Serious incident involving a 4-year-old child who was admitted to hospital in June 2016 after ingesting a potentially lethal dose of a sibling's epilepsy medication. Child I taken to hospital by ambulance having been found unresponsive by Father. Blood tests showed high levels of epilepsy medication. Incident treated as non-accidental. Police unable to prosecute due to insufficient evidence. A strategy meeting was held and Child I's siblings were placed in foster care. Family were well known to services. Mother and Father had presented as homeless prior to becoming parents. There had been multiple reports of domestic abuse and possible physical abuse of Child I's siblings. This led to Section 47 enquiries but concerns were not substantiated. Ethnicity and nationality unknown. Learning points include: thorough risk assessments should be undertaken when a partner has left a domestically abusive relationship but children are with the perpetrator; it is important to be aware of the pressures and difficulties faced by young parents; and all professionals who can offer insights into a family should be invited to meetings examining levels of need and risk for children and families. Uses the SILP methodology. Recommendations include: promote awareness of the Escalation Policy; GPs should consider social issues in a child's life that may affect the ability of the parent/carer to maintain a medication regime when prescribing children medication; and the LSCB to seek assurance from Children's Social Care that issues highlighted are being addresses in a timely manner, particularly the application of Child in Need procedures.
      
 Title:  Serious case review: SCR I17: review report. LSCB: Reading Local Safeguarding Children Board Author: Kevin Ball Date of publication: 2019  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.                           Serious Case Review SCR I17 REVIEW REPORT Lead Reviewer: Kevin Ball Considered by Reading LSCB: 23rd January 2019 This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with Reading Safeguarding Children Board prior to publication. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved. OFFICIAL SENSITIVE1Contents Item Page Introduction 3 Process for conducting the review 3 Family Structure 4 Relevant background information prior to the time-frame under review 4 Other relevant background information during the time-frame under review 5 Key Episodes -Key episode 1: October 2015 – March 2016-Key episode 2: April 2016 – June 2016-Key episode 3: June 20167 – 9 Findings & analysis -The quality of practice & systems in regard to the sibling’s epilepsy-What was known about the parental history, vulnerability & risk factors inthis case? What consideration was given to the impact of these on thechildren?-The quality & effectiveness of any assessment, planning & intervention-The quality & effectiveness of information sharing and use in this case-The use of dissent, professional disagreement and escalation9 – 25 10 12 14 23 24 Good practice 24 Conclusion 25 OFFICIAL SENSITIVE2Recommendations 26 1. Introduction1.1. Reading Local Safeguarding Children Board (LSCB) decided to undertake a Serious Case Review into the case of a child, aged four years, who was admitted into hospital in June 2016 having ingested a potentially lethal dose of a sibling’s epilepsy medication.  For the purpose of this review the child shall be known as Child I. Child I, and siblings, had a long history of agency involvement and the children were considered under Child in Need1 procedures in 2016.  The Police were unable to make a prosecution due to there being insufficient evidence to prove how the child came to ingest the medication. However, the Family Court fact finding process in April 2017 concluded that an adult deliberately administered the medication and that they delayed seeking professional medical help.    2. Process for conducting the review2.1. Reading LSCB recognised the potential to learn lessons from this review regarding the way that agencies work together in Reading to safeguard children2.  2.2. Reading LSCB agreed that this SCR would be undertaken using the SILP3 methodology, which engages frontline staff and their managers in reviewing cases and conforms to the expectations as set out in statutory guidance4. The review was conducted by Kevin Ball, who wrote this report, and Nicki Pettitt. Both are independent safeguarding consultants, experienced chairs and authors of SCRs, and SILP associate reviewers. Both are fully independent of Reading LSCB and its partner agencies.   1 Child in Need Plan - Section 17 of the Children Act 1989 imposes a general duty on the Local Authority to safeguard and promote the welfare of children who are ‘in need’ and to promote the upbringing of children in need by their families by providing a range and level of services to meet those children’s needs.  2 The review has therefore: i) Identified improvements in the way that agencies work together for the prevention of death, serious injury or harm to children and to consolidate good practice; and ii) Clearly identified what lessons have been learned both within and between agencies and within what timescale they will be acted on and what is expected to change as a result. Details of this are contained in single agency action plans as well as the over-arching LSCB action plan.  3 SILP – Significant Incident Learning Process. 4   Working Together 2015 (under which this SCR was commissioned) expects that SCRs should be conducted in a way that; recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what; considers the underlying reasons that led to actions; seeks to understand practice from those 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.   This review has achieved these objectives. OFFICIAL SENSITIVE32.3. Agency reports were completed providing agencies with the opportunity to consider and analyse their practice and any systemic issues5. They provide details of the learning from the case within their agency but also allowed agencies the opportunity to reflect on actions and make recommendations for improving their own practice. Following these reports being submitted practitioners, managers and agency safeguarding leads came together for a multi-agency workshop. All agency reports were shared in advance and the perspectives and opinions of all those involved at the time were discussed at the event. This group then reconvened to examine and debate the first draft of the SCR report. 2.4. It was agreed that the time-frame under review would be from 01/03/2014 in order to capture any relevant information about the initial diagnosis of the sibling’s epilepsy and medication through to June 2016 just after Child I’s admission to hospital having ingested the epilepsy drugs. Relevant information prior to these dates was also considered, particularly involvement with Child I’s parents.    2.5. The contribution of family members is an important part of the SILP model of review.  The Lead Reviewer, via the LSCB, made attempts to meet with Child I’s Mother and Father. Due to Mother’s circumstances it was only possible to have a telephone discussion; which was very helpful. It proved impossible to track down Child I’s Father’s whereabouts and therefore it has not been possible to gain his contribution. Where relevant, and helpful, Mother’s contributions have been integrated in to the report.   3. Family StructureThe relevant family members in this review are: Family member To be known as: Subject child Child I Sibling 1 to Child I Sibling 1 Sibling 2 to Child I Sibling 2 Father to subject child Father Mother to subject child Mother Father’s partner Father’s Partner Mother’s partner Mother’s Partner 4. Relevant background information prior to the time-frame under review4.1. In November 2009 both Mother and Father (prior to becoming parents) presented themselves to the local Housing Advice centre reporting being homeless as they had been evicted from the 5 Agencies that have contributed to this review are: -Reading Borough Council Children’s Social Care- Royal Berkshire NHS Foundation Trust-Thames Valley Police- Nursery-Berkshire West Clinical Commissioning Group- Berkshire Healthcare Foundation NHS Trust-Reading Borough Council Housing Management Service- Berkshire Women’s Aid-Oxford University Hospitals NHS Foundation TrustOFFICIAL SENSITIVE4paternal grandmother’s house due to a violent incident. Father, having been in the care of a neighbouring Local Authority for approximately two years was judged as a relevant child6 and therefore needed to seek advice about his situation. Issues with housing continued, again in 2011 but also during the time frame under review.  4.2. In September 2011 concerns were identified about domestic abuse between Child I’s Mother and Father. At this time Sibling 1 was six months old. No vulnerabilities had been documented by the Midwifery Service during Mother’s pregnancy with Sibling 1. 4.3. In July 2012, an extended family member made a referral to Children’s Social Care describing Sibling 1 as having bruising on the arms and legs, and that Father had squeezed and threatened the child. Section 477 enquiries were made however the concerns were not substantiated. There is no record of a child protection medical taking place. At this time, Sibling 1 was 15 months old and Sibling 2 was two months old. During Mother’s pregnancy with Sibling 2 the main concern reported to the Midwifery Service by Mother was housing; domestic abuse was not mentioned. Given the housing issues Mother was supported by specialist midwives.  4.4. During the pregnancy with Child I Mother did not raise any concerns and no vulnerabilities were recorded. At this point Mother was living with Father.  4.5. Health Visiting records from March and December 2013 indicate that Mother could be difficult to get hold of, and opportunistic visits were often more successful than scheduled appointments. During one appointment the Health Visitor did ask questions about domestic abuse between Mother and Father; despite the Health Visitor being aware of previous incidents, Mother stated that there were no problems, and the Health Visitor described ‘… a stable and loving environment … and the parents had resolved their differences and appeared to be getting on well …’8.  4.6. In February 2014, shortly after Child I was born, both Siblings 1 & 2 were admitted within two days of one another, via ambulance, to Royal Berkshire Hospital with febrile convulsions. The Ambulance Service, on attending the family home, were concerned that the children in the home were dirty and unkempt, with a poor and unclean living environment. This information was 6 Relevant child: A ‘relevant child’ is a child who is not being looked after by any local authority, but was, before last ceasing to be looked after, an eligible child, and is aged 16 or 17. It is the duty of each local authority to take reasonable steps to keep in touch with a relevant child for whom it is the responsible authority, whether he is within their area or not to appoint a personal adviser for each relevant child. An ‘eligible child’ is one aged 16 or 17, who has been looked after by a local authority for a period (13 weeks), or periods amounting in all to that period, which began after he/she reached 14 years of age and ended after he/she reached the age of 16. It is the duty of the local authority looking after an eligible child to advise, assist and befriend him/her with a view to promoting his/her welfare when they have ceased to look after him/her. For each eligible child, the local authority shall carry out an assessment of his/her needs with a view to determining what advice, assistance and support it would be appropriate for them to provide while they are still looking after him, and after they cease to look after him/her, and shall then prepare a pathway plan for him/her, Children Act 1989 & Children (Leaving Care) Act 2000. 7 Section 47, Children Act 1989; where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable to them to decide whether they should take any action to safeguard or promote the child’s welfare. 8 Berkshire Healthcare Foundation NHS Trust, report to Review. OFFICIAL SENSITIVE5passed to the Hospital who, in turn, passed this to the MASH9. The condition of the family home was not judged to be linked to the febrile convulsions although vulnerabilities were recognised and this was passed to Children’s Social Care. This onward referral was not taken any further as it was judged by Children’s Social Care that a threshold for further assessment or intervention was not met. During this period of hospital admission Father is reported as being verbally aggressive to hospital staff but also another patient’s parents. 5. Other relevant background information during the time-frame under review5.1. In March 2014 Sibling 2 was prescribed medication for epilepsy. There were no current risk factors to justify the Health Visiting Service offering any greater level of support beyond that of a universal level of service10.  5.2. The Health Visiting Service conducted a home visit which resulted in a referral to the MASH due to Father becoming aggressive and threatening when the Health Visitor challenged Mother about picking Child I up by the wrists. As consent to make a referral was not sought from the parents by the Health Visitor, and as the aggression was targeted at professionals rather than the children, the outcome of this referral was that it would not be taken any further. Whilst this decision was challenged by the Health Visiting Service it did not result in further action. 5.3. In August and September 2014 the Police were involved on five occasions due to an incident with neighbours, an allegation from Mother that Father was domestically abusive and a heavy cannabis user, reports about domestic incidents, concerns about the children and parental cannabis use. One of these incidents involved a report that Father had attempted to strangle Mother. This was not the first disclosure of this nature. These incidents were automatically notified to Berkshire Women’s Aid, the Health Visiting Service and Children’s Social Care.  5.4. On three occasions the nursery recorded incidents involving Sibling 1. On one occasion she had singed hair (stating that she had fallen in the oven), on another a cut finger (stating that Sibling 2 had cut her with a knife), and on a third, a mark on her arm (stating this was from climbing out of a window). These incidents were discussed internally by staff, but also with Mother. The explanations given seemed plausible, as were the assurances by Mother that she would be more vigilant.  5.5. In the later part of 2014 there were three further Police attendances due to domestic incidents. Risk assessments11 were completed however only information about one incident was passed to Children’s Social Care. Information was also passed to Berkshire Women’s Aid to make contact.  Concerns that emerged were an unclean house, Mother stating that Father was 9 MASH: Multi Agency Safeguarding Hub which is able to undertake an initial assessment and conduct agency checks to determine the best course of action. 10 The Healthy Child Programme: Pregnancy and the first 5 years of life, Department for Health, focuses on a universal preventative service, providing families with a programme of screening, immunisation, health and development reviews, supplemented by advice around health, wellbeing and parenting. Different tiers of service are available dependent on need. The universal level of service is the lowest level of intervention and support offered. 11 DOM5 – Domestic abuse risk assessment form. OFFICIAL SENSITIVE6aggressive and threatening, and Father alleging that Mother was not taking her anti-depressants. The Health Visitor remained involved and increased her input in February 2015 to Universal Partnership Plus12. She had spoken to the MASH following a domestic incident in October 2014 and had stated that, on that occasion, she had no safeguarding concerns. Sibling 2’s epilepsy was being managed via reviews with the hospital paediatric epilepsy clinic and the GP, who was responsible for prescribing medicines.  5.6. Risk factors were noted by the Health Visitor following Child I’s nine-month developmental check in December 2014. These included domestic abuse and the parent’s heavy smoking. Child I was assessed as within developmental milestones except for communication and gross motor skills which were judged as borderline. Further visits did not raise any concern for the children, and in July 2015 the Health Visitor was advised by Mother that she was feeling depressed as she and Child I’s Father had ended their relationship and he was living with his new girlfriend in the house next door. 6. Key Episodes6.1. In wishing to conduct a proportionate review of this case and identify learning for the multi-agency partnership, it is important to remain mindful of the local context. Reading Borough Council was inspected by Ofsted13 in May 2016 and a number of findings were made in respect of the quality of service to children and families. The time-frame under review precedes this inspection, yet contains relevant background information. With the benefit of hindsight, this information provides us with useful insights and as such, is outlined above. However, there are specific periods of intervention with the children and family that are judged to be of greater significance, and which are more recent. They are key from a multi-agency practice perspective rather than to the history of the child. Given the findings of the Ofsted inspection, this Review has therefore focused on these, whilst acknowledging the more historical features of the case, as a way of identifying learning and promoting improvements. This Review has identified three key episodes that warrant closer examination. These are; -Key episode 1: October 2015 – March 2016-Key episode 2: April 2016 – June 2016-Key episode 3: June 2016Key episode 1: October 2015 – March 2016 6.2. In October, November and December 2015 there were four reported domestic incidents; the children were not present during three of these incidents but were present for the fourth, which occurred in early December. This final incident resulted in a conviction of criminal damage. On all 12 See footnote 10; Universal partnership plus is an increased level of visiting and support. 13 Reading Ofsted inspection report, 2016 OFFICIAL SENSITIVE7four of these occasions the domestic abuse assessment form score was rated as medium risk14; an increase from standard as used on previous occasions. As the children were present during the fourth incident, Children’s Social Care were informed and a notification sent to Berkshire Women’s Aid from the Police. The outcome of the information exchange between the Police and Children’s Social Care was that the case was closed and no further action taken by Children’s Social Care; records indicate that this was due to the fact that Father had visited Mother’s property (and the home in which the children were living) rather than him actually living there. 6.3. Towards the end of December, there were another three domestic incidents, in addition to the ones outlined above, requiring Police attendance; the children were confirmed to be present during two of the incidents and Children’s Social Care were informed of these by the Police. During one of the incidents Father had removed Sibling 1 from the home. Again, all three incidents were rated as medium risk and on two occasions Berkshire Women’s Aid were informed by the Police. The outcome of the information exchange was that Children’s Social Care agreed, at the end of December, that a Child & Family Assessment15 was appropriate for the following reasons; the increasing number of domestic incidents, health concerns, threats, home conditions, possible emotional harm, Mother’s mental health and parenting capacity, the drug use and the risk of neglect. This assessment commenced in January 2016, 16 days after the decision had been made. At this stage all three children were now living with Father and his new partner.  6.4. However, prior to the Child & Family Assessment being started the Police were called to three domestic incidents involving the Father and his new partner in a different house on consecutive days; one of these included an incident where Father had tried to ‘throttle’ his new partner. These were categorised as medium risk (one being re-categorised from standard to medium) and Children’s Social Care were informed of two, as the children were present. During this time, the Health Visiting Service received domestic abuse reports, as outlined above, and contacted Children’s Social Care to discuss their involvement. At this time Father’s Partner is reported to have stated that she did not want to be in the relationship and did not want to be mother to his children. 6.5. At the beginning of March, the Police were called to a further domestic abuse incident at Father’s house. Risk was assessed as medium and information was sent to Berkshire Women’s Aid and Children’s Social Care. Records appear to indicate neither the Hospital nor Health Visiting Service were contacted as part of any initial assessment exercise by Children’s Social Care. The Child & Family Assessment was closed in mid-March following management oversight as no concerns were found.  Just prior to the closure of the case, the Police attended a domestic incident between the Father and his Partner. For the second time a risk assessment was declined 14 Medium risk: there are identifiable indicators of risk of serious harm. The offender has the potential to cause harm but is unlikely to do so unless there is a change in circumstances, for example, failure to take medication, loss of accommodation, relationship breakdown, drug or alcohol misuse, *Serious harm is defined as risk which is life-threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible, Thames Valley Police guidance.  15 Child & Family assessment is undertaken under section 17 of the Children Act 1989, where a child may be considered to be in need of support and assistance. OFFICIAL SENSITIVE8by the Father’s Partner however it was categorised as medium and Children’s Social Care were informed.  Key episode 2: April 2016 – June 2016 6.6. Later in April, Father’s Partner called the Police reporting a domestic incident. Despite Father’s Partner not wanting a risk assessment the matter was still categorised; initially standard but then increased to medium as a result of a further review of the incident by the Police. The three children were not present during this episode.  6.7. Following this incident, the case was reviewed by Children’s Social Care who decided to re-look at the situation given the presenting issues. This re-assessment did not result in any action being taken. At this time, Father’s Partner had also reported that she was nine weeks pregnant. It was known that Father’s Partner had experienced a difficult and neglectful childhood herself. 6.8. In May a further domestic incident occurred between Father’s Partner and Father, during which Father is reported to have threatened to ‘… get someone to rape her 12 years old sister …’. Children’s Social Care were informed of this and conducted a visit the same day. The Father’s aggressive shouting in front of the children was observed.  6.9. At the beginning of June a Professionals Meeting was convened by a Social Worker. This was attended by a Family Worker, a School representative and a Nursery representative. No concerns were raised by anyone. Key episode 3: June 2016 6.10. In mid-June Child I, aged two years and five months, was taken by ambulance to the Royal Berkshire Hospital having been found unresponsive by Father at 09.30 hrs.  6.11. Whilst Child I was being stabilised tests were being completed to ascertain the cause of the collapse. At approximately 13.00 hrs blood tests revealed high levels of epilepsy drugs in Child I’s system; which had the potential to cause respiratory arrest. At this point the medical team considered this as a non-accidental incident and Children’s Social Care were contacted by the Hospital at 16.15 hrs. 6.12. At 16.40 hrs Children’s Social Care contacted the Police requesting a Strategy Meeting16 for the following day due to Child I’s circumstances on admission. A further call from the Berkshire Emergency Duty Service (EDS) was logged at 19.15 hrs with a similar request. Following enquires by the Police with the EDS it was established that Sibling 1 & 2 were with Father’s Partner. The following day, the Strategy Meeting took place however it was not established until 18.55 hrs that Siblings 1 & 2 were in fact with the paternal grandmother. The day after the Strategy Meeting, a 16 Strategy Meeting is convened under Section 47, Children Act 1989; where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable to them to decide whether they should take any action to safeguard or promote the child’s welfare.  OFFICIAL SENSITIVE9Legal Planning17 meeting took place and there was a joint assessment of the Siblings. The next day Mother, Father and Father’s Partner were spoken with by the Police, prompting the Siblings to be accommodated under section 20 of the Children Act 198918 by the local authority. Three days after the precipitating incident, both Siblings were placed in foster care. 7. Findings & analysis1. This section offers findings and analysis about the quality and effectiveness of the multi-agencysafeguarding response to Child I, and siblings. It draws on systems thinking concepts19 as a way ofmaking sense of some aspects of how this case was managed, whilst also offering learning pointsfor improving practice.2. This case is subject to review due to the potentially life-threatening ingestion by Child I ofepilepsy drugs. The Family Court made findings about this being deliberately administered. TheCourt also found that that either the Mother, Father or Father’s Partner were negligent in that theyfailed to properly supervise Child I, or siblings, allowing access to the drug.3. As a result of undertaking this Review, and therefore with the benefit of hindsight, the moststriking finding is one that highlights an absence of known risk factors relating to the misuse, ormismanagement, of prescribed medication by the adults in this family. Oversight by theprofessional health system of the management of epilepsy was acceptable, and the prescribingof drugs for this condition from a GP perspective was also acceptable and would not have raisedany concern.4. The Review has highlighted a number of other risk factors which undoubtedly compromised thesafety and welfare of all three children, however it has not been possible to identify anysubstantive links between these and the deliberate administration of epilepsy drugs to Child I. Ithas portrayed a picture of a relatively chaotic family experience for all the children. This, in itself, isa learning point for those working closely with children and families where there are other knownand quantifiable risks highlighting the need to ‘think the unthinkable’ and be open minded aboutsources, motivations and predictability of harm to children.7.1. The quality of practice & systems in regard to the sibling’s epilepsy 7.1.1. Given the other history, and behaviours of the adults, this Review has sought to examine whether the inappropriate use of prescribed drugs was a factor that was missed by those 17 Legal Planning meeting provides an opportunity to discuss evidence and determine whether a threshold is met to initiate legal proceedings (immediate or planned) as a way of safeguarding, and promoting, the welfare of a child. It is convened by the local authority and follows guidance, as set out in the Public Law Outline: Guide to Case Management in Public Law Proceedings.  18 Section 20, Children Act 1989: the provision of accommodation for a child by the local authority, who is deemed in need (even though a person who has parental responsibility for that child is able to do so) if the local authority considers that to do so would safeguard or promote the child’s welfare. 19 i) Systems thinking for safety: Ten Principles – A White paper, Eurocontrol, 2014 ii) A systems approach to policy evaluation, Caffrey, L., & Munro, E., The London School of Economics and Political Science, 2017, iii) Systems approaches to managing change: A Practical Guide, The Open University, 2010. OFFICIAL SENSITIVE10professionals involved with the children and family. On that basis, the following areas have been examined; a) Diagnosis: This Review has found no evidence to indicate the original diagnosis of Sibling 2having epilepsy was incorrect. The Royal Berkshire NHS Foundation Trust Hospital has reflected onthe initial management of Sibling 2 when brought in with seizures in 2014. Whilst there could havebeen some improvements in the initial management this did not impact of the care of the child.Improvements have been implemented as a result of this finding.b) Prescribing: Review and analysis of the prescriptions issued in respect of epilepsy medication forSibling 2 reveal that approximately 50% more medicines were provided than were required,between March and December 2014. Some caution is needed in drawing an automatic negativeconclusion from this finding; firstly, the fact that other adult members of the close family were alsoprescribed with the same medication and it is not knowable whether there was any sharing ofmedicines, and secondly; there was an increase in dosage in December by the PaediatricConsultant. The over-ordering of the medication was not highlighted as an issue at that point. As apoint of learning, on any occasion that a clinician adjusts the dosage or formulation it alsoprovides an opportunity for the prescribing practitioner to undertake a review of pattern of usage.This would apply especially so in families where there are known vulnerability factors. Mother wasable to recall that she was careful about the dosage given, and that she was aware of theimplications of giving an over-dose because a member of her extended family had beenadmitted to hospital once because of this very issue. Discussion with the GP Practice Manager hashighlighted that there is often a leeway given to the seeking and issuing of repeat prescriptions toallow for life e.g. spillage, holidays, etc. The over-collection of prescriptions is rarely seen as anissue of concern, where-as the failure to collect would be flagged as a worry. With an outcomebias in mind (i.e. Child I being over-dosed), caution is needed in drawing a conclusion that theover-prescribing across a 10-month period equates to a deficit in practice, systems and processesgiven the tolerances described. It is impossible to conclude that the over-prescribingautomatically meant over-administration.c) Dispensing: Due to the number of pharmacies in the Reading area it has not been possible, orproportionate, to examine this area. Mother recalled using three different pharmacies, and it isnot known which ones Father used.d)Advice and support: All prescribed medicines have information and safety leafletsaccompanying them. This includes advice about the dosage as well as storage guidelines. Safetyadvice was, and is, not always explicitly documented by the Epilepsy Nurse. Mother describedfeeling certain in her knowledge of the drug.e) Storage of medication: The Health Visiting Service acknowledge that safe storage of medicinesis not always discussed, and was not in this case. General home safety is part of a Health Visitorsassessment and in this case, nothing suggested that the home environment was unsafe. There isevidence in the Social Work assessment that Sibling 2’s epilepsy was discussed, with informationhighlighting that the Father was considered to be the more reliable parent in giving Sibling 2 thedrug. Beyond that, there is little mention of it being explored or being considered an issue. Thestorage of the drug was examined following the critical incident and Father’s Partner indicatedOFFICIAL SENSITIVE11that it was kept in a locked cupboard however on checking this was not the case, with it being in a bag of children’s clothes which was in reach of the children. Mother described that whilst living with her, the medicines were stored in a lockable cupboard. f) Administration of medication: The administration of Sibling 2’s epilepsy medicine was reliant on Mother, Father and Father’s Partner. In the case of children taking prescribed drugs there is an assumption that a competent and responsible adult supervises and supports the administration. As Sibling 2 was being regularly reviewed by the Hospital, it is reasonable to assume that the medicines were being administered appropriately since diagnosis. There is no evidence to suggest this was not the case and to an extent there has to be an element of trust between medical practitioners and parents - trusting that parents will do the right thing in giving prescribed medication to their children. Mother described feeling confident in her handling of the medicines. It is worth noting that Sibling 2 ceased taking epilepsy drugs approximately one year after the critical incident, and no longer has seizures.  g) Review: There is no evidence to indicate that the ongoing management of the condition was inappropriate by professionals. Sibling 2 was reviewed by a Consultant Paediatrician and an Epilepsy Nurse, and whenever there was a failed appointment the GP was informed with further appointments being arranged. 7.1.2. Hair strand tests on Child I indicate drug ingestion from April 2016 onwards. It is impossible to know whether it was administered before this time period. It would be speculative to form views about whether the drug was given when the children lived with the Mother and Father, just the Mother, or whether it began when Father started living with his new partner.  7.1.3. When placing the above findings in context of other known information about how this family functioned and behaved, it magnifies the importance of the case needing to be assessed in a thorough and holistic way when concerns began to escalate in October 2015. With the benefit of hindsight, the gaps and deficits in the quality and effectiveness of assessments and intervention become more pronounced (outlined below). Matching an assessment of need, abuse or harm alongside an assessment of the three adult’s understanding of the management and administration of medication would have been an option worth considering, however it is evident that Children’s Social Care did not consider the inclusion of medicines management in any assessment work. Again, with the benefit of outcome bias it is impossible to know whether the critical incident could have been predicted or prevented. Epilepsy is a life-threatening condition and requires potent drugs to manage it. Research20, although relating to opiate based drugs, highlights the need to think the unthinkable and that some parents may give their children drugs that are prescribed for an adult.  Learning point: When working with children in families where prescribed drugs are used on a regular basis it is important to ask questions about medicine management. This should include an assessment of how these drugs are prescribed, what advice and support is given, and how the drugs are stored and administered. This should apply to prescribed drugs for both adults and 20 Medications in drug treatment: tackling the risks to children, Adfam, 2014.  OFFICIAL SENSITIVE12children. It may then be appropriate to cross reference the information gathered with professionals involved in the prescription and review of those drugs e.g. GPs and hospitals. Learning point: When working with children, whose parents may have poor mental health, limited abilities and learning difficulties (diagnosed or not) it will be important to assess competence and practical understanding about using prescribed drugs, especially when concerns about neglect, children’s safety and welfare have been raised. 7.2. What was known about the parental history, vulnerability & risk factors in this case? What consideration was given to the impact of these on the children?  7.2.1. Both the Mother’s and Father’s background is relevant from a child protection and safeguarding perspective. Relevant information includes; • Both Mother and Father experienced housing, or homelessness issues, at around 17/18 years of age; strongly indicative of extended family disharmony prior to them becoming parents themselves.  • As children themselves, Father, and his Partner, had been in local authority care. Children who have experienced episodes of being in the care of a local authority are more likely to have had adverse childhood experiences, and to have experienced abuse or neglect. In turn, they are also more likely to have experienced less secure and less stable relationships. There is a body of research evidence that supports the view that such experiences may go on to compromise their own parenting capacity and abilities21.  • Father’s Partner explicitly stating that she did not want to be the mother to Father’s three children. • The use of cannabis, anger management problems, attempts at strangulation, domestic incidents and intimidation of professionals. Some of the domestic incidents reached a threshold which resulted in criminal charges being made, and convictions. • A previous referral in 2012 to Children’s Social Care, from a family member, reporting bruising to Sibling 1 allegedly caused by Father. At the time, Sibling 1 was 15 months old and Sibling 2 was two months old. Although not substantiated it does highlight possible concerns about parenting capacity, control and anger management, especially for someone in a household with very young children. • The use of opportunistic visits to the Mother as likely to be more successful than scheduled appointments; this does reflect a degree of dysfunction and chaos by the Mother. • Mother’s mental health; her depression and inconsistent use of medication to treat this. • When admitted to hospital in 2014 with febrile convulsions concerns were noted that the home was dirty and unkempt, with a poor and unclean living environment. Again, this is reflective of parents that were likely to be struggling to manage. 21 Does the past predict the future? Reder, P., in Studies in the Assessment of Parenting, Reder, P., Duncan, S., & Lucey, C., Routledge, 2007.  OFFICIAL SENSITIVE137.2.2. Research22 highlights that the above factors are common in other case reviews conducted and do impact on parent’s capacity to keep their own children safe. Of specific note are; young parenthood, accommodation difficulties, the cumulative risk of harm, particularly mental health, domestic incidents and criminal behaviour. All of these factors featured in this case and were known about by agencies at the time of their involvement with the parents and children. Research23 also highlights that the use of strangulation (known about on at least two occasions with different partners) is significant as a feature of a coercively controlling relationship, but also a strong potential risk indicator of homicide. Research24 also tells us of the difficulties victims of domestic abuse face when attempting to leave an abusive relationship; reminding us that it is a significant, and often bold step to take. Mother described attempts to leave but that she was threatened by Father, either physically, or emotionally with not seeing her children again. Learning point: Recent attempts of strangulation in current intimate partner relationships should always be taken seriously, risk assessed and safety planning discussed. Any agency can refer what they consider to be a ‘high risk’ situation to the Police. Research supports the finding that women who experience attempted strangulation are on the edge of being a victim of homicide. Learning point: In situations where it is known that a partner has left a domestically abusive relationship but left children behind with the known perpetrator it will be appropriate to conduct a thorough assessment of risk to the children. Attempts to end, or the ending of a relationship, may signal an elevation of risk. 7.2.3. The features outlined above are suggestive of individuals, who in themselves, are somewhat vulnerable. When these pre-disposing vulnerabilities are compounded by situational factors, such as becoming a parent and having multiple, and often competing demands, it does increase the likelihood of both individuals being more easily stressed and challenged by the care needs of their children. 7.2.4. The protection of Mother, or Father’s Partner, from Father was considered in isolation of needing, in parallel, think how to reduce the Father’s coercive and abusive behaviours. Father clearly had a role in providing care to his children, yet understanding his background and considering the likelihood of him going on to commit further abuse and harm was absent.  Learning point: The role of men in a household can often be overlooked even though they may be a cause of concern. The care and protection of children is often perceived to be the role of the mother in the household25. Engaging men, as fathers, in the assessment process is an important aspect of assessing risk to children.  22 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, University of Warwick & University of East Anglia, May 2016.  23 i) Domestic Homicide Reviews: Key findings from analysis of domestic homicide reviews, December 2016, Home Office, and ii) Non-fatal strangulation is an important risk factor for homicide of women, 2007, Glass, N., Nancy Glass, Laughon, K., Campbell, J.,  Wolf Chair, A.,  Block, C.R., Hanson, G., Sharps, P., & Taliaferro, E., Journal of Emergency Medicine.  24 Safe lives: about domestic abuse 25 NSPCC briefing: Hidden men: learning from case reviews, April 2015. OFFICIAL SENSITIVE147.2.5. Records and discussions, as part of this Review, support a finding that the Health Visiting Service recognised the above pre-disposing vulnerabilities and risks. This is evidenced by i) the increase in service offer from Universal to Universal Plus; ii) the frequency of visiting but also the acknowledgement that opportunistic appointments usually had a greater success that scheduled meetings; iii) the Health Visitors efforts to remind Mother to attend appointments; and iv) referrals being made to the MASH. It is therefore reasonable to conclude that the Health Visiting Service was aware of the impact of the background vulnerabilities for Siblings 1& 2, and Child I.  7.2.6. The Housing Needs & Management Service were not aware of Mother’s vulnerabilities, as she had not disclosed them in 2009.  Later contact in 2013 did not reveal any change to the original assessment of Mother having no support needs or vulnerabilities. The Housing Needs & Management Service was aware of Father’s background, as this was disclosed by him when he first presented as homeless although he declared that substance misuse was not an issue.  7.2.7. Children’s Social Care were aware of both the Mother and Father’s backgrounds; however, this Review has found that there was little consideration of how these might have had an impact on Siblings 1 & 2, and Child I. The steady accumulation of concerns, particularly domestic incidents did not prompt Children’s Social Care to review the history, or create a chronological account which would highlight how the levels of risk to the children might be increasing. Incidents were dealt with in isolation.  Learning point: Young parents can often experience additional pressures and difficulties, especially when they are unsupported. It is important to be alert to other factors, aside from the age of a young parent, which will further compromise parenting ability e.g. housing issues, mental health, and the quality of the relationship with the other parent. Learning point: Making the links between background information in a parent’s life and current parenting capacity is crucial to effective safeguarding practice; acting on this information when there are concerns is critical in order to prompt other agencies to become involved and promote targeted support and safety planning. 7.3. The quality & effectiveness of any assessment, planning & intervention.  7.3.1. Statutory guidance in place during the timeframe under review26 sets out expectations for the local authority, and relevant partner agencies for providing early help and the identification, assessment and response to those families that would benefit from early intervention as soon as a problem emerges. This offer of early help should sit within a continuum of services which will stretch through children needing support and assistance to children needing statutory intervention to safeguard and protect them from abuse or neglect. Regardless of which level of support is needed, assessment should be based on a holistic understanding of need – usually obtained via  26 Working together to safeguard children, 2015, HM Government.  OFFICIAL SENSITIVE15contact with other agencies and professionals – be child focused, and include an appreciation of the child’s daily lived experience and their voice27.  7.3.2. In this case key episodes 1 & 2 highlight that there were two opportunities to formally assess and intervene with this family by Children’s Social Care under section 1728 of the Children Act 1989; however, there were also opportunities whereby the Police, Health Visiting Service and Housing Needs & Management Service had contact with either the children, the Mother, Father, or Father’s Partner.  7.3.3. Key episode 1 shows a steady increase in the frequency of the Police being called for domestic abuse related incidents. It is likely that there were other incidents where the Police were not contacted, and that domestic disharmony and dispute were common place in the family home at this time.  The children cannot have been immune to this and the observations from the Health Visitor strongly suggests a level of accommodation29 to this behaviour; ‘…throughout the … incident Sibling 1 and 2 seemed unconcerned with the shouting and aggressiveness of the Father’s actions, Child I didn’t cry and it appeared that they were used to this behaviour … I have concerns that the Mother appeared unembarrassed and shrugged off the fact that I was leaving because of the Father’s threatening behaviour …’. Children can be victims of domestic abuse too, although will not necessarily be viewed as the primary, or obvious, victim. Although the children were not present for all of these reported, and attended, incidences it is important to remain mindful of the cumulative impact on the children of living in such an environment. Research30 confirms the harmful effects on children of witnessing and living with domestic abuse, aside from them potentially being injured during conflict ‘… effects include high rates of depression and anxiety, trauma and … behavioural problems …’. These can impact on educational attainment, forming relationships, self-esteem, and general health and wellbeing across the life-span. The perception of children being passive bystanders, or simply witnesses, to domestic abuse should therefore be challenged.  Learning point: Children who live with domestic abuse are victims too. Consideration should always be given to understanding the child’s daily experience of living in such an environment and the potential for emotional harm.  The contribution of the Police & Berkshire Women’s Aid to assessment, planning & intervention 27 The term ‘voice of the child’ is a colloquial term of setting an expectation that children are seen, spoken with and their views ascertained at every available opportunity. Children’s perceptions of events, behaviours and people are important to understand as this supports assessment, planning and intervention being child focused.   28 Section 17 – see footnote 1 & 18.  29 Children living with domestic violence: Towards a framework for assessment & intervention, Calder, M., 2006, Russell House.  30 Stanley, N., Cleaver, H., & Hart, D., The impact of domestic violence, parental mental health problems, substance misuse and learning disability on parenting capacity, in, The Child’s World, 2nd Edition, The comprehensive guide to assessing children in need, Edited by Horwath, J., Jessica Kingsley Publishers, 2010.   OFFICIAL SENSITIVE167.3.4. During this period (October 2015 – March 2016) the Police attended 15 incidents, of which two were specifically classed as child protection incidents, three were classed as domestic abuse incidents between Mother and Father, and 10 were classed as domestic abuse incidents between Father and his Partner. Five of the domestic abuse incidents were categorised as standard risk by the Police but then re-graded as medium risk by an impartial Police Risk Assessor. No incidents were categorised as high risk; if they had of been, they would have been passed to the Police Domestic Abuse Investigation Unit but also MARAC31, and benefitted from greater scrutiny and oversight as a whole, rather than being considered in isolation. The use of strangulation as a method of control or causing fear or abuse must always be taken into account. Learning point: Seeking a fresh, and often impartial, perspective on an assessment of need or risk can be a positive and worthwhile step, for all agencies and professionals involved with a family; particularly when multiple referrals have been received on a case, but also when individual practitioners operate in busy organisations and have competing demands on their time. It reduces the likelihood of professional desensitisation and accommodation to issues that may have serious and lasting consequences. 7.3.5. The Police were asked to record the ‘voice of the child’ on each occasion however records reveal that due to the age of the children this was rarely achieved. This raises questions about how Police Officers can meaningfully capture the experiences of young children, or children whose verbal ability is limited. Training provided to the Police, since this incident, has sought to develop their approach to dealing with domestic abuse incidents and encourages officer to speak to children of all ages to ensure they have a voice.  Learning point: Seeking verbal feedback from children is ideal whenever possible. When this is not possible it may indicate a need to involve other professionals who might be able to gain the children’s views, i.e. schools, nursery. 7.3.6. Importantly, the focus for the Police as a law enforcement agency will be offender and victim centred. Whilst their minds-eye will be alert to a crime being committed, during domestic abuse related call-outs their focus will be on the primary victim of the call out. In this case, it is therefore unsurprising that the views, and lived experience, of the children were not the Police’s greatest priority at the time of the call-out. From a system thinking perspective, this is an inevitable trade-off, which is caused as a result of the Police having a primary role and purpose, as defined in legislation. Trade-offs are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to make trade-offs and choose sub-optimal courses of action. Trade-offs, such as these, help us understand system behaviour and system outcomes. The trade-off in this case for the Police during call-outs was their focus on the adult victim against spending time with the children to gain their contribution. Despite this occurring, the appropriate information about the children being in the house at the time was shared by the Police in a timely manner with the appropriate agency – 31 MARAC – Multi-Agency Risk Assessment Conference is multi-agency risk and information sharing forum led by the Police to manage high risk situations of domestic abuse. OFFICIAL SENSITIVE17Children’s Social Care. Positively, this does indicate a level of understanding by Officers that there was a likely impact on the children’s welfare. 7.3.7. The Police have, and continue to review, the way in which they assess and manage the risk posed by the domestic abuse offender and the risk to the victim. In this case, there was a clear increase in the number of call-outs – especially during the November and December periods – regarding Father being involved with either Mother or his new partner. An evaluation of any emerging patterns, and recognition that the Father was seemingly becoming a serial offender across more than one relationship, would have been beneficial at the time. The Police have recognised that this did not happen in the way they hoped it might at the time and two years on from this incident they have been able to report on improvements. There is also recognition that the concept of coercive control by Father towards Mother, was not considered at the time.  7.3.8. Since this time, the Police have introduced, or strengthened, measures in an attempt to reduce the likelihood of similar oversights recurring, but also improve their response. These measures include; i) a regular Domestic Abuse Repeat Incident meeting which looks at the top 10 repeat risk offenders across the region. This case would have met the criteria to be discussed at this forum, ii) there is now better oversight of domestic abuse incidents at the MASH on a daily basis, iii) the introduction of ENCOMPASS, which is a Police led process whereby domestic abuse incidents will trigger an e-mail to the relevant child’s school. This would not have had any impact in this case due to the age of the children, however it can provide a level of reassurance that Police attendances at disputes where there are school age children will share information with schools, who will be in a position to monitor the child’s welfare, iv) there are also plans to introduce a further strategy, MATAC32, which will work alongside MARAC as an initiative to target the most harmful perpetrators in a particular area.  7.3.9. Berkshire Women’s Aid has highlighted that during this timeframe under review they were commissioned to deliver a pilot project for medium risk victims. This was not focused on offering support but to offer basic safety planning, and onward referral for support of the victim if consenting. Despite referrals being sent by the Police, Mother did not respond to the contacts by Berkshire Women’s Aid due to the ongoing threats. At the point she did engage with them Mother’s relationship with Father had ended. Further offers to support Mother were declined however Mother has described that since the relationship ended with Father, she engaged with them.  7.3.10. Berkshire Women’s Aid also made numerous attempts to contact Father’s Partner having received the referral information from the Police, with the majority of attempts resulting in Father’s Partner not wanting any support.  7.3.11. The response by both Mother, and Father’s Partner does reflect an inherent tension for an organisation such as Berkshire Women’s Aid that is established to have an adult victim focus. In knowing that domestic abuse is taking place in a household where there are children living presents a dilemma for workers in having to apply a threshold. This threshold is whether the safety 32 MATAC – Multi-Agency Tasking & Coordination: a Police led initiative to tackling the most harmful and serial domestic abuse perpetrators.  OFFICIAL SENSITIVE18and welfare of any children is sufficiently compromised by them not making an onward referral to other agencies i.e. Children’s Social Care. They are therefore required to balance risk; ensuring the safety of the adult victim if other agencies become involved in a victim’s life may increase the risk to all in the household. In this case, Berkshire Women’s Aid have reflected, with the benefit of hindsight, that the increasing number of referrals – particularly in relation to Father’s Partner in late 2015 and then 2016 warranted an escalation of their response. This could have happened by Berkshire Women’s Aid increasing their assessment of the risk level category to high, which would have prompted a referral to the MARAC, or by the use of more confident professional judgement which may have resulted in a discussion with Children’s Social Care. It is noteworthy that Mother had implemented her own safety planning by leaving the relationship with Father. This was however limiting as they continued to live as neighbours. Research supports the period around a woman leaving an abusive relationship as being particularly risky33.  7.3.12. Whilst recognising that children are victims of domestic abuse as well, the referral to MARAC can have the effect of removing any dilemma that some professionals may face in trying to juggle the safety and welfare of an adult versus children. Research34 supports the use of MARAC as a mechanism for sharing information but also risk. However, when there are children involved a referral to Children’s Social Care should also, always be considered. Factors which contributed to this not happening at this time by Berkshire Women’s Aid include; the standard of professional supervision of workers, less management capacity and therefore less oversight, and professional confidence in assessing and decision making.  Learning point: Where there are significant concerns about domestic abuse between adults a referral to MARAC may be appropriate in order to raise the profile of the case, but also provoke a greater professional response; any professional can make this referral. This may be alongside a referral to Children’s Social Care if children are in the household. Learning point: Applying professional judgement to situations of risk and harm can be a complex task often informed by factors such as experience, values, personal circumstances, individual bias, work place culture and environmental pressures. Keeping a sense of purpose, and absolute focus on the safety and welfare of the child is critical to applying professional judgement. 7.3.13. Berkshire Women’s Aid are represented at the MASH and has been able to make improvements to their systems and structures in the time period following this incident. The contribution of the Housing Needs & Management Service to assessment, planning & intervention 7.3.14. The Housing Needs & Management Service have identified that in March 2016 a change in the tenancy agreement between Mother and Father was not thoroughly assessed. This lacked any contribution by other agencies or professionals that might have been working with the family 33 Research report: Risk Factors for Children in Situations of Family Violence in the Context of Separation and Divorce, Department of Justice: Government of Canada, accessed 14/11/18  34 Domestic Homicide Reviews: Key findings from analysis of domestic homicide reviews, December 2016, Home Office.  OFFICIAL SENSITIVE19at the time, as well as the involvement of Mother. Also, Father reported that one of the children had a disability; this was not considered any further and taken at face value with no consideration about what this might mean for accommodation. Whilst the change of tenancy went ahead, and it secured a level of stability for the children in terms of them physically remaining in the same house the Housing Needs & Management Service acknowledge that they could have completed a more holistic, and family focused, assessment of the situation.  7.3.15. Since this incident the Service has made considerable improvements to assessment tools but also reporting systems and structures. Tools guide workers to undertake a more holistic assessment based on the requirements of the Homelessness Reduction Act 201735, and which require a Personalised Housing Plan. These Plans are to be shared with other professionals who are working with members of the household (with consent). In terms of risk to the children, housing does not appear to have been a critical factor. However, the proximity of Mother to Father and his new partner i.e. next door, was a contributing factor in that it increased the likelihood of continuing dispute and acrimony. So, whilst the silo assessment by the Housing Needs & Management Service lacked depth, the greater task for them should have been working with the other agencies involved with the family to understand contextual risks. They were not aware that the children were being assessed by Children’s Social Care in January or April 2016. The reasons for this will be examined below. The contribution of the Health Visiting Service to assessment, planning & intervention 7.3.16. Records and discussions confirm that the Health Visiting Service was cognisant of the background information and the situational risks for the children of living in a household where domestic abuse was the norm. As noted above, the Health Visitor recorded her concerns about the children’s apparent immunity to witnessing a domestic incident and appropriately made a referral to the MASH; however, the matter was closed as consent to do so, was not sought from the parents by the Health Visitor. For the Health Visitor to seek consent at the time of visiting, when Father was present, it would have been challenging – especially given the levels of aggression and previous intimidation encountered. Indeed, this experience has had a lasting influence on the accompanying student at the time, helping shape how other challenging home visits might be conducted in the future for this individual. It is therefore unsurprising that consent was not sought on the day.  Learning point: Aggression and intimidation of professionals should always be taken seriously. Not only is there a danger of physical and psychological harm, but there is also the danger that such behaviour may be a deliberate ploy to divert the professional from assessing the risk to children. 35 This assessment must include assessing the circumstances that have caused someone to be homeless or threatened with homelessness, the applicants housing needs, what accommodation would be suitable for them, their household and anybody who might reasonably be expected to live with them and the support that would be necessary for the applicant and anybody who will be living with them, to have and to sustain suitable accommodation. When assessing the housing needs of an applicant we consider the individual members of the household and all relevant needs; this includes an assessment of the size and type of accommodation required, any requirements to meet the needs of a person who is disabled or has specific medical needs, and the location of housing that is required. This should then prompt a Personalised Housing Plan.  OFFICIAL SENSITIVE20Such matters should always be reported, dealt with in a timely and robust manner and seek the involvement of the Police if necessary. 7.3.17. Despite the decision to close, and the matter then being escalated the decision to take no further action was upheld by the MASH Manager at the time. The Health Visiting Service has reflected on the unsuccessful efforts to escalate the matter. As learning from this, the Service plans to increase training to Health Visitors about how to effectively escalate, as well as issue refreshed guidance.  7.3.18. Consent to share information is never needed if there are concerns about the safety and welfare of a child36. The Health Visitor had legitimate and justified concerns. The Health Visitor’s action was appropriate; the response by the MASH was not appropriate. Positively, anecdotal feedback from Managers and practitioners contributing to this Review suggests that there has been considerable improvement since this incident about the MASH’s response to consent not being gained.  Learning point: Government guidance busts the myth that consent is always needed to share personal information. It is not; ‘… you do not necessarily need the consent of the information subject to share their personal information. Wherever possible, you should seek consent and be open and honest with the individual from the outset as to why, what, how and with whom, their information will be shared. You should seek consent where an individual may not expect their information to be passed on. When you gain consent to share information, it must be explicit, and freely given. There may be some circumstances where it is not appropriate to seek consent, either because the individual cannot give consent, it is not reasonable to obtain consent, or because to gain consent would put a child or young person’s safety or well-being at risk. Where a decision to share information without consent is made, a record of what has been shared should be kept’. 7.3.19. The Health Visiting Service had no knowledge of the case being managed as a Child in Need, as this was never communicated to them by Children’s Social Care. As far as they were concerned the case had been closed when their attempts to gain support had failed. The reasons for this will be examined below. The contribution of Children’s Social Care to assessment, planning & intervention 7.3.20. As stated, there were two formal opportunities when Children’s Social Care became involved – January and April 2016. Both of these episodes were processed, and conducted, via Child in Need procedures. On both occasions the case was closed with no further action despite the re-opening of the case in April prompting another look at the issues.  7.3.21. Children’s Social Care has acknowledged deficits in their management of this case37, for both episodes ‘… the assessments undertaken did not fully consider the history of the case. There was optimism displayed when the children were in the Father’s care and short-term improvements 36 Information sharing Advice for practitioners providing safeguarding services to children, young people, parents and carers, HM Government, March 2015 and updated July 2018.  37 Reading Children’s Social Care, report to Review.  OFFICIAL SENSITIVE21were not considered alongside the violence that they were exposed to. This was particularly evident in respect of Sibling 1 who was starting to display challenging behaviour at both home and school …There was no analysis as to the root cause of … behaviours. The assessments undertaken are of limited use and failed to join together all of the information so a clear picture of the children’s lived experience was known. … There was no multi-agency meeting to share information … It appears no professional involved with Child I and siblings clearly understood the family’s circumstances … there was an emphasis on the here and now and with no professional fully considering the longer-term needs of these children … The level of support … was not adequate to protect the children … social work churn was significant and management oversight and supervision was … limited …’. In terms of managing the case via Child in Need guidance, ‘… CiN planning was not effective and there was not a multi-agency plan in place. There was no evidence of multi-agency CiN meetings taking place. On more than one occasion this case should have escalated into the child protection arena …’.  7.3.22. The lack of a meaningful chronology in this case was a contributing factor in Children’s Social Care failing to appreciate the level of risk, but also the daily experience of the children. The preparation of a chronology and using information gathered from multiple sources would have been a good place to begin assessing need. Identifying persisting patterns, rather than focusing on the presenting issue per se, would have supported more meaningful and focused intervention.  Learning point: When concerns or worries begin to emerge, regardless of professional discipline, taking a step back to reflect on what might be happening will be time well spent. Having date ordered, up to date and good quality records about children and families will significantly help your reflections.  Learning point: Gathering and analysing background information in the form of a chronology can be a useful tool in assessing and predicting future behaviours. The chronology may be specific and particular to your context e.g. not brought to appointments, domestic incidents, but the use of chronologies should be a consideration for all professionals involved in working with children and families38.  7.3.23. Children’s Social Care have recognised that there were at least six incidences when the situational risks to the children might have resulted in an escalation of their response, rather than an assessment and stepping down of intervention. These mostly relate to various domestic abuse incidents between June 2014 and February 2016. Mother described wishing she had received more help, as she was managing three children on her own and had very limited support from anyone else.  7.3.24. In recognising these significant deficits, there are clear themes emerging from this case review which are similarly reflected by the Ofsted findings from their inspection in 2016 which relate to whole system failures. Ofsted noted children were ‘… left at potential risk of significant harm for too long before action was taken. These failures were particularly prominent where children were affected by domestic violence … A breakdown in management oversight and too 38 Risk in child protection: Assessment challenges and frameworks for practice, Calder, M., with Archer, J., Jessica Kingsley, 2016.  OFFICIAL SENSITIVE22many changes of managers, alongside the failure of professionals to recognise the level of risk posed to children, were all too evident in far too many cases …’. The incident which prompted this SCR to be commissioned took place at the time of the inspection; it is therefore not unreasonable to draw conclusions from the findings of this Review, and place them within the context of the Ofsted findings in the preceding months to the inspection. Whilst being alert to bias, it is possible to make sense of the findings from this Review knowing the challenges and pressures Children’s Social Care were facing at that time. From a system thinking perspective, demand and pressure, coupled with resources and constraints, will impact on efficiency and performance. With the Children’s Social Care system experiencing a high staff turnover and inconsistent management oversight, there is an inevitable consequence passed on to the service user; in this case, the children and families in receipt of services. The lack of a chronology may be viewed as another example of a trade-off being used at the time in order to manage demand; some aspects of practice had to give and chronologies were one.  Trade-offs are an inevitable consequence of a system and process managed by people – especially balancing efficiency against thoroughness. For managers and those responsible for examining practice quality and performance, it is important to consider how busy front-line workers make trade-offs from their point of view and explore how they balance efficiency and thoroughness in light of the conditions and environment in which they operate. Remaining alert to the impact this has on children’s welfare and decision making is crucial. 7.3.25. The systems thinking concept that can accompany a trade-off is emergence.  Emergence39 is a key property of complex systems – of which the multi-agency child protection system in one. The strength of a complex and self-organising system can often be tested against its ability to respond to emerging issues which cannot be controlled, predicted or easily managed. Emergence as a concept is therefore relevant as it allows us, often with the benefit of hindsight, to better examine system weaknesses – rather than purely concentrating on the efforts, or errors, of individual practitioners. Ofsted found embedded and anchored practice that had emerged due to demand and pressure. The impact in this case of taking the short-cut was inadequate assessments, and silo working arrangements. Research40 highlights this stating ‘… a danger that can arise in such situations is cultural normalisation and professional desensitisation. This maybe a very appropriate coping mechanism by professionals overwhelmed by the volume and complexity of their task, but can result in vulnerable children being left without adequate assessment of their needs’.  Learning point: From a safeguarding system perspective, when the system struggles to manage the demand, there may be value to gaining an understanding about the likely trade-offs that will be used by workers and managers to cope e.g. not using chronologies to inform safety planning, not involving all relevant partner agencies, or not providing supervision. Agree which are acceptable, and which are not negotiable. Monitor, and remain alert to risks to children for when the safety net might fail.  39 Seel, R., Emergence in organisations, 2006.  40 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, University of Warwick & University of East Anglia, May 2016  OFFICIAL SENSITIVE23The multi-agency contribution to assessment, planning & intervention 7.3.26. The contributions and actions of agencies involved with Child I and siblings has been examined above from a single agency perspective thus far – in relation to key episodes 1 & 2. However, the cornerstone of contemporary child protection practice is the operation of a multi-agency safeguarding partnership. Statutory guidance41 states that ‘… no single professional can have a full picture of a child’s needs and circumstances and, if children and families are to receive the right help at the right time, everyone who comes into contact with them has a role to play in identifying concerns, sharing information and taking prompt action…’. 7.3.27. As already stated, submissions by Children’s Social Care have revealed that there was no Child in Need plan in place, nor any evidence of Child in Need meetings taking place. This is supported by the findings across other agencies and professionals involved with the three children. The Health Visitor was not aware that the children were being ‘managed’ or ‘processed’ as a Child in Need case, nor were the Police, the GP or the Housing Needs & Management Service. This confirms a break-down – in the management of this particular case – on information sharing, but also recognition of the role other agencies and professionals could offer in supporting or safeguarding these children. As a result, there was no multi-agency assessment and no holistic plan which resulted in fragmented intervention. This was seen when a ‘professionals meeting’ was held in June 2016 at Sibling 1’s school. This meeting appears to have been convened following knowledge of a further domestic incident between Father and his Partner. It is unclear on what basis this meeting was being held i.e. Child in Need, and whether it was with or without the knowledge of Mother, Father and his Partner, or whether it was as a pre-cursor to an escalation of concern. Regardless, the record indicates that no concerns were expressed by anyone attending about any of the children (Family Worker, School and Nursery). Crucially, neither the Health Visitor nor the Police were invited. The case was subsequently closed. This example highlights the need to work with all other relevant professionals involved with a child, and family, so as to gain a holistic, current and accurate assessment of need and risk.   Learning point: When holding a meeting to examine levels of need, and risk, for children and families it is important to be clear about the basis for the meeting and under which procedure the meeting is being held. It is also always worthwhile asking ‘… is there anyone that is not here today that knows the child/family and who can offer any insights?’. If other professionals were invited but could not attend, have they been able to offer their contribution, either via the phone, e-mail, or written report? If not, why not, and who will take responsibility for seeking any outstanding information? 7.4. The quality & effectiveness of information sharing and use in this case 7.4.1. Information sharing has been examined above in respect of parental history, and assessments and intervention from the perspective of the relevant agencies involved at the time. In some cases the timely and effective sharing of information was seen e.g. by the Police notifications to Children’s Social Care, but also examples of inadequate sharing have been noted e.g. Children’s Social Care informing and involving other agencies in Child in Need planning. 41 Working together to safeguard children, 2015, HM Government. OFFICIAL SENSITIVE247.4.2. Key episode 3 is significant in that, again, it highlights examples of good information sharing i.e. timely and necessary, but also practice that is less than optimal.   7.4.3. The response by the Ambulance Service was good, in that Father made the phone call at 09.30 hours and Child I was admitted to hospital 40 minutes later. The initial response by the emergency staff was also good in terms of history taking, assessment, and obtaining information from Father about the epilepsy drugs for Sibling 2. Child I was being stabilised whilst blood was being tested – including testing for epilepsy drugs. This assisted with diagnosis by 13.00 hours and treatment at an early stage. Once the blood tests confirmed the presence of the epilepsy drug, the Consultant was able to consider a differential diagnosis, and Children’s Social Care was contacted around 16.15 hrs. The above management reflects timely and effective use of information from a medical management angle, but also in considering what the most appropriate pathway would be, given the confirmation of the diagnosis.  7.4.4. Records then indicate delays creeping in. The Police were contacted at 16.40 hours on the day of admission by Children’s Social Care but noted they ‘…were not clear about what they want the Police to do other than to arrange a strategy discussion for the next day …’. A further call from Children’s Social Care is noted to have asked what the Police’s intentions were; clearly these two calls reflect some uncertainty about how to manage the situation. From a Children’s Services perspective, the reasons for these delays rest in the systemic issues identified by Ofsted noting ‘… widespread and serious failures in the assessment, planning and management of children in need of help and protection …’.  From a Police perspective, at the time of the incident the Police Child Abuse Investigation Unit (CAIU) did not work late shifts so the matter went to CID to deal with, causing delays. The working arrangements in the Police CAIU have now changed. With the benefit of hindsight the Police have been able to see that limited background checks were completed at this time with information gathering and consideration about the two siblings not being as thorough as it could have been. This impacted on the initial quality of the police investigation undermining the potential for any witnesses to be interviewed at the earliest opportunity. Had the initial response been more coordinated it might have strengthened the Police investigation. As a result there was no specific medical, with a child protection focus, to see if Sibling 1 had traces of epilepsy drug in her system, or if Sibling 2 had the correct levels of drug in her system. An assumption was made that because they were with an extended family member, they were safe.  The Strategy Meeting happened the day after the admission, and the joint assessment of the Siblings took place the day after this – almost two full days after Child I had been admitted. The day after this, all children were placed in the care of the local authority.  7.4.5. Sibling 2 attended Nursery, on two separate occasions with either singed hair (stating that she had fallen in the oven), a cut finger (stating that Sibling 2 had cut her with a knife), and a mark on her arm (stating this was from climbing out of a window). This information was not shared with Children’s Social Care or the Police as the Nursery were satisfied with the explanations given by Mother. The Nursery were confident in their handling of these incidents and it has been noted that the Nursery was judged as good by Ofsted in 2015 and outstanding in 2017. 7.5. The use of dissent, professional disagreement and escalation OFFICIAL SENSITIVE257.5.1. The use of escalation, as a result of professional disagreement is a feature in this Review on two separate occasions. The first incident, in February 2014, was where the Ambulance Service were concerned about the home conditions and the children’s appearance. Appropriately, this information was shared with the MASH however the matter was not taken any further. 7.5.2. Information from Children’s Social Care for this Review reveals that a decision was made by the MASH that a welfare visit was needed. The term ‘welfare visit’ is misleading as a visit conducted by a Social Worker, fundamentally, is an opportunity to conduct an assessment. However, the management decision of the Access to Assessment Team was that a welfare visit was not necessary which resulted in the referral being closed and no further action. There is no evidence to indicate that this decision was challenged or escalated. Whilst it might be possible to place this scenario in practice from over four years ago, Practitioners, and Managers have advised that this could, and does still happen occasionally. This highlights two issues;  7.5.3. Firstly, a continued mismatch in understanding about thresholds for conducting an initial, exploratory assessment to gain a view about the safety and welfare of children. This mismatch is located at the front-door of the safeguarding system – potentially having a significant impact of the initial evaluation of risk and safety planning. 7.5.4. Secondly, it highlights a flawed communication loop – again, at the front-door of the safeguarding system – in which practitioners and Managers may not have a completely shared understanding about the interaction and flow of work through the system. This dysfunction is then viewed by those outside of that dynamic as ‘… the referral was not accepted because the threshold was not met …’. If the original referrer had known that the referral was, in fact, not accepted because the Managers in the MASH and Access to Assessment disagreed about threshold, it may have prompted further discussion or escalation. From a system thinking perspective, there are two feedback loops at play in this situation; internally between the Managers, and then externally, back to the referrer. The driving factor should be ‘… is the safety and interests of the child paramount in the process …? Learning point: Effective communication between professionals – both within their own agency as well as across agencies – is important. Effective child centred communication can reinforce positive practice42. Ensuring communication is open and transparent with all relevant people, is one way to reduce the likelihood of unintended consequences, such as misunderstandings about outcomes and expectations. 7.5.5. The second incident when escalation was used concerned the referral by the Health Visitor, again in 2014. This was in relation to the Health Visitor not gaining consent to make the referral, and the case being closed despite the matter being escalated to the MASH Manager. This report has already discussed the matter of consent and highlighted that it is not necessary if there are concerns about the safety and welfare of a child. The Health Visiting Service has acknowledged that there is learning for them in terms of strengthening their understanding and confidence in using escalation. Despite the matter being closed down, there is always another avenue to take 42 The Munro Review of child protection Part one: A systems analysis, HM Government, 2010 & Systems Dynamics by Morecroft, J., in Systems approaches to managing change: A Practical Guide, Reynolds, M., & Holwell, S., The Open University, 2010. OFFICIAL SENSITIVE26in order to raise the profile of the concerns held. Using Named/Designated Safeguarding Nurses within health organisations provides a further opportunity and/or allowing a more strategic role to argue for the best interests of the child, rather than operational staff becoming embroiled in further exchanges. A professional disagreement & escalation protocol can; be an opportunity to reflect on decision making; encourage professional curiosity; be a way of avoiding professional disputes that put children at risk or obscure the focus on the child; allow a way of resolving the differences within and between agencies quickly and openly. On this occasion, this opportunity was not taken.  Learning point:  In working with high numbers of children and families, but also other professionals it is inevitable, but also healthy, that there will be professional disagreement at times. Consideration of whether decisions made are in the best interests of a child should be the driving principle. 8. Good practice8.1. The focus of this Review is to learn and improve services. As such, it is important to learn from practice that is considered good and supports good outcomes for children. Good practice from a number of agencies and professionals has been acknowledged; this includes, •The consistency offered by the Health Visiting Service, supporting a better relationship withMother and a more informed view about levels of risk over time.•The Health Visitors attempts to escalate concerns, when initially informed the case wouldnot be opened for an assessment by Children’s Social Care. This demonstrated a childfocused intervention, but also a degree of tenacity.•The use of text messages by the Health Visitor to support Mother in taking the siblings toappointments.•Discussions between the Health Visitor and Mother about domestic abuse when opportunemoments arose without Father being present.•The family being discussed in the vulnerable families’ supervision and child protectionsupervision sessions by the Health Visiting Service.•The medical response to Child I when admitted to hospital unresponsive, being timely andearly consideration of a differential diagnosis.•Good liaison between the Health Visitor and the Nursery in order to access funding for anursery place for Siblings 1 & 2.•The impartial oversight provided by the Police Risk Assessor and increasing the risk categoryfrom standard to medium.•The timeliness of notifications about domestic incidents by the Police to Children’s SocialCare.9. Conclusion9.1. This Review has examined the circumstances in which Child I, and Siblings came into contact with a range of agencies over a four-year period. It has gathered documentary information from those agencies and organisations who had contact with Child I and siblings but also benefitted from the contributions of front-line practitioners and managers involved with those services. Mother was able to make a contribution; however, a limiting factor has been the absence of the Father’s contribution.  OFFICIAL SENSITIVE279.2. The Review has highlighted a small number of features that can be described as good practice. It is important that these are used to strengthen the multi-agency safeguarding arrangements across the Reading area.  9.3. The Review has also identified a number of factors and areas where practice could have been more robust, or where a different course of action might have been considered. These include the use of case history to inform assessment and planning, the critical need to fully assess children’s experience of living with domestic abuse, and the important role that Children’s Social Care have in leading, coordinating and reviewing safety planning for children. These issues serve as reminders of the constant need to remain child focused but also alert to how organisational pressures can divert professionals away from keeping children safe.   9.4. The Review has identified a number of learning points throughout for agencies and professionals to consider and use to strengthen their practice.  9.5. The Review concludes with recommendations to the LSCB, which build on the recommendations and actions already identified by single agencies.  10. Recommendations10.1. A number of single agencies have identified learning during the process of researching their involvement in this case; as such they have completed action plans and are already working to make improvements to services. In a number of cases, actions have already been taken to reduce the likelihood of reoccurrence. The following additional recommendations are provided to ensure that Reading LSCB and its partner agencies are confident that any other areas are addressed and that the LSCB is able to monitor progress. 1. The LSCB to promote the learning from this review across all relevant partner agencies, andseek assurances that it has been disseminated and embedded.2. The LSCB to monitor implementation, and seek progress reports, on the implementationand embedding of actions from all single agency action plans,3. The LSCB to promote awareness of the recently revised (May 2017) Escalation Policy:Resolution of professional disagreements relating to safeguarding of children and youngpeople, across the children’s workforce.4. Where possible, when GPs and other clinicians are prescribing medications for a child(particularly those drugs that could be used as a sedative and/or where over-dose couldbe fatal) consideration should be given to social issues in the child’s life which may impacton the ability of the parent/carer to maintain a medication regime safely.5. The LSCB to seek assurance from Children’s Social Care that the issues highlighted in thisreport are being addressed in a robust and timely manner; particularly in relation to theapplication of Child in Need procedures, and including the use of history to informassessment and planning, the quality of assessments especially of those situations wherechildren are living with domestic abuse, the recognition of risk, the coordination andeffectiveness of multi-agency meetings to safeguard and protect children.OFFICIAL SENSITIVE28