Death of a 15-year-old-boy in August 2021 from complications due to multiple, non-accidental rib fractures. Learning includes: the need for all professionals to understand the challenges of being a new arrival to the UK; the importance of understanding relationships in families and a full background history where new arrivals are concerned; the need for professional curiosity and allowing practitioners the freedom and space to exercise it; concerns around domestic abuse in families over lockdown during the coronavirus pandemic, and whether they may be under pressure not to report. Recommendations include: ensure that practitioners have the training to be able to understand the challenges for a new arrival into the UK, including how to access health, education, and support services; ensure that practitioners can access information from originating countries to assist in the care of children arriving in the UK; ensure that support is being provided to practitioners to provide resilience within the workforce; ensure the workforce have been given the tools and training to support children and young people coming out of the pandemic to aid their recovery; ensure that where professionals have identified risks within families that the risk is thoroughly assessed and recorded; ensure multi-agency assessments of risk are taking place on which plans of action are based; the National Panel are to engage with the border force to explore the processes in place when a child or young person enters the UK and gain clarity on how safeguarding concerns are identified and communicated to the relevant local authority.
      
 Title:  Local child safeguarding practice review: Paul – Child Q. LSCB: Kirklees Safeguarding Children Partnership Author: Matt Brayford Date of publication: 2023  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1                LOCAL CHILD SAFEGUARDING PRACTICE REVIEW  PAUL - CHILD Q     Author: Matt Brayford Publication: 4 April 2023          2  Contents    1 Introduction and Context 3 2 Arrangements for the Child Safeguarding Practice Review 4 3 Methodology  6 4 Family Composition 7 5 The incident of concern 8 6 Background and Previous involvement 9 7 Key Practice Episodes and Analysis  12 8 Comparator Cases  16 9 Practitioner Learning Event Capture 17 10 Learning & Recommendations 19 11 Next steps to embed learning  22 12 Appendices  Appendix 1 - Kirklees Locala Procedural document 2020 Appendix 2 - Domestic Homicide Reviews within Polish nationals living in the United Kingdom  - Matejci Matusiak Appendix 3 – Child Mortality Database -Covid deaths in children: (How has the pandemic impacted child mortality?) Appendix 4 – Ofsted Annual Report 2021  23                           3  1.Introduction and Context  About the author  The author comes from primarily an education background with experience of Senior Leadership (including the role of Designated Safeguarding Lead) at the secondary phase. Previous roles and relationships included partnership working with the Home Office, Counter Terrorism Police and Social Services. The author is familiar with Local Government services, functions and has used this information to support the writing of this review.  1.1. This is an overview report from a Local Child Safeguarding Practice Review (CSPR) conducted by Kirklees Safeguarding Children Partnership (KSCP). The matter which has led to the review is fatality of a child aged 15, who had been living in the UK for a period of less than 12 months when the incident occurred on August 13th, 2021. The exact circumstances surrounding the injuries to the child are not clear, but at the time that it occurred, the child was at home and it was mothers’ partner who made the 999 call.  1.2. A rapid review of the case was held in accordance with the criteria set out in Working Together 2018 and highlighted several issues to explore:   ➢ The fatality of a child under the aged of 15, who had been in the UK for a period of less than 12 months  ➢ The support offered to children and young people who are new to the UK even when parents have been resident for a period of time prior to their arrival ➢ Considerations of safeguarding young people new to the UK  ➢ The impact of the Covid-19 global pandemic on child deaths in the UK ➢ The role of agencies in noticing issues of concern and communication with partners  1.3 Completion of this Review includes consideration of children new to the UK and access to Universal and International new arrival services. It uses some comparator cases to consider common factors and the implications for practice regarding Domestic Abuse in the family home specifically linked to Polish families.  1.4 The work in completing this review also considers the significance of criminality in the history of the parents/carers.  With a consideration of how this is shared with schools and wider services.             4  2. Arrangements for a Child Safeguarding Practice Review    2.1 The aim of a Local Child Safeguarding Practice Review is for individuals and agencies to learn lessons about the way in which they work both individually and collectively to safeguard and promote the welfare of children. It draws on the criteria set out in Working Together 2018 and at its core, seeks to identify learning to support the local system to improve safeguarding practice.   2.2 It is not about apportioning blame for what occurred, but about learning how the system could improve its response. For these reasons, this review was conducted in such a way that it:   ➢ Recognises the complex circumstances in which professionals work together to safeguard children.  ➢ Seeks to understand key practice episodes, where it may have been possible to intervene differently.  ➢ Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight.  ➢ Makes use of some comparator cases to consider themes that might further develop the service offered to families of varying backgrounds and origins  ➢  Considers relevant research and case evidence from regional and national sources to inform the findings.   2.3 A panel representing partner agencies of the Kirklees Safeguarding Children Partnership developed the terms of reference in line with Working Together to Safeguard Children (2018), and West Yorkshire Safeguarding Children Procedures, Chapter 10.1 (8.20).   2.4 The following agencies, identified as having been involved with the child and family, were asked to contribute, and supply information to the process including some analysis of significant events. Agencies were also requested to identify some comparator cases involving children from Polish backgrounds and domestic abuse. An analysis of the comparator cases is highlighted at section 6.   The agencies invited to participate and submit information to support this review were as follows:   ➢ Mid Yorkshire Health Trust  ➢ West Yorkshire Police  ➢ Education via the school  ➢ The GP  ➢ Locala: Health Visitor Service / School Nurse  ➢ MAST Health Practitioner ➢ Immigration Enforcement - National Command and Control Unit      5    2.6 The methodology followed to complete this review is a local proportionate response. The child was unknown to statutory agencies and wider support services prior to the incident of concern. Accordingly, this review has been compiled following the gathering of information from agencies and case discussion with key practitioners. The gathered information has been reviewed, screened and challenged externally by the Independent Scrutineer and forms the considerations and learning discussed within.                                         6  3. Methodology   3.1 This report has been prepared following a Rapid Review and submission of documentation by engaged agencies. It has considered additional information submitted on request and has also had the benefit of considering learning collated by the NSPCC and from other Safeguarding Practice Reviews and particularly those involving a history of Domestic Abuse in Polish families.   3.2 The review has been conducted and written with the benefit of hindsight and it is recognised that this often distorts the view of the predictability of events, which may not have been evident at the time. It is important to be aware as Munro (2011) 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 can often become much clearer after an event has occurred. This review is therefore sensitive to this ‘bias’.   3.3 The review is also sensitive to pressures on agencies and the demands of the work. The completion of this review also coincides with the challenges agencies and schools have felt in responding to the Covid Pandemic which has drawn on capacity and has impacted upon participation. In completing a proportionate report, it has therefore been essential to recognise those demands and to highlight learning, which can be disseminated with some reflection on how the lessons can help change practice rather than apportion blame to agencies or individuals.                         7  4. Family Composition   4.1 The family composition in this case is drawn from records provided by agencies. It includes those reported as living at the address at the time when the incident was reported to have occurred and biological father (Steve) who resides in Eastern Europe. Throughout this process Steve has been supported and regularly updated with the progress of this investigation and the review process by the Police Family Liaison Officer. To protect the identity of those involved pseudonyms have been used, see below-:  Subject Child Paul Mother of Subject Child Marie Mother’s Partner Mark Father of Subject Child Steve                                    8    5. Incident of Concern   5.1 On August 13th, 2021, the emergency service team responded to a 999 call at 10:55am regarding Paul who was not breathing in the bathroom. The call was made by Mark who was the biological mother’s partner. It is unclear if mother (Marie) was present in the family home at the time of the incident. The ambulance arrived at 11:01am. The Patient Care Record reports Paul was in cardiac arrest. It was also documented that the family told the ambulance crew Paul had previously experienced physical and emotional abuse by his biological father, Steve. Paul was transported to Huddersfield Royal Infirmary.  5.2 Police records state at 11:00 am hours on Friday 13th August 2021 a call was received from an ambulance reporting a 15-year-old male was in cardiac arrest at an address in Huddersfield. The male was located unresponsive at the property. Life was pronounced extinct at 11:34 am hours and the scene secured. Two people linked to the address were arrested and charged on suspicion of murder.  5.3 There were no additional siblings or linked family members requiring Local authority intervention.   5.4. The Forensic Pathologist in completing the post-mortem report said that there were a significant number of fractures at various stages of healing, indicating several non-accidental injuries on different days. Four of the fractures may be as a result of resuscitation and four fractures that were healing were infected with pus. The initial cause of death had been noted as complications due to multiple rib fractures and the infection caused by those. Paul’s blood results indicated an infection, and he was also noted to have fluid on his lungs. It is the overall pathologist’s opinion that Paul’s injuries were a result of numerous non-accidental injuries.  5.5 The injuries that have been identified as multiple rib fractures are considered as the cause of death as without the fractures, the infection would not have been able to take hold and develop.  Some of the injuries would have been extremely painful and would have changed how Paul walked or sat.  Some of the noted injuries were fresher and some which were scabbing over.             9     6. Background and Previous Involvement including chronology of events   6.1 Marie and Mark resided in the UK for a number of years prior to Paul`s arrival on October 4th, 2020. Criminal activities have been logged for both subjects between May 2012 and November 2020. Concerns regarding criminal behaviour included robbery, handling stolen goods, burglary, possession of illegal drugs, assault, and public order offences. Predominantly these offences resulted in cautions and warnings however, Mark was sentenced to imprisonment in 2012 relating to an assault and robbery.  The drugs matter involving Mark related to possession of Cannabis where he was stopped alone in his vehicle. This resulted in him receiving a Community order which he complied with and was in line  with guidance.   Mark and Marie were unknown to support services at this time. Police involvement with the adults was very limited and there were no safeguarding concerns in relation to the criminal activity.  6.2 In addition to Police involvement prior to Paul`s arrival in the UK Marie and Mark had presented at Mid Yorkshire Hospital trust with a variety of injuries. Mark on separate occasions reporting neck pain following a road traffic accident and head injuries following fighting. Mark had not been registered with a GP since 2015. Marie has one case referred for abdominal pain and pelvic bleeding (where pregnancy was not an issue).   6.3 Paul arrived in the UK on October 4th, 2020. It is understood that Paul entered the UK accompanied by Marie and Mark. This was confirmed by the border agency.  6.4 Paul was registered at a Kirklees school on October 19th, 2020. Marie was given access to the My Ed system for school to home communication. In this case, Marie had made use of the system to communicate with school on a number of occasions.  Paul had what would be considered an appropriate attendance level (94%), and any absences did not follow a pattern or cause concern. Paul’s character statement can be seen in appendix 5.  6.5 Records show in October 2020 Paul had email correspondence with school regarding online learning tasks and activities. School report there was some supportive communication from members of staff with instructions and additional information pertaining to learning.  Communication from Paul at this time was largely around seeking clarification on activities and points of learning; several of them are in response to questions/tasks.  School report Google translate was used in some communication and some of the emails from Paul supported a limited understanding and use of English. On one communication soon after registering with the school Paul indicated he wasn’t feeling well, it is unclear if any follow up was carried out by school as to why Paul was unwell. School reported that Paul was not flagged as vulnerable and had a good attendance record.  School maintains there was evidence of engaging in learning with a consistent flow of communication between Paul and members of staff.  School state as a student with limited English, Paul was being supported by the “English as an Additional Language” department in  10  school. Information from school indicates Paul had an attendance of 94% with only 14 sessions having been missed for illness or lateness in the academic year 2020/21. Paul`s school report reads of a well-behaved child who engaged with school life and interacted with peers and staff. The school dates below are important to understand the time Paul would have spent in school and at home (including the government lock down period) -:    Autumn term started – 14/09/20 Paul started school – 19/10/20* October Half term – 26-30/10/20 Autumn term end – 17/12/20 Spring Term started – 05/01/21 Government lockdown – 05/01/21 – 10/03/21 – Remote learning  Spring term ends – 26/03/21 Easter holiday – 29/03/21 – 09/04/21 Summer term starts – 12/04/21 May half term – 31/05/21 – 04/06/21 Summer term end – 23/07/21 School Holidays 26/07/21 – 3/09/21 – Incident date 13/8/21  *Because Paul commenced after the beginning of the academic year he would not have been included in the movement in list from education to Child Health.  6.6 On April 7th, 2021, Paul registered at a local GP Practice. According to NHS standards - Children under 16 should be registered by their parent(s), but don't have to register with the same GP as the rest the family. From GP records and following a conversation with the GP practice it still remains unclear who attended with Paul to register. New patient assessments are offered to all patients, and they are encouraged to book this with the Health Care Assistants as part of their registration.  It is reported from the GP records there was no evidence that Paul or his family booked an initial health care assessment.  6.7. In April 2021 Locala sent out a letter to the family introducing the Thriving Kirklees 0-19 Team. A leaflet regarding the School Nursing service was also enclosed, which included advice to register Paul with a GP, dentist, and contact the GP for information regarding childhood immunisations. Information was included indicating if any assistance with communication was needed to get in contact using a number supplied. The information sent out to the family was written in English. School report that Marie had an operational level of understanding of English.   6.8 When reviewing information in April 2021, the Health Practitioner deemed that no further action was required at this time due to information about the 0-19 service having been sent out, and records indicated that Paul had an identified school. It was reported that on examination of the records, there were no details regarding school, and this had been recorded in error. However, as there were no known clinical concerns, no further action was  11  reported and was in line with current practice guidance outlined in the Kirklees 0-19 Procedural Document 2020 (Appendix 1).  6.9 A Meningitis immunisation was scheduled on July 15th, 2021, following correspondence via mobile phone with the family. This appointment was cancelled by the GP practice.   School-aged children who are due inoculations would be picked up within scheduled vaccinations by the school nurse.  If appointments are missed in the Autumn term school can arrange catch up appointments.  A review of research shared with the Home Office ‘Domestic Homicide Reviews within Polish Nationals living in the United Kingdom’ authored by Maciej Matusiak a frontline service Police officer in Merseyside Police is of particular interest here (Appendix 2). The report cites ‘Polish culture’, language and cultural barriers alongside reporting as potential barriers to engaging with local area services and reporting domestic abuse.  6.10 August 13th, 2021, emergency services were called to the family home in response to a child being unconscious in the bathroom not breathing. Paul was transported to Huddersfield Royal infirmary; Paul was pronounced dead in the Emergency Care Facility. The Police enquiry was handed to the Homicide and Major Enquiry Team (HMET) who arrested Marie and Mark on suspicion of murder.  6.11 After the event of Pauls death schools CPOMs, (Safeguarding recording tool) record indicates an entry dated September 9th, 2021.The date of the CPOMS entry has been confirmed as the date the information was shared with school by the pupil and is not a retrospective entry. The entry stated, that Paul was ‘frightened’ of his mother. The child disclosing stated they had witnessed this outside the school gates on October 19th, 2020. Marie was seen to berate and shout aggressively at Paul in view of other learners. It is sadly noted that this was not shared by learners with school pastoral staff at the time. This could also be a subtle link to Maciej Matusiak’s research briefly discussed earlier where communities new to the UK find it increasingly difficult to reach out and accept support from services and professionals.                    12             7. Key Practice Episodes and Analysis  7.1 In considering this case several key issues and themes arise, that are worthy of some consideration. These would include the support offered to children and families that are new arrivals to the UK. This support should lead to careful screening and checks of parents and carers including background issues linked to criminality and ultimately safeguarding. It is also important to consider when young people are registered with a GP that Initial health screening should be carried out on all new patients and any concerns flagged with essential services. Processes were identified that support the notification of children registered with a GP Practice to Child Health.  7.2 It is important to note though that in day-to-day presentation the health and wellbeing of Paul did not present concerns to professionals. This is important because in the absence of a safeguarding concern regarding Paul it was increasingly difficult to predict the events of August 13th, 2021. However, there are some areas that merit some further discussion.   A) The Importance of children new to the UK being identified and supported.  From the information gathered whilst compiling this review it has become apparent that Paul was unknown to the Kirklees International New Arrivals Team (INAT) that sits within the Education Safeguarding Service. The service offers a variety of support to families new to Kirklees including housing support, signposting, and support in accessing health and education and language/communication support. In the case of Paul, he perhaps was not logged with the INAT team because Marie and Mark were residing within the country for approximately 10 plus years prior to Paul`s arrival in the UK. There should be an emphasis when schools or admissions register a new learner to mark the child as new to the country. When considering the previously mentioned research around Polish families and engagement this highlights an area of future sign posting through safeguarding training and updates to all Kirklees education/health care settings. There must be strong guidance to notify the INAT when a child born outside the UK registers at their school regardless of the length of time spent in the UK by parents or carers. This would allow for support of the family and give the opportunity as required to conduct a family assessment and flag any potential safeguarding concerns. In the sad case of Paul this could have considered a full background history and could have indicated potential risks and would have allowed for appropriate escalation.   13   B) The safeguarding support and challenge of education settings  Schools in Kirklees have several visits conducted by Kirklees Learning Partners (KLP) throughout the academic year and are required to complete a Section 175 safeguarding audit. These visits and audits challenge the schools safeguarding policies and execution of policy in practice. Schools also must have Designated Safeguarding Leads (DSL) that are required to complete specific training and refreshers to be compliant in the role. It is through this partnership working and forum that schools can receive appropriate support in meeting the requirements set out in Keeping Children Safe in Education (2021, KCSIE) guidance.  When considering the case of Paul how aware were the school of the support available through the Kirklees INAT team, Early Support Services and Family Support and the benefits it could bring. Is there a robust understanding of the risks associated with certain cultures regarding domestic abuse and engaging with services? It is a view that through partnership working with appropriate challenge and support can be developed further to safeguard all children.  C) The role of health services in raising concern Paul was registered as a new patient on April 7th, 2021, at a local GP practice. This presents a very large gap between arrival in the UK and registration for health care. It is unclear if this was with the presence of Marie or Mark. It has been confirmed that Paul did not have a routine health care screening that should be in place for a new patient joining a practice. A health screening should take place and any concerns escalated and communicated to service and partners. It is worth considering if it was clear to Paul ‘how things work in the UK’ in terms of raising and sharing concerns he may have had, and or the way health services work such as Accident and Emergency and safeguarding. There is also an element of understanding family medical history this would be especially important for children born outside the UK. In the case of Paul, Marie and Mark reported previous physical and mental abuse to Paul by Steve. These allegations are largely unproven, if declared in advance of August 13th, 2021, further investigations could have taken place.   D) Professional curiosity Professional curiosity is the capacity and communication skill to explore and understand what is happening in a family rather than making assumptions or accepting things at face value.  There were several opportunities in understanding this family, from the chronology that may have given a greater insight into the day to day lived experience of Paul  • Marie`s and Mark`s background history appears not to have been explored or considered. • The issues relating to health screening and vaccination appointments and the importance of communication between services.  14  • Reports of Marie in June 2021 of suffering with shortness of breath and only being able to walk short distance, leading to a neurology referral following GP consultation. What impact this could have on the family home and directly to Paul? There is a strong possibility that if Marie was struggling at home additional pressures could have been placed on Paul in terms of self-care and day to day responsibility. There is also a consideration of the impact of Mark and the outcomes of this in the home. • The consideration of children being notified to 0-19 services with limited past health information and being new to the country and whether this would be a factor to offer more than an information letter. • Based on post-mortem information there is a clear indication that Paul would have been in significant pain in the weeks leading up to the events on August 13th, 2021, and there would have been biomechanical changes in walking/sitting. This must be considered given Paul was present in school for 19 out of 20 sessions in the last 2 weeks of term and it would seem as there were no observations made regarding behaviour, welfare or difficulty sitting or walking. • For example, prior to the summer holidays commencing Paul had been struck to the bottom on a couple of occasions with a wooden slat.  • The abuse Paul suffered significantly increased as did the ferocity of the assaults including whipping with a cable flex once Paul had finished school for the summer.  Curious professionals will spend time engaging with families. They will ask questions and seek clarity on the situation for children, to better understand risk. It is well known that children find it hard to talk about their lived experience when it involves abuse or neglect. When they do ‘tell’ it can be through behaviour or comments that are explored sensitively. This was not evident for Paul who presented as ‘a good’ learner. In the case of Paul many barriers existed to disclosure of neglect or abuse if abuse in the home was taking place before August 13th, 2021. These included cultural barriers, language and engagement with services/professionals as previously considered through research (Appendix 2)   E) The global pandemic and remote learning It would be wholly remiss not to consider the impact of the global pandemic when considering learning around this sad case. Based on research the National Child Mortality Database indicate the number of children in England who died fell to 3,067 between April 2020 and March 2021. This is 356 fewer deaths than were recorded in the preceding 12 months (Appendix 3). Police statistics show that domestic homicides have not increased during the pandemic and have largely remained at the same level as the year previous. However, its agreed that there is still a prevalence that the number recorded is significantly high. Data may not present a raised concern as a result of the global pandemic. However, its entirely fair to suggest children and young people suffered because of bubble closures, local lockdowns and schools’ closures. These concerns are flagged in the Ofsted Annual report published December 7th, 2021 (Appendix 4). The report discusses barriers children faced  15  during the lockdown periods in accessing online material, progress that was lost and that ‘many vulnerable children disappeared from teachers’ line of sight’. The report talks about children with known vulnerabilities who had been encouraged by government to attend school throughout the ‘closure’ period, and that relatively few did. Approximately 33% of learners classed at vulnerable attended Paul`s school during the lockdown period January 1st, 2021 to April 12th, 2021. It is reported by school that contact remained in place with Paul during this period. With an acknowledgment that children who were not permitted to attend, there was often no way to spot signs that something was going wrong at home. This is concerning, given the general context of the high numbers of domestic abuse. The learning to consider from this for services and education providers would be what constitutes a vulnerability in child or family that requires regular and significant welfare checks.  Welfare checks are also another point to consider when deciding what constitutes ‘suitable’.  What training is given to staff conducting visits regarding spotting signs or neglect and identifying ‘tells’ as a call for help? School confirmed that in the case of Paul welfare checks were carried out. The long-term impact of the pandemic on children is yet to be fully realised however, from early data there is clear indication of increased mental health issues, behavioural issues, and significantly reduced progress. There is also an increase in school anxiety that has led to an increase nationally of 38% in children being electively home educated. This is a significant point to consider when trying to understand possible domestic abuse and its impact on the family dynamic and vulnerability in families.                         16            8. Comparator Cases   8.1 In considering the case of Paul several other cases were considered. These cases involved three children in total. These were cases where Domestic Abuse was a feature and involved families living in England from where England was not the country of origin. A brief synopsis of each case is highlighted below   • Case 1(Child D) concerns the death of a 7-week-old English/Polish child in January 2014, as the result of a severe head injury and multiple other injuries. Mother, mother's boyfriend, and another adult male were arrested on suspicion of murder. Mother was known to Police following several allegations of assault and domestic harassment. Insufficient professional curiosity was identified in this case as Mother was able to conceal her pregnancy from professionals. • Case 2 (SOT14) concerns the death of a 6-year-old girl and her 1-year-old sister. Children were murdered by their mother who then took her own life. Family was of Polish origin, but children were both born in England. Children had recently been given “child in need” status although the case had not been allocated at the time of their deaths. Mother had been anxious about the elder daughter's health although health professionals had assured her that there were no serious concerns. Mother reported low mood and thoughts of harming herself and her children to her GP.  8.2 The difference in the comparator cases was that in those cases the families had been known to services and had reported concerns regarding mental health to professionals or had actively avoided medical support and intervention.  8.3 Research was also considered that was presented to the Home Office by Matejci Matusiak a frontline service Police officer in Merseyside Police titled ‘Domestic Homicide Reviews within Polish nationals living in the United Kingdom’, 2019, this research highlights the barriers that can exist with communities and the issues around engaging with services and accepting support (Appendix 2)  8.4 Research was also considered using the National Child Mortality Database, Police Crime figures and Ofsted Annual Review 2021. Around the impact of the global pandemic on child mortality, domestic homicide, and the overall impact of the pandemic on educational settings and children (Appendices 3 and 4)  17   8.5 Ofsted’s Annual Report published on December 7th, 2021, was also reviewed when considering the impact of the global pandemic on children’s welfare, mental health and school progress.       9. Practitioner Learning  Event Capture  A practitioner event was held on January 26th, 2022, with 57 active frontline staff contributing to the discussions and learning captured below.   Attendees at Practitioner learning event for Child Q  • West Yorkshire Police • Children’s Social care • Youth Justice Service • Kirklees Neighbourhood Housing • Early Support Services • Education Safeguarding  • The school • Youth Engagement Service • Locala • South West Yorkshire Partnership Foundation Trust • Kirklees Corporate Safeguarding Partnership • Clinical Commissioning Group  Key discussion Points included-:  Not every school in Kirklees will be in the same position as in this case. This school works a lot with International New Arrivals Team (INAT) due to having quite a transient population – there can be approximately 40-50 students arriving and leaving school within one academic year. As soon as a family comes to them, they will link with the team. They probably have more awareness than other schools that will have less need for the service. With new arrivals from outside the EU, INAT will notify school about them before they arrive. With arrivals from within the EU, they might not be flagged straight away – INAT doesn’t know about them until the paperwork comes from the Home Office. If a family was struggling, school would refer back the other way, but that would be more unusual. In terms of Paul’s level of English language, the level was low initially but had picked up quickly.  0-19 Services will be looking at strengthening the process for children new to the UK or other children where they don’t have any information.    18  A missed opportunity was discussed – the health practitioner assessed no intervention required because there were no concerns, but that was because there was no information about him. Consideration of how to strengthen that professional curiosity and getting learning out to colleagues and make improvements. Learning point that no information does not translate to no concerns – it means professionals may need to be more curious.  Cultural awareness training would be very useful for Locala colleagues. They will also explore whether they can send the texts in other languages.  It’s important that not only parents but children have access to physical resources to read about abuse.  There may be trauma uncovered as part of asking the question regarding the child’s background and reasons for coming to the UK, but how else can schools get support for that? It’s important to hear the child’s voice regarding their journey to the UK. As part of this, what is the wraparound support if school start having trauma-informed conversations?  Over the years, midwifery have increased their questions about domestic abuse. Could an equivalent be done through services to give children an opportunity to ask questions?  How can services enable the culture where it is OK to talk and OK to disclose? Can this be done through the curriculum, via assemblies, etc? This would enable young person to realise they may not be the only one going through this. How can we support schools and partners to develop cultures where young people feel it is OK to disclose?  What are the barriers to engagement for specific cultures? People may have certain views of social care and what might happen when they ask for help.  The format of the learning event was recognised as having been very useful in terms of learning and information sharing.                    19             10. Learning  This is an extremely upsetting case in which a 15-year-old boy lost his life. There is nothing to suggest that the events that transpired on August 13th, 2021, were entirely preventable or predictable. Professionals could not have known what was going to occur that morning. There had been no presentation of concern raised relating to safeguarding regarding Paul in the months leading to this incident.   The case does remind us though, of the importance of understanding the role of agencies in supporting children born outside the UK and carefully screening their health (physical and mental) and communicating any concerns with partner agencies.   Learning point 1:  All professionals need to understand the challenges of being a new arrival to the UK and the requirements and opportunities to access health, education, and support services including INAT.  Recommendation 1: The Local Safeguarding Children Partnership to ensure that practitioners have the training to be able to understand the challenges of being a new arrival into the UK.  This training needs to include information on how to access health, education, and support services.   Learning point 2: It is important for professionals to understand relationships in families and understand a full background history of where new arrivals are concerned.  Recommendation 2: The Local Safeguarding Children Partnership to ensure that practitioners have access to tools to assist in accessing information from originating countries to assist in making decisions in relation to the care of children arriving in the UK.   Learning point 3:  20  Professional curiosity cannot be overlooked or discounted and should be promoted through training and challenge. When talking about the need for professional curiosity, services have to give practitioners the freedom and space to do that – it takes longer to exercise professional curiosity. If services are serious about this, they have to consider allowing staff to work towards outcome rather than outputs which will require a significant programme of organisation and training.     Recommendation 3: The Local Safeguarding Children Partnership to receive assurance that professionals ask questions to obtain a full picture of the family and the familial relationships and to ensure this is evidenced in records.    Learning point 4: Significant time needs to be spent understanding the impact of the global pandemic nationally and locally and how locally the systems and processes applied by services and settings work. The impact of Covid-19 on professionals needs to be recognised and that the workforce are feeling the pressure of this. Work needs to be done to support resilience in the workforce.  Recommendation 4: The Local Safeguarding Children Partnership to receive assurance that support is being provided to practitioners to provide resilience within the workforce.   Learning point 5: Consideration around the recovery phase especially for children coming out of a pandemic and the support that can be sought to aid that recovery.  Recommendation 5: The Local Safeguarding Children Partnership to receive assurance that the workforce have been given the tools and training to support children and young people coming out of the pandemic to aid their recovery.   Learning point 6: The statistics note that domestic abuse in families has not been increasing over lockdown, but from anecdotal evidence, a lot of families were really struggling in lockdown – maybe the statistics do not show the whole picture. They may be under pressure not to report, so cases may just be staying under the radar.  Recommendation 6:   21  The Local Safeguarding Children Partnership to receive assurance that where professionals have identified risks within families that the risk is thoroughly assessed and recorded on records.    Learning point 7:  Consideration should be given to how and when we share information to support families and young people, to be aware of services and how to access them, be that health or wider services. Also, to ensure that they are tailored to meet the individual needs of that family.     Recommendation 7:  The Local Safeguarding Children Partnership to receive assurance on how separate assessments of risk are being brought together to provide a clear multi-agency assessment of risk on which plans of action are based.   Learning point 8:  Work is ongoing on the Corporate Safeguarding Strategy that sets out the role of all individuals who might come across children, families, adults and how they might recognise concerns and what to do about those concerns.   Recommendation 8: The Local Safeguarding Children Partnership to receive assurance that all staff have a basic awareness of child abuse and neglect hand have the knowledge of how to report this.  Learning Point 9:  What understanding is there of the Border Force Safeguarding processes when a child or young person enters the UK whether accompanied or not by a family member/other adult?  Recommendation 9: The National Panel to engage with the Border force to explore the processes in place when a child or young person enters the UK and gain clarity on how safeguarding concerns are identified and communicated in a timely manner to the relevant Local authority           22                           11. Next Steps: Embed Learning   This report will be shared widely, and the key messages disseminated by the Safeguarding Children Partnership and practice learning events. Also shared with the National panel, NSPCC and the learning summary will be placed on the Kirklees Safeguarding partnership website.                   23                            12. Appendices   Appendix 1 -  Thriving Kirklees 0-19 Clinical Procedural Document V1.1.pdf   Appendix 2 - MJ DHR Forward.pdf  Appendix 3  Covid deaths in children: How has the pandemic impacted child mortality? (ncmd.info)  Appendix 4  The Annual Report of Her Majesty’s Chief Inspector of Education, Children’s Services and Skills 2020/21 - GOV.UK (www.gov.uk)   24   Appendix 5  • Home Office Child Safeguarding Update - September 2022.pdf    Appendix 6 - Paul Character statement.pdf 