following an alcohol binge with his ex-wife (believed to be Ms X). NB Ms X would have been 8/9 weeks pregnant at the time.    5.3.16. Mr R presented a further four times to A&Es and had several contacts with mental health services during the review period. On each occasion this was due to excessive alcohol use (or complications associated with alcohol use), depression and suicidal thoughts.  Notably one of these was the 14th October, which was the day Baby V was born.  Mr R had fallen over and had cuts over his face and body.                 April 2014   5.3.17. There are two significant events that happened in relation to members of the family in April 2014. On the 12th April an ambulance was called regarding Ms X. On arrival of the ambulance staff it was explained that Ms X believed she was having twins as she could feel two babies. She described having contractions every minute or so.  5.3.18. On examination in hospital all clinical observations were within expected   parameters and it is documented by the ambulance crew that Ms X had no apparent bump but claimed she was 22 weeks pregnant. In the hospital the pregnancy was confirmed, as was the normal development of a single foetus.   5.3.19. As a result of this seemingly bizarre episode the Ambulance Service made a referral to MHS1 querying Ms X’s mental health.   5.3.20. The referral was discussed at the Multi-Disciplinary Team meeting on the 22nd April and a decision was made to request further information from Ms X’s GP. A telephone call to the GP was made on the 30th April and a written request was sent as advised on the same day. Information from the surgery was faxed from the GP confirming that Ms X was pregnant and was prescribed fluoxetine4 and thiamine5. Further attempts were made to contact the surgery for more information about Ms X’s mental health but no contact was made. The outcome was that Ms X was not offered a service by LA1 mental health services in relation to the referral.                                                           4 A prescribed medication taken to treat depression 5 Thiamine is also known as vitamin B, essential for the metabolism of carbohydrates in order to release energy for growth, nerve function and muscle tone  17  5.3.21. Ms X had registered her pregnancy and her first ante natal appointment took place three days after the ambulance was called on the 15th April, by which time Ms X was in fact 14 weeks pregnant not 22. Mr W attended the antenatal appointment with Ms X and they were asked routine questions about mental health and drug and alcohol use. It is recorded that Ms X admitted to smoking 12 cigarettes a day and drinking 3-4 units of alcohol a day.  She also stated that she was being treated for depression as was her partner (Mr W). She did not disclose past or present domestic violence although there is some ambiguity in the Health Service IMR about whether or not a direct question in relation to this was asked.   5.3.22 When asked the mental health questions she answered ‘yes’ to past     and present mental illness, previous treatment, family history of mental health issues and also answered yes to the question ‘does your partner have any history of mental health illness’? She also answered positively (i.e. yes) to being asked if she felt low, depressed or hopeless, having little interest or pleasure in doing things, worrying or feeling anxious about things and was it something she needed help with.  5.3.23 As a result of the above booking appointment the midwife became    concerned for two reasons. One was concern for the unborn baby and the amount of alcohol and cigarettes that had been disclosed as being consumed, and the other was in relation to Ms X’s mental health  5.3.24 On the 24th April the midwife made a referral to LA1 CSC asking for support for Ms X and her partner in relation to their alcohol use, smoking during the pregnancy and depression. The referral mentions the impending issue about being evicted and Mr W’s severe anxiety issues.  5.3.25 The referral was considered by CSC but not accepted as a referral that would progress to assessment. Instead the recommendation was that, as Ms X was willing to engage in support, a health-led Common Assessment Framework (CAF) should be put in place. In a letter dated 6th May CSC informed the midwife that there would be NFA from CSC and that they recommended she complete a CAF. There is no record of this letter on the files held by the Health Service and no CAF was completed.   5.3.26 The midwifery service received a copy of the reply from the MASH which was addressed to Ms X, confirming that no further action was to be taken at this time. It advised her to engage with her GP and midwifery services and ensure that her mental health needs were adequately met.   5.3.27 In relation to the second issue of Ms X’s mental health the midwife also made a referral to the Perinatal Mental Health Team (PMHT). However PMHT did not assess Ms X’s mental health or offer any  18  support at that time because she was already under the care of the GP who had prescribed medication. The GP was informed and a prescribing guideline was dispatched, advising the GP to re-refer if they had any concerns.   5.3.28 Of further significance in April was the continuing issue with Child B and her mental health. The school became increasingly concerned about the deterioration in her mood and presentation. As a result the school contacted MHS2 and expressed their continued concern about Child B’s low mood and high anxiety.  They reported that she was experiencing suicidal thoughts and had self-harmed through superficial cutting. As a result of this intervention by school, Child B was placed on the semi-urgent waiting list a day later. The initial assessment of Child B eventually took place on the 05/08/2014 (approximately 7 months after the original referral) when a comprehensive history about Child B and the family was obtained and a mental state examination of Child B was conducted.   5.3.29 Child B remained under the care of MHS2 throughout the rest of the review period and attended a number of appointments in August and September. There were no appointments attended in October despite several contacts from MHS2 to arrange one. Ms X was reluctant to take Child B due to the impending birth of Baby V and the fact that they were about to be evicted. At an appointment on 21st November Child B was prescribed fluoxetine for anxiety and depression.    May 2014  5.3.30 On May 14th 2014 Ms X attended a routine antenatal appointment. There were no noted concerns about the pregnancy and Ms X told the midwife that she had given up smoking and drinking. This was the only other record of the question of smoking and alcohol consumption being addressed in the midwifery appointments.   5.3.31 From that point on there were no major concerns noted about her or the unborn baby and she attended antenatal appointments as requested. In all she attended 11 appointments shared between the consultant clinic and community midwives.   5.3.32 July 2014 saw the start of some considerable contact between Mr R and various Adult Mental Health Services and it would appear that Mr R’s mental health was deteriorating during this time. Over the next three month period he was assessed and treated for depression, suicidal ideation and attempts. This was on top of several presentations to A&E against a similar background of chronic alcohol dependence and past history of suicide attempts.       5.3.33 On 9th July Mr R was assessed at MHS4 for depression and suicidal ideation; he was accompanied by Ms X on this occasion. As a result of this assessment he was admitted to the Hospital 8 for alcohol detox  19  and discharged on the 12th July. After this he had various contacts including the following:   One further contact with MHS4 (21st July)  Two contacts with Hospital 3 Psychiatric Liaison Team (30th July and 7th September)  Four Community Psychiatric Reviews (31/07/14, 01/08/14, 18/08/14, 02/09/14)   Two further admissions to hospital; Hospital 10 triage ward (8-10th September) and Hospital 7  (10th September to 13th October)  5.3.34. It was understood by these services that at times Mr R was living in the family home with Ms X, Child U and Child B and also that Child B was receiving a service from MHS2 for depression and anxiety. The children also visited him in hospital with Ms X and Mr W. MHS2 were however unaware of Mr R’s contact with services.   5.3.35. It is documented in the IMR provided by MHS1 that risk assessments took place, which included information about Mr R's family and were completed on numerous occasions. These related to the risks Mr R posed to others, including his children and to himself across different domains including self harm, neglect, violence, and suicide. This was an internal process and no other agency was contacted to inform the risk assessment. It would be normal practice to share these with the person’s GP but as Mr R was not registered with a GP this did not happen.   5.3.36. Mr R did not respond to attempts to organise follow-up appointments after his discharge from the Hospital 7 so much of the intervention was centered around crisis management.       August 2014  5.3.37. In August 2014 Child B had her first appointment with MHS2. She was accompanied by Ms X. A comprehensive history was taken from Child B and Ms X and among other things Ms X was asked about her use of drugs and alcohol during her pregnancy with Child B and she denied use. Information about other members of the family and Ms X’s partner, Mr W, was also obtained. Child B’s father, Mr R, was identified as having alcohol-related problems and concerns about Mr W’s behaviour were raised by Child B. These included violent behaviour towards her (twisting her arm) and the inappropriate behaviour of kissing the cuts on her arms which she had made whilst self harming.  Child B also disclosed that she believed (and it was not disputed by Ms X), that Mr W was not allowed contact with his son from a previous relationship but she did not know the detail of why this was the case.    20  5.3.38. An assessment was completed and Child B was discussed in a MDT meeting on the 7th August where a decision was made to make a child protection referral to CSC in view of the disclosures made by Child B.  5.3.39. The referral was delayed due to attempting to gain consent from Ms X which was eventually obtained on the 14th August. It was further delayed by IT problems in completing the on line referral form for CSC. The referral was eventually made on the 27th August three weeks and one day after Child B’s original disclosures.   5.3.40. The referral to CSC progressed to a detailed single assessment, planned to take 45 days and a social worker was allocated to complete the assessment under s17 Children Act 1989.    5.3.41. Further issues emerged in relation to the health of Mr W when at the end of August (28th) an ambulance was called for him and he was taken to Hospital 1.  It was reported that he was experiencing chest pain, pain in between his shoulders and pins and needles in his legs, arms and hands. He was diagnosed with a respiratory infection and discharged.       September 2014  5.3.42. On the 10th September Mr R was admitted to Hospital 10 Triage Ward for assessment of his suicide risk and depression. He was transferred to Hospital 7 for treatment where he remained in hospital until 13th October, an admission of just over one month.   5.3.43. The following day a further incident similar to the one on the 28th August occurred (described in 5.3.41) when an ambulance was again called for Mr W who was experiencing chest pain. Following the crew’s examination, Mr W was conveyed to Hospital 1. He complained of pain similar to that described in the previous section and it is significant to note that he reported having had 20 units of alcohol that day. Mr W left A&E before being seen.  5.3.44. The same day on the 11th September CSC received a referral from an anonymous source concerned about Child U, Child B and the unborn baby. The referrer was worried about the following issues;    Mother and father of unborn drinking all day   Mother admitting to drinking  Mother supplying the children with cigarettes  Father of unborn walking round with a knife and a hammer  Ex-husband also living in the property. She (Ms X) says he was taken into an ‘institute’ as he was found lying on a train track recently  Father of unborn held Child U up by his neck when he was drunk  Children have not been going to school  21   Caller says mother was home at attempted last visit but didn’t come to the door to see Social Services (CSC have recorded that a visit was made on the 3rd September but it was reported by her older son that no one was home except him)   5.3.45. It is not clear what action was taken by CSC as a response to the referral but the SW undertook a visit on the 12th September (but no notes were recorded). There are however references to the information as part of the later s47 enquiries conducted in October after the birth of Baby V. The issues from the referral were also raised at the ICPC held on 11th November and were assessed on balance to be accurate.   5.3.46. Throughout September Child B continued to have various appointments (four in total) with MHS2 for psychological interventions. These sessions were designed to target her low mood and anxiety and one of the appointments was with the team’s doctor who was a Specialist Trainee Child and Adolescent Psychiatrist.      October 2014  5.3.47. A number of significant events occurred in October 2014.   5.3.48. LA4 had accepted housing responsibility for Mr W, he had been allocated accommodation and he had registered with a GP (September 2014).   5.3.49. On the 8th October Mr W presented to his GP and gave a history of feeling suicidal. He disclosed a past history of deliberate overdose and self harm. The GP also elicited that Mr W had alcohol dependency syndrome and he admitted drinking more than 9 units daily. The GP made appropriate referrals to alcohol services and the Mental Health Team. Mr W declined mental health service input despite the recommendation from his GP, who was concerned about Mr W’s suicidal ideation and alcohol abuse. The impending birth of Baby V was not discussed; the GP practice was unaware of the birth and Mr W did not mention it.   5.3.50. Six days later on the 14th October Baby V was born in hospital. The birth was normal with no complications. Ms X however remained in hospital for a further three days due to a request from CSC that there be a discharge planning meeting before mother and baby were discharged home.   5.3.51. The next day two members of staff from the school conducted a visit to the family home to check on the older two children who had not been in school. After visiting the grandparents first (as that was the  22  address they had) they then went to the family home and were met by a man (later confirmed as Mr R) who was drunk and had lacerations and bruises all over his face and body.  Mr R stated that the children were not present and it was later established that they were with their mother in the hospital at the time. They did however stay with their father in their own home whilst their mother was in hospital. The school did not pursue any other lines of enquiry as they felt unsafe with Mr R. On their return to the school a referral to CSC was made.   5.3.52. As a result of this referral a strategy discussion between the police and CSC took place the same day and a decision made that single agency s47 enquiries should be commenced in relation to all three children.   5.3.53. Amid the growing concerns for the children (including Baby V) a discharge planning meeting was held in the hospital prior to the baby being discharged home. Representatives from the school, the midwives and CSC attended the meeting. A full exchange of information took place in relation to the background of the original referral from MHS2 and the two more recent ones. Mr W confirmed that what Child B had disclosed to MHS2 was correct which was that he had been prevented from having contact with his son from a previous relationship. He was open about the fact that this was to do with issues around excessive alcohol use but stated that this was not an on-going problem.   5.3.54. A Written Agreement (WA) was put in place prior to Ms X and Baby V’s discharge home which included that there was to be no contact between any of the children and Mr R.  Ms X and Mr W however refused to sign this version of the agreement and from information gleaned it would appear that the agreement was changed in favour of Mr R being allowed contact with the children with conditions applied. The lack of clarity around the agreement, and its exact content at this stage, is due to being unable to locate the final version signed by Ms X and Mr W. However the Child Protection Plan made on November 11th clarified that Mr R was not to visit the home address and that the core group should put plans in place to ensure that any contact between Child U, Child B and Mr R was safe.   5.3.55. The document also stated that Ms X was not to leave Baby V, Child U or Child B in the sole care of Mr W. Mr W was further asked not to have any unsupervised contact with them until the result of initial alcohol screening and the outcome of a risk assessment.   5.3.56. The WA had made a stipulation that the baby’s parents needed to be tested for alcohol use.  On the 20th October Ms X and Mr W attended  23  CDAS1 of their own volition explaining that they needed to be assessed to demonstrate to CSC that they did not have problematic alcohol use.   5.3.57. Both adults (Ms X and Mr W) were offered an assessment to determine their needs around how they used alcohol. Both denied there were any concerns with their alcohol use and suggested they had presented to CDAS1 on the advice of CSC and not because it was something that they were worried about.  The worker explained that support could be given in terms of an assessment, care plan, alcometer test and support from a key worker. Both declined the offer of any of these services.  5.3.58. After a formal referral from the SW Ms X then presented to CDAS1 on 25th November and was screened to determine risk prior to being given a full assessment appointment. Again, Ms X denied her use of alcohol was problematic, hazardous or high risk.   5.3.59. A further appointment for the full assessment was offered but was not attended as this was after the death of Baby V.   5.3.60. On the 21st October Mr W attended his GP surgery and became aggressive and intimidating as he was demanding painkillers for his shoulder, which the GP would not prescribe due to not having his previous medical records.   5.3.61. On 24th October the HV completed a new birth visit at the home address. Both parents were present and Ms X denied any history of mental illness and denied drinking 3-4 units of alcohol a day stating that the midwives had recorded it incorrectly and it was 3-4 units per week. She said that she had stopped drinking and smoking cigarettes altogether in September. The HV discussed issues around DV and Ms X disclosed DV between her and ex-husband but stated that she did not see him now.  This was at odds with her subsequent admission that he looked after the dogs and the children while she was in hospital.  5.3.62. The HV completed a thorough assessment of Baby V, who was healthy and good bonding was observed between Baby V and Ms X.  Various routine health promotion leaflets were given.  No concerns were noted about the care of the baby. Ms X had opted to breastfeed, which was going well and the decision of the HV was to offer a Universal Plus Service to mother and family due to the impending eviction.    24  5.3.63. The family were evicted from their home on the 27th October and placed in emergency accommodation in a neighbouring area. It would appear that only Ms X, Baby V and the two older children moved to this accommodation.       November 2014 5.3.64. On the 1st November a Social Worker in the LA4 contacted the police concerned about the welfare of Baby V because he was being transported in the street in a pram that was unsuitable for a newborn baby and the parents appeared to have been drinking.  Police were sent to conduct a welfare check on the child.    5.3.65. Ms X was assessed as being able to care for Baby V who was warm and sleeping. She was drinking a can of pre mixed alcohol but was judged not to be drunk and therefore police assessed that she was capable of caring for the baby. The police took No Further Action (NFA) except to send a MERLIN to LA4 Children’s Social Care (CSC) which was then forwarded to LA1 CSC. Baby V was two weeks old when this incident occurred.   5.3.66. On the 7th November a newly allocated Health visitor based in LA3 completed a ‘Transfer in’ home visit. Baby V was seen with both parents and there were no major concerns noted at the visit. Ms X informed the HV about the impending CPC which was due to take place on the 11th November. The allocated HV was unable to attend the ICPC and her manager went in her place.   5.3.67. Amid the growing concerns as referred to above an ICPC took place on the 11th November in LA1. All three children were made subject to CPPs under the category of Neglect and Physical Abuse. Concerns were expressed in relation to the parents’ excessive alcohol use and past violence in all the relationships. The conference was attended by Ms X and Mr W, but not Mr R. Ms X’s mother also attended.  5.3.68. After the conference the case transferred to the locality team and an introductory visit was conducted by the new workers on the 17th November. They discussed the issues raised at the ICPC.   5.3.69. On Thursday 27 November 2014 Ms X left the temporary accommodation in LA3 and went to Mr W’s home in LA4 taking Baby V with her and leaving Child U and Child B alone overnight. She left her mobile phone with them so that she could be contacted (via Mr W). On Saturday 29 November the Ambulance Service were called by the parents and they attended father’s address. The baby was not breathing and was judged to have been dead for some considerable time.   25  5.3.70. On the morning of the 28th November the Health Visitor called to see Ms. X and the intercom was answered by Child U who said that his mother was not in and that he had not seen her since the day before. The HV left a message with Child U for his mother to call her.    5.3.71. When the school realised that the children were not in they rang Ms X’s mobile phone. It was answered by Child U and the teacher asked him to come into school with Child B which they did. On arriving at school they became distressed and disclosed that Ms X had been drinking and had left the previous evening with Baby V because she was worried about Mr W. She had said that she would be back in order to take them to school but she had not returned.   5.3.72. The police and CSC were contacted later that afternoon by the school who responded straight away in trying to locate the baby and his parents. The parents were not located on the 28th November due to an incorrect address for Mr W being held by both the Maternal Grandfather (MGF) and CSC. The police arrived at the scene on the morning of the 29th November.   5.3.73. Exact events in relation to the death of Baby V between 27th November and 29th November have not been established for this review and the cause of Baby V’s death has been officially recorded as ‘unascertained’.  What is known is that both parents admitted to drinking heavily and failed to respond appropriately when they discovered Baby V not breathing. The parents did eventually contact emergency services on the morning of the 29th November and the Ambulance Service was dispatched to Mr W’s home address immediately. The parents were arrested at the scene and taken to hospital to be medically examined due to their disclosures that they had taken overdoses of Phenergan (anti-histamine)  5.3.74. On 29 Nov Ms X and Mr W were arrested and remanded in custody facing charges in relation to Baby V’s death.  Child U and Child B were removed to the care of relatives and remain in their care.    5.3.75. On April 2015 Ms X and Mr W both pleaded Guilty to the charge of Child Neglect in respect of baby V.  Additional charges of Child Neglect against Ms X were withdrawn.  Mr W and Ms X each received a custodial sentence of two months and fifteen days, which had been served whilst they were on remand; they were released with immediate effect.     26  6     KEY THEMES IDENTIFIED BY THE REVIEW PROCESS  6.1.     The impact of alcohol abuse in families.   6.1.1. A feature of the work with this family is that presentations to agencies were dominated by the needs of the adults Ms X, Mr W and Mr R. Between them their contacts with agencies number in excess of 70 during the period under review (just under a year) with a significant proportion of these contacts being in relation to the alcohol abuse of one or other of the adults.  This compared with Children U and B which, save for the time they spent in school (which was also patchy), number approximately 10. Between August and November MHS2 saw Child B seven times and the SW who conducted the assessment and subsequent s47 enquiries saw Child B twice and Child U once.   6.1.2. We know from extensive research that children are particularly affected by parental alcohol use and that parents become physically and emotionally unavailable often to the detriment of parental responsibilities. Increasing amounts of time are spent drinking or recovering from drinking which is associated with increased risk for children. Parental alcohol problems are associated with negative outcomes in children, e.g. poorer physical and psychological health (and therefore higher hospital admission rates), poor educational achievement, eating disorders and addiction problems (West & Prinz, 1987;6 Girling et al., 2006)7, many of which persist into adulthood (Balsa et al., 2009)8.   6.1.3. In this family much of the adults’ contacts were with a range of services such as GP appointments and A&E departments which then led to other services such as psychiatric assessments, hospital admissions and the offer of on-going treatment plans and support. The latter was rarely taken up by any of the adults.   6.1.4. It has become clear throughout the process of this review that these services were in possession of information which provided a worrying perspective on the adults involved in the lives of the children. Examples of these contacts include dates going back to 2011 when Ms X disclosed to her GP that she had been drinking more than 75 units per week at a time when Child U and Child B would have been 12 and 10 respectively. Later on in January 2014 she also admits                                                         6 West, M.O., and Prinz, R.J Parental alcoholism and childhood psychopathology. Psychological Bulletins 102:204–218, 1987.   7 Girling, M., Huakau, J., Casswell, S. and Conway, K. (2006). Families and heavy drinking: Impacts on children's wellbeing. Wellington, New Zealand: Families Commission  8 Balsa, A.I., Homer, J.F. and French, M.T. (2009). The health effects of parental problem drinking on adult children. The Journal of Mental Health Policy and Economics, , 55-66.    27  again to the GP that she has been ‘drinking heavily’ for the past year. This is with the backdrop of Mr R and Mr W (the children’s other two caregivers) also having significant problems with alcohol misuse.   6.1.5. More examples of these are Mr W’s two admissions to hospital in February and March 2014 when he disclosed information about his background, his mental health history and his history of alcohol abuse. He talked openly about his difficult relationship with his girlfriend’s children and cites them at one point as part of the reason he wants to kill himself describing Child B as ‘spiteful’.   6.1.6. Similarly Mr R presented many times to health services requiring treatment for excessive alcohol use, depression and suicide ideation. Much was known to these services about his family life as he was accompanied by his ex-wife Ms X on at least one occasion and the whole family (including Mr W) visited him whilst he was in hospital. Risk assessments were regularly conducted which included the risk to himself and considered risk to his immediate family. These were however internal processes and did not involve exchanging information with other agencies.   6.1.7. Ms X disclosed to the SW conducting the assessment that Mr R had been admitted to hospital due to excessive alcohol use and associated mental health difficulties but this was not followed up.   6.1.8. The reasons why practitioners did not assess this information as significant in terms of the impact on the children are very complex. No doubt the issue about Mr W in particular choosing to present to services outside of the LA1 area is a particular challenge. He accessed health services in LA4 and LA5 with similar issues (excessive alcohol use, depression and suicidal ideation) and although he talked about his girlfriend’s children he ostensibly presented as a single man with either his own address or as itinerant. The extent of his contact with the children was not considered.   6.1.9. The impact of the relationship between Ms X and Mr W which was one largely borne out of their mutual alcohol misuse was not understood by any agency. Furthermore attempts to understand the impact of this relationship on the children were few and far between.   6.1.10. There is a significant gap in information about the level of alcohol used on a regular basis by Ms X. As mentioned above in her history there are references to as much as an excess of 75 units of alcohol per week and at other times she describes ‘drinking heavily’. These descriptions are probably Ms X at her most candid (and may also be conservative) as when the referral to CSC by the midwife was made in April 2014 she did not disclose problematic drinking and claimed  28  that she had ‘given up’ both cigarettes and alcohol. She was not however consistent as to the date that she had given up but due to the number of different professionals involved this went unnoticed and therefore unchallenged by agencies. NB - The government’s current proposed safe limit of daily alcohol consumption is 2-3 units for women and 3-4 units for men.   Smoking and drinking any amount in pregnancy is actively discouraged.   6.1.11. In April 2014 at her booking appointment Ms X disclosed to the midwife that she was drinking 3-4 units of alcohol per day. In November after CSC became involved and began to conduct their assessment she stated to the Health visitor that the original midwife recorded this amount incorrectly and that it was 3-4 units per week.   6.1.12. Along with these factors it is noteworthy that no service or agency had an accurate assessment of the actual level of alcohol each adult was consuming on a daily basis. The levels of alcohol allegedly consumed were entirely self-reported and different amounts were reported to different professionals.   6.1.13. Whilst Mr W disclosed harmful amounts of alcohol to mental health professionals and his GP, his stance with CSC was that his alcohol use was no longer a problem. As these services were not connected up professionals were not able to establish a holistic picture and therefore make a more educated assessment of the impact that this was likely to be having on the children.   6.1.14. The CSC IMR’s analysis of this issue makes much of the fact that alcohol is a socially acceptable drug and argues that this may have been a factor in the failure to explore the issue further. Whilst there is no doubt this is true the answer is much more complex than that. It perhaps lies in the myriad of misinformation provided by the adults coupled with the lack of cogent information-sharing between agencies which happened largely because they were unaware of each other’s contact with the family. A combination of factors were at play here and some are summarised below:   Ms X never appeared under the influence of alcohol when she met with professionals.  Ms X in particular appeared to professionals to function effectively in her day to day life e.g. she was on top of her housing crisis; she appeared to hold down a job and attended all her antenatal appointments.  Although it is not clear if the children were asked directly about their parents’ alcohol use they did not disclose any concerns about their parents’ use of alcohol.   29   The midwives did not revisit the issue of cigarette and alcohol use in ante natal appointments and it is likely that if they had Ms X would have stuck to her script of having ‘given up’.  The GP in Practice 1 who held information about Mr W and his history was not present at the CP conference and did not provide a report.   CSC and other children’s agencies were unaware of Mr W’s presentations to hospitals.    Mr R was not assessed by a multi agency network in relation to his children and the impact of his presentation on them.  CDAS1 did not identify any concerns with problematic alcohol use when the parents presented there.  Historical information was not treated with due weight and consideration (see next section).  6.1.15. At critical points when all of the information should have come together such as the discharge planning meeting after Baby V was born, the ICPC and the subsequent core groups, large chunks of information about the adults were missing - e.g. those professionals were unaware of Mr W’s hospital admissions earlier in the year.  Information about Mr R’s admissions to hospital was not followed up.   6.1.16. Furthermore information that was available was not considered robustly enough. For example the meaning behind the crucial piece of information from LA2 CSC that Mr W was not allowed contact with his own son (not a decision that is ever taken lightly) was lost in favour of Mr W’s assertion that this was ‘no longer an issue’. This was despite information to the contrary which is discussed in more detail in section 6.3.   6.2      Early Intervention as a tool for safeguarding   6.1.17. One feature of work with this family was that throughout the period under review agencies involved with the children were concerned about them for a variety of reasons.  6.1.18. In August 2014 MHS2 made the referral that led to CSC intervention but prior to that the school had ongoing worries about their attendance and Child B’s presentation. They were also aware of Ms X’s drinking and had concerns about nutrition and hygiene. The midwife was concerned about the unborn baby in relation to Ms X’s and Mr W’s alcohol use and mental health issues, resulting in her making a referral to CSC.      30  6.1.19. These were all early indications that the needs of the children were not being fully met. Early Intervention (EI) through universal services or more targeted provision is the nationally identified mechanism by which families can be encouraged to accept help from a range of agencies. The Common Assessment Framework (CAF) is the most commonly used conduit to providing services to families whose needs fall below the threshold for intervention from CSC.   6.1.20. School did provide some services that could be described as Early Intervention in that the children were provided with extra help and support and were often in special classes where they could be more easily nurtured and supported. There was also good communication between school and MHS2 particularly when Child B’s mental health deteriorated.   6.1.21. No agency however conducted a formal CAF assessment despite at least one recommendation by CSC that one should be undertaken. It has transpired during the process of this review that the midwifery service have no record of a letter that CSC sent following the referral in April 2014 recommending that they complete a CAF. It has not been established how this went astray but it meant that agencies failed to identify one of the key benefits of EI which is that it engages the parent in a positive partnership on behalf of the child/ren. It is clear that there were increasing concerns about the children’s well-being throughout this year but there was no evidence that Ms X (or Mr R for that matter) was engaged in a purposeful dialogue about them.   6.1.22. Eileen Munro in her review in 2011 identified the challenge for professionals working with families. ‘There is a tension in providing support to parents. For most, the right approach is to offer services with families making a voluntary choice to receive them. There are families whose level of parenting raises some concern and the relevant services make more strenuous efforts to make them aware of the help available and to gain their co-operation. A complicating factor is that parents who voluntarily engage with support services tend to make more progress while a more coercive approach can deteriorate into an adversarial relationship which blocks progress.’ 9   6.1.23. The benefits of a CAF can be assessed as it being the opportunity for agencies to gather information and have a more structured multi-agency response to the presenting issues. This in turn may have uncovered further evidence of harmful behaviour traits associated with the adults. It may also have elicited more information from the children themselves about their lived experience. The absence of this process meant that the signs of neglect already evident were not shared. As Eileen Munro goes on to comment in her later document                                                         9 Page 21, The Munro Review of Child Protection Interim Report: The Child’s Journey Professor Eileen Munro Crown Copyright 2011    31  there is a risk that ‘parents who are neglectful may become more harmful’10.   6.1.24. It is possible that Ms X would have refused such an intervention and as can be seen, particularly in the latter stages of her involvement with CSC, she not only begins to withdraw her minimal acceptance of services, she becomes unco-operative. E.g. Ms X fails to let the SW know her new address and Housing provided this. She did however at least on the surface engage (in so much as she generally attended meetings and appointments) with other agencies despite the fact that she was sometimes less than truthful about her lifestyle. She attended many meetings with school who attempted to assist her in improving the children’s attendance.   6.1.25. The agency that Ms X had the strongest relationship with was school and they rightly analyse this issue in their IMR and see it as a missed opportunity to work with the family in a more structured way.   6.2.        Lack of dynamic assessment   6.2.1.     When undertaking a serious case review it is important not only to understand what professionals did but also why they took the actions they did. A factor in this case is the way in which childcare professionals accepted the word of the adults without cross referencing this with other information available.   6.2.2.      Ms X and Mr W were dishonest about their alcohol intake. Ms X was not truthful about her relationship with Mr R, telling professionals (Housing and Midwifery) that due to an incident of DV she no longer had any contact with him. This is in direct contrast to what Child B said in September who described her mother as having a strong relationship with Mr R. More conflicting information became particularly apparent from the end of August when separate pieces of information began to emerge. Examples include the anonymous referral in September which stated that the adults were ‘drinking all day’ and Ms X had ‘admitted to drinking’, and the police referral at the beginning of November where although not described as drunk Ms X was drinking alcohol in the street with Baby V aged two weeks. Further concerning information was received from LA2 CSC in relation to Mr W’s extensive history.   6.2.3.     Adult services in turn had a more accurate picture of the extent of the adults’ alcohol use but for perhaps for some of the reasons stated in section 6.1 did not share the information with children’s services colleagues.                                                           10 Page 25, The Munro Review of Child Protection Part One: A Systems Analysis Professor Eileen Munro Crown Copyright 2010    32  6.2.4. One of the most persistent and problematic tendencies in human cognition is a reluctance to revise an initial assessment of a situation. Once people have formed a view on what they believe is an accurate picture of a given situation, there is a tendency to dismiss later evidence to the contrary. As Eileen Munro has described it, ‘Becoming fixated on one assessment despite an emerging picture that conflicts with it becomes a significant source of cognitive error.’11   6.2.5. Opportunities to identify and assess the conflicting information were not used effectively. The CSC assessment stemming from the referral from MHS2 at the end of August lacked analysis and the report presented to the ICPC is a factual narrative of the presenting concerns with limited analysis included. Working Together 2015 (p.22) states that the aim of the Child Protection investigation is to “reach a judgement about the nature and level of needs and/or risks that the child may be facing within their family”. It would appear that no such meaningful judgement was made with the information available. The CSC IMR rightly concludes “professionals appeared optimistic about the mother’s abilities and intentions, misguided by her presentation and the fact that she had seemingly carried out her care of Baby V without any incident or notable concerns”. The optimism in my view is not just with regard to Ms X but also about all the adults responsible for the care of the children.  6.2.6. Many of the agencies that had had significant contact with the family throughout this review period did not attend the ICPC: The Housing Needs Officer, the Midwifery Service, the Health Visitor, MHS2, Ms X’s GP, Mr W’s GP, CDAS1 and most importantly the children, all had information to contribute but were not present. Ms X’s GP gave a verbal update to the SW prior to the conference and did not report any safeguarding concerns.   A document was faxed to Mr W’s GP surgery but there was some confusion at the surgery as to what the document was and through the review it has been established that it was believed to be a set of incomplete conference minutes and as such they did not respond. It is not clear why this was not followed up with CSC to try to clarify the information.   6.2.7. In 2013 LA1 LSCB endorsed the model of ‘Strengthening Families’ for Child Protection Conferences. This is a strengths based model based on the work of Andrew Turnell who developed the risk assessment tools known as ‘Signs of Safety’. This model allows all those present to contribute to what they perceive the risks, strengths and protective factors are and these are openly discussed and displayed on whiteboard (or equivalent) during the meeting. Complicating factors and grey areas are also discussed and it is significant to note that the amount of alcohol the adults consumed                                                         11 Page 53, A review of safety management literature, Eileen Munro, London School of Economics. SCIE 2008   33  was not listed as a grey area, nor was the question of how much time the respective fathers spent with the children and what the quality of that contact was.  A more thorough assessment prior to the ICPC may have answered some of those questions but equally they were not posed by any of the professionals present.    6.2.8. It is possible that the professionals attached more significance than was warranted to positive information such as Ms X’s interaction with Baby V to the detriment of attaching more meaning to the worrying information. This is again a common flaw in human thinking and can be explained because “early cues strongly suggest [plausible but] incorrect answers, and later, usually weaker cues suggest answers that are correct’12 This coupled with the fact that significant information was missing from the complete picture led to insufficiently robust action by the multi-agency network.   6.2.9.   Reflective Supervision is crucial when addressing cognitive issues. These types of erroneous thinking and decision making are unlikely to be recognised by the individuals themselves. The role of the manager is to provide an opportunity for reflective thinking and to challenge the worker to consider whether the assessment process has been sufficiently broad and robust. This is a challenge faced by health, social care and other professionals working in the field of safeguarding. (More is said on the subject of supervision in 6.6.)   6.3.       The Voice of the Child   6.3.1. An important theme that arises from many SCRs is how well professionals ensured that children were at the centre of the service delivered. The child’s voice within any assessment or ongoing contact is important as it ensures that professionals understand the impact of issues on each individual child.  The ultimate aim of the assessment is to improve outcomes and life chances for children.  6.3.2. The three children in the family came into contact with a range of     services throughout the period under review and all had differing needs. In relation to Child U and Child B agencies’ contact was limited and as been said elsewhere the number of contacts for the children was considerably less than that of the adults. As the children presented with such differing needs there is a separate section for each one in turn.   Child U   6.3.3. At the time of the death of Baby V Child U would have been 15 years and 6 months old. He was a year 11 student preparing to undertake his GCSEs. The education IMR prepared for this review                                                         12 Page 53, A review of safety management literature, Eileen Munro, London School of Economics. SCIE 2008   34  details how he presented in school and it seems that the school and particular teachers had a positive relationship with him. The IMR also does however describe Child U as a child with low self esteem and little motivation with an unusual sleeping pattern which did not appear to have any explanation (i.e. he slept from 5pm and was awake from midnight onwards). The school provided him with an alternative provision which consisted of a small group of students and teachers.  Within the unit he was supported in catching up with school work that he had missed, in a more nurturing environment.   6.3.4. A major feature covered by the education IMR was the chronic poor school attendance of both children which at times during the period covered was as low as 50%. No statutory action was taken in relation to the poor school attendance and although the school worked hard to maintain relationships with the children and Ms X this was to the detriment of the children’s need and right to education. Specifically in relation to Child U, there was a period of prolonged absence between May and June 2014, when due to an administrative error about how the absence had been recorded, he was not seen in school for a period of 28 days. This had implications regarding increased risk for both children. The education IMR is right to be concerned about this putting Child U ‘in an increasingly vulnerable position, which subsequently may have also minimised the perceived level of risk placed on Child B’s absence when she was absent during some of the same period of time’.    6.3.5. During the review period Child U was also seen by the family GP who made an hour long appointment to see the family to assess them prior to the ICPC. This was very good practice on behalf of the GP in terms of making the appointment and seeing the family altogether and she did offer the children the chance to be seen on their own but they declined. During the interview neither child disclosed anything remarkable but they were unlikely to do so given that mother was present. The information provided by the GP to the ICPC did not highlight any concerns and it would seem that Ms X was not challenged in relation to historical information about her past alcohol use or the children’s relationship with Mr W. It is however unlikely that this would have elicited more accurate information.    6.3.6. Child U was seen once by the SW from CSC during an assessment period that lasted from the beginning of September to the start of November.  This is unacceptable as it would appear that when the case status changed from s17 to s47 enquiries in October Child U was not consulted separately about the particular concerns raised by the s47. In the interview the SW conducted with him it would appear that specific questions were not directly asked. This may have been due to the SW trying to get to know him first and from information contained in the CSC IMR he appeared reluctant to give any information about his life. Further opportunities to build a more  35  meaningful rapport did not present themselves and Child U was clear with the SW that he would prefer not to have further contact.   6.3.7. It is not clear if Child U was invited to the ICPC in his own right or if it was discussed whether, and if so how, he would like to participate but he was not present. His views were discussed at the conference and were based on his conversation with the SW. The views shared were around Child U’s worries about their financial situation and the fact that he was worried about housing and where they would live. Appropriate significance was attached to these concerns being beyond what a fifteen year old boy should be concerned about but the truth of his lived experience was largely unknown at that stage. Child U was seen twice by the new SW after the ICPC but there was little time before the death of Baby V to attempt to build a relationship. This has been rectified since and the children’s grandparents reported that the children enjoyed a positive relationship with their social workers through the care proceedings.   6.3.8. In the period under review save the time he spent in school Child U was seen only four times by other professionals and only one of these was on his own. As has been discussed elsewhere in the report earlier opportunities to assess Child U’s needs in a more structured way via Early Help were missed and therefore the extent of the neglect he suffered went undetected.       Child B   6.3.9. Child B was 13 years and 8 months old at the time of the incident. She had more contact with professionals largely due to her mental health difficulties and subsequent involvement with MHS2. She was also more open about her feelings than Child U. Although the referral took several months to come to fruition, once established regular appointments were offered. Sadly not all of these were taken up for various reasons but there was some targeted intervention to try and assist Child B with her anxieties.   6.3.10. At the first appointment with MHS2 Child B’s description of her experience with Mr W resulted in them making the referral, which led to the CSC involvement. The referral was delayed but it did indicate that the service had taken her statements seriously and that they had listened to her concerns appropriately linking her distress with his arrival in the family home. The service continued to attempt to work with her but there was an inconsistent pattern of attendance and apart from four appointments that were attended in September attendance was sporadic. It is significant to note that no further appointments were attended in August after the referral was made to CSC and there was a gap of at least 7 weeks between September and the last appointment before the death of Baby V on the 21st November. It is not clear if or how the lack of attendance was communicated to CSC who by mid October were conducting s47  36  enquiries and by mid November had made the children subject to CPPs.  6.3.11. As with Child U the school had a positive relationship with Child B and facilitated the referral to MHS2 when she made her disclosures about hearing voices. School made every effort to support Child B whilst the referral to MHS2 was in the offing and made a further referral when her mental health appeared to deteriorate. Again as with Child U, Child B was able to make use of the special unit (alternative provision) and there is no doubt that she benefitted from the extra support they were able to offer. The lessons to be learned in terms of her poor attendance are echoed from the previous section concerning Child U.   6.3.12. Child B was seen twice by the SW who completed the C&F assessment but again was not consulted separately about the concerns raised via the s47 enquiries. The SW engaged her in some Direct Work and the information gathered was shared at the ICPC but Child B and Child U were anxious about the conference and would have benefitted from greater preparation for the meeting and being able to participate more fully.      Baby V  6.3.13. Ensuring that the voice of the child is assessed and analysed becomes trickier when the child is preverbal as was the case with Baby V. As has been discussed opportunities to assess Baby V prior to his birth were not taken and opportunities after he was born were few and far between. In situations where children are not verbal professionals rely on other cues such as observations, eye contact and physical contact between parent and baby. Further in the case of a newborn baby professionals may also consider whether or not they were planned and what preparations had been made for their birth.  Parents’ lifestyles may also be assessed and as we have seen there were such gaps in the information known that these did not have as much bearing as they might have done. Two health visitors made encouraging observations of Ms X and Baby V, and no concerns were noted by hospital midwifery staff in the days following his birth, further reinforcing the positive aspects of Ms X’s parenting.   6.3.14. Assessments were completed by CSC, Midwifery, Health Visiting Services and police (on one occasion) but were cursory in terms of the impact of the parents’ lifestyle on the needs of a new born baby.   6.4.15 The child’s voice is missing from the referral from the Midwife in April as it details the need for support for Ms X and Mr W but does not specifically mention the needs or risk of harm to Baby V as an unborn child.   37  6.4.16 Other adults may also try and speak on behalf of the child or children by expressing concerns – this can be said of the anonymous referral received by CSC at the beginning of September but the concerns were not specifically addressed with any of the children prior to the ICPC.     6.4.17 The ICPC itself was mostly silent in relation to Baby V and his lived experience and there was further scope within the conference to be much more specific about the incompatibility of parents who are heavily reliant on alcohol and being able to meet the emotional and physical needs of an infant. More focused outcomes in relation to the baby may have been beneficial for him and indeed for the older two children.   7.         ANALYSIS FROM THE IMRs        Introduction     The IMRs reviewed by the panel in relation to this review were all accepted by the panel and were generally of good quality. A training event was held at the beginning of the SCR process where the authors were given guidance on what information to include in their reports. The authors were invited to complete a first draft on a specific template which was reviewed by the panel. This was followed by a presentation by each author at an extraordinary panel where authors were given feedback and asked to amend their reports. The IMRs contain relevant details about the particular issues to be addressed from the ToR and these have been commented on where necessary either drawing on them directly or the author drawing conclusions obtained in the process of pulling the review together. These are mainly points where the author particularly agrees or disagrees with the conclusions reached by the various agencies. Other points have been made where issues were particularly significant.  Where these have already been commented on at length the section refers the reader to the relevant section.    7.1.        Were established policies and procedures well understood and followed?   7.1.1. All agencies referred to appropriate policies and procedures being in place and generally followed and where they were not followed agencies have endeavoured to correct these well before the publication of this review. For example Housing have changed their policy on attending Child Protection Conferences and will now always try to keep families who are subject to CP procedures remaining in their home borough.  Education note that their Missing from Education policy was not adhered to in the first half of 2014 but this has been rectified by the latter half of the year.   38  7.1.2. There are a few exceptions regarding procedures that had implications for the way in which the case was dealt with. The MHS2 referral in relation to Child B at the end of August was delayed by some three weeks. The reason for this was due first of all to waiting for consent from Ms X. Whilst it is good practice to inform the parent of a referral it is not necessary to gain consent for a CP referral and this caused an unnecessary delay as Ms X proved difficult to get hold of. It has become clearer through the process of the review that she became more avoidant of MHS2 after Child B’s disclosures particularly in August.   7.1.3. The second reason was due to difficulties in accessing LA1’s on line referral form which was experiencing technical problems. Although it is recorded by the worker that the system was down, and they had attempted on several occasions to make the referral it is not clear why an alternative method (phone, email, letter) was not considered sooner. The London Child Protection Procedures are clear that once a concern has been identified the referral should be made ‘not longer than within one working day’ (1.5.7 p22). This practice falls short of acceptable standards due to the serious nature of the concerns that were disclosed by Child B. This was then exacerbated by the tardiness of CSC in establishing the reasons behind Mr W’s non-contact with his son, which were not confirmed until the beginning of November.   7.1.4. It is also worthy of note that the MHS2 referral took 8 months to come to fruition and for Child B to be seen. The author understands that the referral passed through the appropriate channels and that this length of time from referral to assessment was not unusual. NB Separate to this process a review of MHS2 has been undertaken and a plan is in now in place, which will be managed through the local relevant Partnership covering children and their families. As part of this plan, a significant uplift in resources is being made available to MHS2 over two years to improve access times for children and young people within LA1, with the impact of this work starting in 2015-16.  7.1.5. Local Health Services failed to keep the issue of Ms X and her alcohol use under review throughout her pregnancy. Although it is unlikely that this line of questioning would have elicited a different response other than she had given up it would have kept the issue on the agenda. This was important as she had not accessed help or support for it and this could have been routinely offered through the services of the CDAS2.  Hospital 3’s IMR rightly points out that ‘this was not done and therefore, a robust approach to monitoring Ms X's alcohol consumption was missing throughout the pregnancy’  39   7.1.6. It is unfortunate that on the day of the crisis (28th November) following Ms X’s disappearance with Baby V a series of misinformation and other events prevented more urgent action from being taken.   7.1.7. The HV called to see the family for a pre-arranged appointment but was told by Child U that his mother had left for LA4 the evening before and had not returned. The HV was not concerned about Child U being on his own as rightly he was at an age where this would not be a problem. However it overlooked the safeguarding concern that two children under the age of 16 who were the subject of CP plans due to neglect, had been left alone overnight. No action was taken and on reflection there has been an acknowledgement that it would have been good practice to have made contact with the social worker to inform her of this. Further exploration of the children’s circumstances by the HV and more professional curiosity about the whereabouts of Ms X and why she had not returned may have alerted other agencies sooner that something was amiss.   7.1.8. Child U and Child B were then contacted by the school and made their way there. They arrived at school at about midday and according to school records Child U became distraught and disclosed that their mother had been drinking heavily and had left with Baby V the evening before and had not returned. The children were extremely upset and the school’s attitude and approach to ensuring they were looked after including feeding them was exemplary. The school made several attempts to contact Ms X via Mr W’s mobile phone but to no avail (they had the wrong number for Mr W) and it was not until 3.30 that the first call was made to the police.  The immediacy of needing to ensure the safety of the baby was overlooked.  A further call was made to the SW at 4pm. School had also attempted to contact the children’s grandfather who was also not contactable straight away. He did however respond as soon as he was able and acted appropriately.   7.1.9. When the police became aware of the situation they responded straight away but were dispatched to the wrong address because of an error in the information held by both the MGF and CSC. The police did not arrive at the address until the following morning after the ambulance had been called.   This matter is subject to an investigation by the Police’s Professional Standards Unit so what can be said in this review is limited by that.      40  7.2.        Were appropriate and robust assessments, including risk assessments carried out in view of the parents’ historic involvement with agencies, and ongoing issues with alcohol and substance misuse, and Baby V’s father’s previous involvement with social care?  7.2.1. Much of this subject has been covered in section in 6.1 and 6.3 but other analysis is also worthy of note in this section.   7.2.2. Many of the agencies conducted assessments throughout this period and with the exception of CSC all were carried out in isolation without consultation with other agencies. This meant that none of the agencies had a holistic picture of the family and their day to day lives. The CSC assessment was lacking information from adult services for the reasons discussed in section 6.1.   7.2.3. As discussed in section 6.2 there were missed opportunities to initiate the CAF process which would have brought together at least some of this information much earlier in the year leading up to the death of Baby V.   7.2.4. School missed an opportunity to formally assess Child U and Child B’s lack of school attendance under statutory regulations despite their attendance being well below the threshold (the threshold being 85% and their attendance for significant periods was as low as 50%) where statutory intervention would apply. Although much support was offered to the family by the school the rationale for not considering referring to the LA was to try and maintain a relationship with Ms X and not further alienate her.   7.2.5. Unfortunately the support offered did not improve the children’s attendance to a satisfactory level and as current guidance indicates should have been considered more robustly as per the Education (Pupil Registration) Regulations 2006, therefore triggering a Criminal Investigation by the Local Authority. The IMR provided by Education makes this point well, stating that ‘Prosecution is only one of a variety of outcomes of an investigation, and will not be considered if it is evident where a family has unmet needs that would benefit from further support from professionals’.  Further support may have then been offered in the form of an Early Intervention Support Plan. The added benefit of an investigation of this nature would have been in the gathering of information from a range of other sources as well as more targeted help with getting the children to school.  The school nurse would have been one such professional to have contributed to a more multi-agency approach to consider any health problems the children may have had.     41   7.2.6. In their IMRs mental health services (children and adults) refer to risk assessments carried out in their agencies. These are internal assessments and were not shared with, or completed with, information from other agencies. There may well be fundamental cultural and organisational differences in the term ‘Risk Assessment’ with its meaning between agencies at considerable variance in terms of the types of information that make up an assessment of this kind. In a review of effective approaches to risk assessment Dr. Monica Barry states that “differing organisational cultures, differing definitions of risk and a hierarchy of professional expertise may deter the development of a common understanding and language of risk”13   7.2.7. As discussed elsewhere in the report a fundamental difficulty with many of the assessments was either the lack of knowledge of the history of the adults or the failure to place it in the context of an overall assessment. A further example of this is the assessment made by GP Practice 2 who concluded after an hour appointment with Ms X, child U and Child B prior to the ICPC that there were no safeguarding concerns. Although this thoroughness was very commendable and more proactive than most GPs are usually able to be, it failed to take into consideration the history held on record by the surgery re Ms X and added weight to the notion that alcohol was not a current problem for her.   7.2.8. Mr W’s GP failed to make the connection between the unborn baby and Mr W by not exploring this issue further when the information presented itself in March 2014. This was further compounded by confusion over the receipt of information about the ICPC. The result of this was that no risk assessment was made on receipt of this information and no contact re Mr W and the children was made between the practice and CSC to inform the ICPC.   7.2.9. The drug and alcohol agency CDAS1 took over the services previously provided by another provider from the 1st October 2014. On advice from the SW and to demonstrate compliance with the Written Agreement Ms X and Mr W presented themselves to that agency on the 20th October but were not fully assessed. This was due to the fact that there had not been a formal referral at that point from the social worker. The parents presented denying any misuse or abuse of alcohol and the referral from the social worker with supporting information was made the following day. Ms X was then                                                         13 Page iv Effective  Approaches  to  risk assessment  in  social work: An International  Literature Review: Dr. Monica Barry Social Work Research Centre University of Stirling (2007)   42  offered a triage appointment which took place towards the end of November (3 days prior to the death of Baby V). Again Ms X denied any problematic alcohol use and nothing in the appointment alerted the worker to think otherwise, perhaps compounding the view further that Ms X’s alcohol use was under control.   7.2.10. A common feature of all the assessments examined as part of this review is that they lacked the professional curiosity described by Lord Laming (2009)14.  The importance of ‘respectful challenge’ of parents, colleagues and professional in other agencies, needs to be an integral part of professional practice. Pertinent issues were identified in all of them and this is to be commended but there was limited on-going challenge of the presenting vs. the emerging picture.  Much has been said already in this review about the use of supervision which is also integral (see section 7.6)  7.3.       Did professionals have sufficient understanding of how cases of alcohol misuse may present?  How was this addressed and the possible impact on the parents and children considered?   7.3.1.     This subject is covered extensively in section 6.1  7.4.        Did professionals have sufficient understanding of how cases of neglect may present? How was this addressed and the possible impact on the parents and children considered?   7.4.1.     Much of this has been covered in section 6.2 when considering issues about Early Intervention but other issues should be noted in this section.   7.4.2.     The Health Overview Report (HOR) rightly makes the point about the needs of Baby V as an unborn child. There is no evidence to suggest that there was consideration of the impact of Ms X’s alcohol consumption on foetal development or the risks associated with safe care and breastfeeding.   7.4.3.     The midwife who booked the ante-natal care did make the referral to CSC in April 2014 but the issues were not explicitly stated and the referral requested ‘support’ for Ms X in her alcohol consumption and mental health. There was no follow up communication between the midwife and CSC which would have further verified the concern and helped clarify the way forward. According to CSC workers who were consulted as part of this review the volume of referrals received simply does not permit follow up for this type of (as perceived) low                                                         14 The Victoria Climbie Inquiry, 2009  43  level referral. The issue of alcohol and smoking cigarettes was not addressed again through the pregnancy.   7.4.4. There was no challenge to CSC’s decision not to pursue an assessment but the issues identified did not disappear. This serves as a reminder that referring concerns to another agency does not discharge agencies’ safeguarding responsibilities.  The referral would have benefitted from being discussed between agencies and if no resolution at that stage could be reached about the best way forward escalated to senior managers to resolve.   7.4.5. The review also highlights the challenges of working with teenagers suffering neglect and it is surprising in many ways that Child U and Child B did not come to the attention of statutory services sooner. As mentioned previously the CAF process may have assisted in this case but it would appear that when the children were spoken to they  (unsurprisingly) remained loyal to their mother and father.   7.4.6. The difficulties of assessing neglected children are well documented (Reder and Duncan (2004). They may be silent, have no expectations that their needs will be met and, despite their suffering will remain loyal to their parents. Child B’s disclosures to MHS2 were entirely in relation to Mr W – an adult she felt no loyalty to and resented the presence of, but there were no such disclosures regarding either of her parents despite their turbulent and neglectful behaviour. Child U similarly does not disclose problems at home other than worrying about their housing and financial situation.   7.4.7. There are indications that despite the difficulties there were aspects of good parenting and both children are described as polite and respectful. This is perhaps another reason professionals did not realise the extent of the problems within the home. Children displaying more problematic behaviour are more likely to come to the attention of statutory services sooner.    7.5.       To what extent was the relationship between any of the parents explored by professionals.   7.5.1    A feature of this case was the uncertain nature of the relationship between all of the adults. Some of the history is known through the information collected by the social worker for the assessment and s47 enquiries but information about the current situation from the family was sketchy and not always completely accurate. Information shared between professionals about the extent of the contact between all three adults was also sketchy and was underlined by a  44  lack of curiosity about the relationships. The result was that no one agency had a complete picture.   7.5.2        Information and therefore assessment about the men in particular was weakened by the fact that neither of them lived permanently in the family home. Their extensive contact and influence was overlooked.  7.5.3. This reflects a previously considered topic in SCRs (including a recent LA1 one) about practitioners failing to assess the impact of men who have significant involvement in children’s lives. Much has already been said about how little was known about the two men. Turney et al (2011) says it succinctly: ‘Professional vigilance is necessary to ensure that information about fathers is available whenever possible, especially as fathers may exert a considerable influence even when they are not living with their children’15   7.5.4. Furthermore in this family the impact of all three adults’ lives being heavily dominated by alcohol, associated mental health problems and domestic abuse was underestimated. The dynamics of having all three of them together in the household (referred to on at least one occasion by Child B) was not considered.   7.6.       Management oversight and supervision   7.6.1. Many of the IMRs are silent on the issue of supervision as they do not generally describe the supervision process and its impact on how the case developed and how decisions were made.   7.6.2. There are also discrepancies in agencies about the expectations of supervision in a safeguarding context. For example in some agencies such as the Health Service, health visiting and midwifery the volume of cases means that not every case is discussed in supervision and it is the responsibility of the practitioner to flag up those that need specialist attention. There is an expectation that cases where children are subject to CP plans would always be presented but this does not preclude practitioners discussing other cases of concern.  This did not happen in either of these services despite the referral to CSC having been made in April 2014 and their subsequent involvement from August 2014.                                                           15 Social work assessment of Children in need: what do we know? Messages from research: Turney et al DFE 2011  45  7.6.3. The HV in LA3 did take the case to supervision as the case had been presented to ICPC (albeit in another borough). Not much detail is given about the content of that other than to say that the HV plan (which was appropriate) was to visit fortnightly. It was also fortuitous that the supervisor in this case was familiar with the family as she had attended the ICPC on behalf of the HV.   7.6.4. The review also highlights the lack of safeguarding supervision for schools and GPs who deal with children at risk on a regular basis.   7.6.5. The CSC IMR analyses this issue effectively by asserting that the supervision conducted about this case summarised the concerns clearly but did not act as a catalyst to move the case on and revise current thinking. The author goes on to describe the likely organisational context in which this happened such as the high pressured environment in which practitioners work, high caseloads and raised thresholds. The extent of this has not been confirmed for this review but it was noted in the SCR panel that a recent audit of LA1’s MASH arrangements found that thresholds were in line with the London Continuum of Need Threshold document.   7.6.6. The review has found that not enough attention was given to the supervision process in any agency given the complexities of this family situation.     8.       CONTRIBUTION FROM THE FAMILY       Maternal Grandparents  8.1.       The maternal grandparents (MGP) were interviewed as part of the review and were open and honest about the events leading up to the death of Baby V. They were informative and considered in the information they gave and were happy to contribute.   8.2.       The MGPs felt that there had been a big build up to Ms X becoming very stressed and very low which as far as they could tell began in late 2013 when she was threatened with eviction. They said that some of the information about this is incorrectly stated in reports and that the impending eviction was not due to rent arrears (as depicted in some agencies records) but because the landlord wanted the property back. Ms X did not have the money for a deposit for a new property hence her seeking assistance from Housing in LA1.     46  8.3.       In terms of services offered to the family they felt very strongly that Housing should have offered the family accommodation which would have enabled them to remain in the LA1 area. They felt the move to LA3 had contributed to Ms X feeling low as the accommodation was so far away the family lost their support network. The move made life very difficult as the children now had a long journey to school, Child U was very upset about the fact that he could not take the family dogs and Ms X was isolated from her family. They all missed the familiarity of their previous surroundings.   8.4.       The MGPs also felt that it was difficult to liaise with professionals such as CSC Emergency Duty Services (EDS) and the police on the night that their daughter was missing (28th November). They stated that they had expected a visit from the police that evening but they didn’t visit and they rang EDS and were told that someone would ring them back which they did not. They were naturally very worried about their daughter and grandson and were unable to glean information from agencies about the progress of any enquiries to determine their whereabouts. They did however also comment that services had been ‘brilliant’ since the death of their grandson, particularly school, CSC and the police.   8.5.       The MGPs commented that their daughter had a very loving relationship with all her children but treated them more like friends. They thought that this might be one of the reasons why she struggled to get Child U and Child B to school as sometimes when they refused to go she found it hard to display the necessary firmness to get them up out of bed and to school. The MGPs appreciated everything that school had done for them and were continuing to do so whilst the children were with them.    Ms X and Mr W  8.6.    Ms X and Mr W were interviewed together by the overview author together with the LSCB Manager and at the time of writing the report they had lived together in rented accommodation virtually since the time of their release from prison.   8.7.    Their overwhelming sense of sadness at the loss of their baby was very evident and it is to their credit that they offered their views to the review at such a difficult time.   8.8.   Both Ms X and Mr W felt that they needed to raise the fact that they felt services had made them out to be much worse than they were  47  and also felt that they had been maligned in a way that was neither accurate nor fair, particularly during the care proceedings initiated by CSC. For example they disputed the fact that the children ever went to school looking unkempt and stated that Ms X always made every effort to get them to school. Ms X acknowledged that she sometimes treated Child U and Child B more like her siblings than her children and despite her best efforts she could not get them to school if they did not wish to go. She recounted the various meetings that had been held with school to try to improve their attendance but nothing worked and she could not suggest anything different that could have been done at the time to assist further.   8.9.    School and MHS2 had tried to help with Child B’s behavioural difficulties but this was also to no avail – again she could not think of any other services that could have been offered or that services could have done more to help her or the children in this respect. They both acknowledged the difficult relationship between Mr W and the children, especially Child B.  They felt this was caused by jealousy and that when Mr W had twisted her arm behind her back this was in self defence as they advised that Child B had jumped on Mr W to assault him.  Ms X advised that she had told Mr W that it was inappropriate to kiss the Child B’s self-harm scars and they both dismissed the account of having held Child U up by the neck as untrue and malicious.   8.10.    In terms of their housing situation at the end of October when the family were evicted they both felt (as did the MGPs) that placing them outside the borough put undue pressure on the household and that life became very burdensome after this move. The children would not go to school unless Ms X drove them in the car, which with a tiny baby and a car that was parked some distance away from the accommodation (due to parking restrictions), proved almost impossible.   8.11.     In relation to their drinking Mr W acknowledged that his drinking at one time was problematic and that he had spent considerable time in rehabilitation centres. He did however gain control of his drinking and prior to meeting Ms X in 2013 he had been abstinent for 3 years. He became an AA sponsor and was part of AA’s management team using his experience to help other problem drinkers turn their lives around. One person he sponsored was a family friend of Ms X and the couple met through her.  He turned to drink again due to the stress of his living situation but claimed that it was under control during pregnancy with Baby V.   48   8.12.    Ms X said that her drinking was never problematic and that she never drank or smoked in front of the children, and therefore she did not require any help to curtail it.  However, she did advise of having an addictive personality.   8.13.    On the night in question before Ms X realised that Baby V had died she had every intention of going back to the accommodation in the morning to take the older children to school. She did not think it was a problem to leave them on their own due to their ages and the fact that Child U in particular was very sensible. She acknowledged that she had been drinking (two drinks) before she left but was still able to care for the baby. When she realised that Baby V had passed away she was too distressed to leave him and could not return to the flat.  The parents feel very strongly that it was nobody’s fault that Baby V died and there were no services that could have prevented it.       9.         LESSONS LEARNED FROM THE REVIEW        Better use of early help and intervention  9.1. Children are much more likely to have a positive outcome if their difficulties are recognised at an early stage and they receive help. The importance of early intervention processes that are understood and   owned by all agencies are crucial. Early signs of neglect were not shared between professionals because no use was made of the current mechanism for doing so e.g. a CAF assessment.   Individual agencies offered a range of support to the children but the extent of their neglect went unchecked. As has been said teenagers who are neglected can be particularly difficult to engage but a multi-agency approach would have had the advantage of considering the forms of help available and who was best placed to provide this.  The role of supervision for all agencies   9.2. The review highlights the necessity of good reflective supervision and management scrutiny in all agencies to minimise the effect of common cognitive errors which practitioners need assistance with. The role of managers to stand back and help practitioners unpick and fully appreciate the complexities of a situation was missing. This is particularly prevalent in families such as this where the issues are multi-faceted and complex.     49  Assessment and impact of males in families  9.3. Fathers and other significant males can be very influential in families and as such there is need for all agencies to ensure that relevant information about them is collected during the assessment process and kept under review. Very little information was known or considered about either of the fathers in this family particularly in relation to their role as carers, how their difficulties with alcohol and its associated problems impacted on the children and how the dynamic between all the adults influenced the day to day lives of the children. Professionals should take time in establishing the role of fathers and other significant males who have frequent contact with children, to assess the meaning of their presence in children’s lives.  Mr R was not engaged as part of the s47 enquiries, did not attend the CPC and the information about his hospital admissions was not followed up.  Follow up about Mr W and his lack of contact with his other son was not treated as a priority.  Exchange of information between agencies 9.4. In an assessment process the exchange of information between agencies is crucial. Poor exchange of information is likely to result in a flawed assessment and in this case the exchange of information between Adult Services and Children’s Services was distinctly lacking. The needs of the adults in this family were overwhelming and their needs dominated contacts with agencies. The review has highlighted the need for Adult Services to ‘think family’. This problem was exacerbated by the myriad of services accessed by the adults that crossed several other areas, hospital trusts and GP practices.   Assessing neglect and the impact of alcohol misuse 9.5. Children suffering neglect are likely to remain loyal to their parents and as such in the light of a lack of clear disclosures professionals should be alert to other signs of neglect and assess accordingly.  There was insufficient exploration or appreciation of the day to day experiences of Child U and Child B and the likely impact on development and life chances. There was uncertainty among professionals about the level of alcohol use by each of the adults, the extent to which each of them prioritised alcohol and what amount of alcohol would be problematic in parenting adequately.  The net effect of this was no shared assessment of risk about these issues was completed.      50  10.          RECOMMENDATIONS FROM THIS OVERVIEW REPORT   These should be read in conjunction with the recommendations from IMRs detailed in Appendix 1.  LSCB  10.1.    LSCB to review and report on the effectiveness of Early Intervention in enabling front-line professionals to provide early help to vulnerable families.   10.2.    LSCB to review its learning programme to ensure it includes multi agency training on children living with parents who have complex needs including substance or alcohol misuse, DV and mental health difficulties  10.3.    The LSCB via the Section 11 process should require all agencies to report on the effectiveness of their supervision and management processes in ensuring that the work of front-line professionals is scrutinised and challenged.   10.4.     In disseminating the learning from this review LSCB should remind all agencies of their safeguarding responsibilities and the need to be child focused when dealing with adults with complex difficulties.   10.5.    LSCB to ensure, and review if necessary, that the current method of conducting Child Protection Conferences is sufficiently robust i.e. child centred, outcome focused and well understood by all agencies.   10.6.    That all partner agencies should satisfy LSCB that assessment processes and ongoing work with families ensures the effective consideration of significant males in children’s lives. This should not be limited to males who live within households but should include fathers, stepfathers, partners and family friends even where they do not reside with children.  10.7.    LSCB to ensure that the commissioning arrangements for assessing parents and carers who have problematic drug and alcohol use are in place and that there is a clear pathway to accessing services for families.   10.8.    Relevant learning from this review should be shared with the appropriate LSCBs from the various LAs involved in this review.   Independent Social Work Consultant  July 2015   51  Appendix 1   Recommendations from IMRs  These recommendations have been taken from the agencies IMRs and have been accepted by the panel  Children’s Social Care      CSC to take steps to understand the barriers to implementing learning from serious case reviews and develop a strategy to address any barriers identified     Review the current links and work with maternity services to develop a pre-birth referral pathway     Review the management oversight of No Further Action contacts within the MASH    CSC should ensure that practitioners receive effective supervision which enables them to reflect critically on factors that may be impacting on their practice, including workload concerns, personal biases and intuitive responses    CSC should review the current caseloads of Social Workers in the assessment service to ensure Social Workers have manageable caseloads, so they can spend more time with children, young people and families     CSC to review staff development programmes and ensure that they include support for practitioners in developing and sustaining skills for working with avoidant families    Training and assessment tools on the effects of alcohol abuse on parenting to be available to practitioners, to enable them to understand how they can address this issue without reliance on specialist agencies     Consideration to be given to how to work most effectively with fathers and improve their engagement in the assessment process    CSC should ensure processes are in place for monitoring the effectiveness of supervision. These should evaluate the appropriateness of case allocation, the quality and impact of supervision on case planning, and management oversight in individual cases.  Education     The school to access training and support from their Early Help Advisor and the Early Help Co-ordinator.  The focus of the training should be around the use of the Early Help Assessment, The London Continuum of Need, and conversations with parents around the Early Help Assessment and how to undertake EHA’s.  There should also be an increased understanding of the Team around the Family.  There is an expectation that Heads of Year, the Student Support Team and the Deputy Head teacher attend this training.  52      The school to access training and support from their Education Safeguarding and Investigations Officer in relation to the staged approach to poor school attendance.  This should lead to the school making requests for statutory intervention from the Local Authority in relation to children whose attendance hits the threshold for intervention.  The threshold for intervention is any child whose attendance is below 80% and has recorded 20 or more unauthorised absences in the last 12 school weeks.     The school to review its policy and procedures around record keeping to ensure all records of contacts made with children and their parent/carer(s) around issues such as child protection, safeguarding and poor attendance meet local and national guidance.      The school to discuss children with high levels of absence due to illness with their allocated School Nurse.  Discussions to be recorded in line with Recommendation 3, including agreed actions.  (Joint Action with the School Health Service). GP Practice – Practice 1     The authors to contact the Safeguarding Lead at NHS England to share the report, and request a review of GP patient medical record systems.  Moving to an electronic/web based system for all GP practices, to facilitate electronic transfer of records to avoid delay.      Practice 2 should introduce a system for receipt of child protection conference paperwork to ensure it is reviewed by the Safeguarding lead for the practice and alerts added to the parent’s records.    GP Practice – Practice 2  The aims of these recommendations are firstly; to improve the systems of communicating with other safeguarding agencies and secondly, to ensure that all practices in the local areas have the opportunity to learn the lessons from cases.  Nearly all GP practices would be well served  from developing systems and knowledge as a collective team.  1. NHS England Local Area Team should write to the GP2GP electronic notes transfer team, explaining the benefit of allowing all patients notes to be transferred electronically.  This communication should include a brief summary of this case and ask for a risk assessment to be completed around the issue.  2. Local CCGs and NHS England should advise GP Practices to develop their policies and procedures to include compliance against the 2014 RCGP Safeguarding Toolkit self assessment audits (Chapter 5).   53  3. Professionals communication systems which relate to safeguarding children should be reviewed, specifically looking to ensure that:   GPs are proactive in gathering relevant detailed information when completing a safeguarding report.   Safeguarding information that is communicated by GPs to children’s social care should be confirmed in writing.   GP practices should be advised to develop robust systems for processing child protection/child in need requests and reports in order to ensure that these are completed within timeframes and that there is satisfactory documentation within records.  Police Service     The actions taken by police between 28 and 29 November 2014 to identify the whereabouts of Ms X and Baby V for the purposes of a welfare check are subject to an ongoing internal DPS inquiry.  It is expected that the pathologist will, in his post mortem report, provide comment on the length of time Baby V was assessed to have been dead prior to the attendance of the LAS.  This may be of significance to the DPS inquiry.      The DPS inquiry may identify recommendations that would have impacted on this IMR.  However, the enquiry is not expected to conclude for many months.  There are no recommendations to be made in respect of all other police contact with the subjects and family at the time of submission of this IMR to the SCR Review Panel.       PS will ensure that any relevant information or actions from the current DPS enquiry will be reported to the LSCB on its conclusion.       Housing   The Housing Department will ensure that they attend all Child Protection Conferences where families have a housing need.   Housing will change their policy in relation to families where there are child protection concerns and wherever possible place them in borough (except in cases where it is deemed beneficial for the family to be placed out of borough.)  MHS    MHS2 to conduct a Clinical Audit of case notes to determine if letters to GPs following the initial assessment are sent in a timely fashion and include adequate information about the family composition and family history of mental illness and substance misuse.   54     Teaching session for staff responsible for the initial assessment of children on the importance of family history of mental illness and family composition to be organised in MHS2.     MHS1 NHS Foundation Trust Named Nurse for Safeguarding Children to review Level 3 training in MAP and design training session to highlight the importance of communication of AMHS with MHS2 and Social Care when safeguarding issues are identified in adult service users.  Health Service      The new process within Health Services is that on completion of the IMR, the author will visit the services involved and discuss the findings pertinent to their agency and ask for suggestions on how they will redress the issues highlighted.  Hospital 2’s NHS Foundation Trust      LA3 Health Visiting team to review the way in which they deal with and record communications from other agencies/teams.    More robust and timely communication from agencies where there are child protection and safeguarding concerns when transferring care to another borough.     Review the process of families of concern being housed in another borough, particularly where child protection concerns exist.   MHS3   It is recommended that the Psychiatric Liaison Team at A&E and the Psychiatric Inpatient Services, with support from the Safeguarding Children Team, review their documentation and arrangements to prompt staff to gather information about children in contact with adult service users, to discuss concerns with managers / psychiatrists and to consider when to seek or share information about children with other agencies.  Health Overview Report        Recommendation 1  Consideration must be given to improving communication links between GPs and health visitors. This will need to take into account the capacity of the relevant professionals and require a creative approach to finding a suitable solution. (This will be discussed with commissioners in light of  the 2015-16 NHS HV Core Service Specification requirements for an HV to be linked to each GP).     55        Recommendation 2   The quality and standard of referrals into MASH should be included in  the multiagency audit programme.  If findings identify that there are  issues of concern, consideration must be given as to how this can be  addressed across the health economy and the partnership if required.         Recommendation 3   All local health agencies must ensure that practitioners are aware of  alternative referral process into MASH when the on line referral fails.        Recommendation 4    Consideration must be given to how health professionals can develop  their understanding of the complex nature of alcohol abuse and the  consequential impact on parenting capacity. This may be through a  learning and development programme but should also include the  development of relationships with expert practitioners working in alcohol misuse services in order to seek advice and support.        Recommendation 5    Health service providers should review their systems for transferring information particularly across borders in order to ensure that there are  no gaps in communication and the sharing of identified risks. (GP  authors have made their own recommendations re transfer of GP  records).         Recommendation 6    The multi-agency partnership should consider how information is shared or requested by children’s social care in order to promote a culture of collaborative working and shared responsibility, providing timely  opportunity for all professionals working with families to contribute to  child protection and safeguarding processes.        Recommendation 7    All GP practices should be reminded of the need to link patients who are family members and to ensure that cases of concern are identified  through the appropriate use of read codes.       56  Appendix 2   ACRONYM   MEANING A&E Accident and Emergency  AA Alcoholics Anonymous AS  Ambulance Service  CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Service CCG Clinical Commissioning Group CP Child Protection CPP  Child Protection Plan CSC Children’s Social Care  DV Domestic Violence  EI Early Intervention GP General Practitioner  HNO Housing Needs Officer HOR Health Overview Report HV Health Visitor  ICPC Initial Child Protection Conference  IMR Independent Management Review  LA Local Authority LSCB Local Safeguarding Children Board  MASH Multi Agency Safeguarding Hub MDT Multi Disciplinary Team MGPs Maternal Grandparents MH Mental Health NFA No Further Action PMHT Perinatal Mental Health Team SCR  Serious Case Review  SW Social Worker  WA Written Agreement  WT Working Together to Safeguard Children    