Death of a 2-year-7-month-old boy in January 2013 as the result of drowning in the bath whilst left unattended. Post-mortem examination revealed hot water burns to Child T's body, caused after his death. Mother was convicted of manslaughter and received a 3 year custodial sentence. Mother and father were both on methadone programmes; tests conducted after the incident showed mother had also recently taken Diazepam, Temazepam, Nitrazepam, Heroin, Cocaine and Cannabis, along with Methadone, Tramadol and pain-killer Pregabalin. Family were well known to agencies including children's services. Both parents had a significant history of drug misuse, there was a history of domestic abuse and father had spent time in prison for drugs related offences. Issues identified include: insufficient focus on father's role in Child T's life; and poor prescription control practices leading to the over-prescription of medication to father. Makes recommendations including that the local Public Health Service should undertake a targeted public awareness campaign highlighting the risks associated with consuming a mixture of substances. Uses the Significant Incident Learning Process (SILP).
      
 Title:  Serious case review: Child T: born: May 2010: died: January 2013: overview report. LSCB: Hull Safeguarding Children Board Author: Paul Tudor Date of publication: 2014  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.                              HULL SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW CHILD T Born: May 2010 DiedJanuary 2013  OVERVIEW REPORT         Lead Reviewer: Paul Tudor     September 2014  CONTENTS 1. INTRODUCTION 1.1. Introduction to the Circumstances 1.2. Introduction to the family 1.3. Introduction to Serious Case Reviews and SILP 1.4. Introduction to the Lead Reviewer 1.5. Introduction to the process for this Serious Case Review 2. A BRIEF TIMELINE 3. FAMILY HISTORY AND BACKGROUND PRIOR TO NOVEMBER 2009 4. KEY PRACTICE EVENTS IN THE PRE-SCOPING PERIOD 5. KEY PRACTICE EVENTS AND EPISODES FROM NOVEMBER 2009 WITH SYSTEMIC LEARNING 6. SYSTEMIC LEARNING IN RELATION TO DOMESTIC ABUSE 7. AN UNDERSTANDING OF THE SUBSTANCE MISUSE SERVICES AND SHARED CARE OFFERED TO THE PARENTS WITHIN THE SCOPED PERIOD 8. THE ROUTINE AND UNIVERSAL SERVICES OFFERED TO THE FAMILY WITHIN THE SCOPING PERIOD 9. CONCLUSIONS (including the specific Terms of Reference)  10. AN OVERVIEW 11. FINDINGS FOR THE HULL SAFEGUARDING CHILDREN BOARD 12. RECOMMENDATIONS Appendices  i. Terms of Reference and Project Plan ii. Agency Author Report Template iii. Glossary of Terminology iv. Drug Treatment System Referral Guidance v. HSC letter to all GPs regarding Pregabalin    11. INTRODUCTION 1.1. Introduction to the circumstances On 5.1.13 the subject child T (then aged 2 years 7 months) was brought into hospital by ambulance. He was in cardiac arrest. Resuscitation was unsuccessful, and he died shortly afterwards. He had severe scalding to his body and the Pathologist later recorded the cause of death as “consistent with drowning and post-mortem scalding injuries”, i.e. the burns were caused after he had drowned. His mother (Adult V) had woken from sleep at home to find Child T face down in the bath water. His father (Adult W) was asleep in bed. Both parents were on Methadone programmes. Toxicology tests indicated that other substances were also in both their systems at the time of the incident (see below). Initially both parents were arrested and bailed; subsequently Adult W was released from bail; and Adult V faced charges of manslaughter. On 4.7.14 Adult V was convicted of manslaughter and received a 3-year custodial sentence. Evidence presented at the trial indicated that she had left Child T unattended in the bath probably for up to 2 hours. Blood and urine tests showed she had taken Diazepam, Temazepam, Nitrazepam, Heroin, Cocaine and Cannabis, along with Methadone, Tramadol and pain-killer Pregabalin; The judge at the Trial made it clear there was never any suggestion Adult V was responsible for the burns, which he accepted happened after Child T drowned. He accepted that once Adult V fell asleep Child T switched on the hot tap. He then tried to get out when the temperature increased but fell back in and drowned. Mr Justice Coulson accepted that Adult V had been a good parent before Child T’s death. He told Adult V: “You did not intend this to happen. You were a good mother to Child T with good maternal instincts”.  1.2. Introduction to the family Adult V Mother (*37 years) Adult W Father (42 years)      2      (*Ages at time of incident *)  The family are White British with no known disabilities or special needs. Children X and Y were twins. In 2001 Child Y died of natural causes (bronchial problems) aged 9 months. For much of the period covered by this Serious Case Review, Adult V and her two older children (Child X and Child Z) lived with maternal grandmother. In November 2009 she secured her own tenancy. Child X (then aged 8½ years) came with Adult V to the new tenancy; Child Z remained living with maternal grandmother by choice as she had lived with her for most of her life; but Adult V’s new tenancy was within 5 minutes walking distance of maternal grandmother and Adult V reported that she saw Child Z most days. The relationship between Adult V and Adult W was volatile (see incidents in Sections 4 and 5 of this report) and when he was released from prison in early 2007, Adult V had said she wanted nothing more to do with him. However, during the latter part of 2007 they re-established their relationship and he was spending more time with his daughters, Child X and Child Z.   1.3. Introduction to Serious Case Reviews (SCR) and Significant Incident Learning Process (SILP) Serious Case Reviews have operated for many years, until recently under 2010 guidance “Working Together To Safeguard Children”.  Child X (11 years)   Child Y Deceased Child Z (13 years)  (9 months)  Subject: Child T Deceased (2½ years)    3                                                           This guidance contained mandatory and discretionary thresholds for holding Serious Case Reviews and prescriptive advice on processes, on Individual Management Reports (IMR) and Overview Report templates. In April 2013 new guidance was issued1 and Chapter 4 of this guidance emphasises the importance of a Learning and Improvement Framework2, of which reviews on specific cases is one element. Regulation 5 (2)(a) of the Local Safeguarding Children Board (LSCB) Regulations 2006 still requires Serious Case Reviews to be undertaken in defined circumstances; but the new guidance stipulates that reviews should be completed in a way which: - recognises the complex circumstances in which professionals work - seeks to understand the reasons that led individuals and organisations to act as they did - seeks to understand practice from the viewpoint of individuals and organisations at the time - is transparent about the way in which data is collected and analysed. The guidance also advises that any learning model may be used, consistent with the principles contained in the guidance at para. 11. In 2010 Paul Tudor and Leicestershire & Rutland Safeguarding Children Board devised a methodology entitled Significant Incident Learning Process (SILP). The key principles of SILP are: - proportionality - learning from good practice - the active engagement of practitioners - engaging with families - systems methodology.  1 Working Together To Safeguard Children April 2013 2 Chapter 4 Learning and Improvement Framework, para. 10    4These principles and the SILP methodology (including Learning and Recall Events) are entirely consistent with the 2013 Working Together To Safeguard Children guidance, particularly “to hear the voice of the practitioner” as advocated by Professor Eileen Munro following the Serious Case Review on Daniel Pelka (Coventry Safeguarding Children Board 2013). 1.4. Introduction to the Lead Reviewer After a 20-year career with the NSPCC primarily focussed on Child Protection systems, Paul Tudor has had a further 22-year career as an independent Safeguarding Advisor. His portfolio has comprised a significant number of Serious Case Reviews, locum contracts as a Child Protection Conference Chair and Independent Reviewing Officer and offering training on a range of safeguarding issues. 1.5. Introduction to the process for this Serious Case Review The decision by the Independent Chairperson of the Hull Safeguarding Children Board to initiate a Serious Case Review was made in early October 2013. This was a considerable time after the death of child T. The reason for the delay was due to the period required for parental toxicology results to be confirmed. Prior to this point the Chair assessed that there was insufficient information to reach an informed view as to whether the criteria for a Serious Case Review were met. The Police were also investigating the circumstances to determine whether any charges were to be made against one or both parents.  The Post Mortem results on child T ruled out death by natural causes.  When, at the end of September 2013 there was still no final decision about whether either or both parents were to be charged in relation to the death, a decision was reached to initiate this Serious Case Review. Subsequently in November 2013,  Adult V was charged with manslaughter.   The National SCR Panel were kept up-to-date throughout about the decision-making process.     5The Lead Reviewer met with the Chair and the Manager of the Hull Safeguarding Children Board in early October 2013 and commissioning took place on 11.10.13. The Lead Reviewer then met with members of the Serious Case Review Sub-Committee on 8.11.13 to undertake a scoping exercise. The full Terms of Reference, a Project Plan and an Authors’ template were developed and appear as Appendices (i) and (ii).  It was decided that the scope of the Serious Case Review would be from November 2009 (the confirmation of the pregnancy with Child T) to 5.1.13 (the date of the fatal incident). However, agencies were also asked to review and report on significant events and any safeguarding issues prior to November 2009 in order to set the context of family life in which Child T lived. A briefing for authors took place on 22.11.13 and during early December further negotiations took place with CPS and Police as there were concerns about potential witnesses in a criminal trial coming together and discussing the case in a Learning Event, with a risk of possible contamination of the evidence. As Lead Reviewer I am very grateful to all parties for the way in which a compromise was negotiated, i.e. three practitioners had to be excluded; but otherwise a full Learning Event took place on 24.1.14 (30 participants); and the three excluded professionals were subsequently interviewed and contributed to the review after Adult V’s trial had been completed. An early draft of this report was shared at a Recall Event on 28.2.14.  Again, it was well attended (24 participants) and further debate and analysis took place.  Subsequently a further draft of this report has been circulated to participants with an opportunity for them to offer consultative comments electronically; and a Serious Case Review Panel (comprising of Hull Safeguarding Children Board members and lead agency authors) was held on 11.8.14.     6Letters of explanation were prepared for both parents but it was established that Adult W did not wish to receive it or to hear anything about the Serious Case Review at this stage. The letter to Adult V was received by her in prison a few weeks after the trial and she agreed to meet the Lead Reviewer and the Professional Practice Officer of the Hull Safeguarding Children Board . An interview was conducted on 21.8.14 at which Adult V was supported by an Offender Supervisor. Adult V’s views and comments are woven into the text of this report at relevant points. The whole process has been very efficiently and thoughtfully administered by the Hull Safeguarding Children Board Administrator, to whom my thanks.    7 2. A BRIEF TIMELINE This is designed to assist the reader in gaining a quick and early understanding of the events and issues which are to be described in this Overview Report. Father – Adult W; born May 1970 Mother – Adult V; January 1976 December 1994 Birth of Child Z 11.7.96 Referral to Children’s Social Care from Health Visitor 1.8.96 Anonymous referral to Children’s Social Care 22.8.96 Referral to Children’s Social Care from Police 12.3.97 Referral to Children’s Social Care from maternal grandmother 3.4.00 Police call-out to a domestic incident March 2001 Birth of twins – Child X and Child Y 17.3.01 Referral to Children’s Social Care from Special Care Baby Unit December 2001 Death of Child Y aged 9 months from natural causes 31.10.03 Police call-out to a domestic incident 6.8.04 Police call-out to a domestic incident 11.10.05 Anonymous referral to Children’s Social Care  25.5.06 Health Visitor made a home visit and found Child X home alone; referred to Children’s Social Care and Police 5.6.07 Child with Additional Needs Meeting (CWANM) 17.9.07 Review CWANM 3.4.08 Adult V arrested for Possession with intent to supply 6.5.09 Adult V arrested for breach of the peace  24.09.09  The GP referred Adult V to the maternity service, for pregnancy in relation to child T. 13.1.10 The first of monthly Substance User Assessment Tool (SUAT) meetings in relation to Child T  24.3.10 A reconvened CWANM    8May 2010 Birth of Child T 30.6.10 Child X reported to school a scratch under her eye 16.9.10 Child X reported to school that she cares for Child T (feeds him and changes his nappy) 9.10.10 Police called out to a verbal argument between parents 19.1.11 Police called out to a domestic incident 3.2.11 Parents arrested for burglary, Adult V cautioned for possessing Cannabis. A Section 47 enquiry was conducted on a single agency basis by a social worker 3.7.11 Police called to a domestic incident 19.7.11 The case discussed at Families Affected By Domestic Abuse (FABDA)Panel Meeting 5.11.12 Adult V referred to Compass, but she failed to attend the Preparation Group on 22.11.12 and 6.12.12 January 2013 Death of Child T    93. FAMILY HISTORY AND BACKGROUND PRIOR TO NOVEMBER 2009 3.a. Context The evidence suggests that the family’s living arrangements changed from time to time, but as already stated at Section 1.2, for most of the period of the pre-scoped period (i.e. up to November 2009) Adult V and the two children (Child Z and Child X) were living with maternal grandmother; and for a 2-year period up to 2007 Adult W was serving a prison sentence. Adult V and Adult W were  known to the Police for convictions and other matters.  3.b. Child Z Within the scoping period she has lived with maternal grandmother for most of her life and no information relevant to this Review has been brought forward.  3.c. Child Y Child Y died of bronchial problems at the age of 9 months (in December 2001). 3.d. Child X Child X is the surviving twin. There is one noteworthy entry in medical records: On 26.8.04 the GP recorded “not sleeping, witnessed assault by dad on mum; advised needs support and contact”. There is no evidence that any action arose from this; and it may be regarded as a missed opportunity for checks to be made by the GP, e.g. contact with the Health Visitor. The Home/School Liaison Officer from the Primary School made a home visit in the autumn of 2006 following up concerns about Child X not being collected from school at the end of the day (the family were living with maternal grandmother). Information that Adult V shared regarding being the victim of domestic abuse and Adult W serving a substance misuse-related prison    10sentence were noted and shared with the school Child Protection Co-ordinator. Child X is the subject of some of the Key Practice Events at Section 4; but otherwise there were no reported concerns and Child X appears to have been making satisfactory progress. Indeed the school records analysed for this Serious Case Review note the emotional warmth between Adult V and Child X. 3.e. Adult W (father) Since the birth of Child Z in December 1994 Adult W has given the Police 17 different addresses and several aliases. In 1996 the Probation Service made a referral to Adult Services for a drug rehabilitation placement. Following a custodial sentence he was supervised by the Probation Service for 5 months from February to July 2007.   The Probation Officer and Adult W were both advised about the Community Care Assessment process at that time From 1996 he was receiving regular prescriptions for medication. In August 2003 a urine test proved positive for opiates (although none had been prescribed for a year) and for Benzodiazepines (also not prescribed). Adult W had reported that he had first started using Heroin aged 21 (1991) and he received support from Compass between May 2007-April 2009 in the form of Methadone prescriptions, whilst the care-coordination remained with Drug Intervention Programme (DIP). He was also accessing other unprescribed opiates and Benzodiazepines. In February 2009 he appeared to be stable (self-reported); and he was on a supervised prescription of daily Methadone at 100mgs3 and results of tests by the GP showed that he had been free of illicit substances for 6 months.                                                              3 The dosage is expressed in terms of 1mg of Methadone per 1mg of fluid. The figures appear as mgs.    11In April 2009 the prescribing was transferred from Compass to GP Shared Care. During the rest of 2009 he only reported smoking Cannabis; otherwise he reported that he was free of illicit substances. Between April 1996-October 2007 he had six contacts with Hull & East Yorkshire Hospitals NHS Trust (HEYHT); of which five were attendances at Accident & Emergency and one planned admission. Four of the six contacts related to complications associated with substance misuse.  3.f. Adult V  (mother) In June 1996 she presented at hospital with a broken nose, having been head-butted four days previously (the identity of the assailant was not recorded). During her pregnancy with twins Y and  Z in 2000/2001 she was on daily Methadone of 28-30mgs and attended 7 out of 11 antenatal appointments. In September 2003 she attended hospital following an alleged assault by “a man she knows, not her husband”.  She sustained a suspected fractured cheek bone. Appropriately, she was given a “Violence Card” produced by Women’s Aid to signpost her to support services.  There was a history of having been referred to and then discharged from Specialist Substance Misuse Services within the hospital from 2005. She reported having commenced using illicit substances in 1997 and having commenced on a Methadone programme the same year. When seen in 2005, her daily prescription was 55mgs Methadone daily with 5mgs Diazepam at night. Three non-attendances for appointments led to her discharge from the service which was normal practice. A urine test at the GP surgery in August 2006 evidenced illicit substance misuse. However, there is no record of either direct safeguarding concerns or    12of the possible impact of Adult V’s substance misuse on her parenting ability being considered.  Substance Misuse Services started to work with Adult V in 2006, at which point she was living with maternal grandmother ; Adult W was in prison. She was described as lacking confidence, was withdrawn and was heavily dependent on maternal grandmother to help care for the children. In 2007 her GP had advised that she should receive Mental Health/Bereavement services regarding the death of Child Y; but she declined. At that time she was using illicit Benzodiazepines but stated that she was not using Heroin. Over the next two years (2008 and 2009) reports from Substance Misuse Services suggest that Adult V began to regain some stability; she appeared more positive, more focused and she reportedly stopped using illicit substances. She is described as wanting to reduce both her prescribed Diazepam and her prescribed Methadone.    13 4. KEY PRACTICE EVENTS IN THE PRE-SCOPING PERIOD 4.1. On 11.7.96 a neighbour (who wished to remain anonymous) passed her concerns to a Health Visitor, relating to parental substance misuse, shoplifting and taking Child Z (aged 19 months) out late at night. In turn, the Health Visitor referred this to Children’s Social Care. 4.2. A home visit was undertaken by a member of Children’s Social Care staff on 15.7.96 at which Adult V confirmed Adult W’s substance misuse and that he had left the family home and she did not allow him to have contact with Child Z when he was under the influence. Child Z was seen and no concerns were raised and a decision was reached by Children’s Social Care that there was no assessed need for any further Children’s Social Care involvement.  4.3. A second referral to Children’s Social Care came anonymously from a neighbour on 1.8.96 alleging that Child Z was “covered in bruises 3 weeks previously”. Concern was also expressed in the referral about both parents misusing substances and frequent visitors to the house. Checks were carried out by Children’s Social Care with the Health Visitor and the Police and 3 no-reply home visits took place. There is no record of any further action. Comment On the one hand this is clearly unsatisfactory as the child should have been seen in the light of the referring information. However, it is acknowledged that the child had been seen 2 weeks previously (see above) which is after the alleged sighting of bruises three weeks previously (but before the referral). Nevertheless, the visit on 15.7.96 did not focus on bruising as this was not the subject of that first referral, as it was on the second referral. 4.4. The Police referred to Children’s Social Care on 22.8.96 following a home visit at which Adult V was considered by a Police Officer to be “as high as a kite” albeit described as being capable. Child Z was said to look OK though grabbing a bottle which might indicate she was hungry.     14A no reply home visit was made by a social worker the same day, followed by two further no reply visits until a successful home visit on 30.8.96. Child Z was seen to be well dressed; and Adult V insisted she was only taking sleeping tablets at night. The case was closed to Children’s Social Care. 4.5. A caller made a referral to Children’s Social Care on 12.3.97.  She expressed a concern that Adult house was “full of drug users” and thought that Adult V had started using substances again.  She was worried about Child Z living in that environment. In a home visit by a Social Worker Adult V stated that she was not misusing substances and that even though her friends did use, she would not allow taking or supplying in her house in front of Child Z. 4.6. On 3.4.00 the Police were called to a domestic abuse incident. Adult V told the Police that she had refused Adult W entry to the house, that he had kicked the door off its hinges and had assaulted her while she was holding Child Z. Adult W was arrested and interviewed but Adult V withdrew her complaint. Children’s Social Care were notified (14.4.00) and made a successful telephone call with Adult V on 27.4.00 after 3 failed home visits. Adult V explained that she and Child Z were now living with maternal grandmother. A check was made with Child Z’s school who reported no concerns and the case was closed to Children’s Social Care. 4.7. Adult V was the subject of discussion at monthly substance misuse meetings at the Maternity Hospital between December 2000 and March 2001 in relation to her pregnancy with twins (Child X & Child Y).  These meetings were newly established and chaired by the Hospital Social Worker; they are a multi-agency forum for sharing information about pregnant women who are known to be using substances (see Systemic Learning after Key Practice Episode 1, para. 5.8a). At that time Adult V and Adult W were believed to be living with their respective parents; and by the time of the March 2001 meeting Adult V had reduced her Methadone use from 30 to 28mgs per day.      154.8. Despite Adult V being discussed at the monthly substance misuse meetings (described above),  2 days after the birth of the twins (March 2001), the Special Care Baby Unit made a referral to Children’s Social Care based on the history of substance misuse by both parents. This resulted in an Initial Assessment. Adult V was visited on 20.3.01 and reported that she was not living with Adult W. No concerns regarding parenting capacity were reported by Special Care Baby Unit staff, nor by the school who were contacted in relation to Child Z. Adult V declined any further support and as no safeguarding concerns were identified, the case was closed to Children’s Social Care. Comment This was a missed opportunity to see and assess Adult W. The issue of the invisibility of men/fathers is discussed at later sections of this report. 4.9. Child Y died from natural causes (bronchial problems) in December 2001; and subsequently two visits were made by a social worker to assess how the family were coping and to offer support, but the family declined any further help and Child Z and Child X appeared to be well-cared for. It is recorded that the Health Visitor also offered support to the family. 4.10. On 31.10.03 the Police were called to the house when Adult W refused to leave. The caller had stated that Adult V and the children were threatened by Adult W, but when the Police spoke to her at the house she stated that there were no threats, just a verbal argument and no complaint was made. A Form 913 was submitted to Children’s Social Care by the Police (see Glossary at Appendix iii for an explanation of this form). 4.11. On 6.8.04 the Police were called by Adult V alleging that Adult W had dragged her out of a chair by her hair, had kicked and punched her repeatedly, had bitten her leg and then wrecked the house. The Police could not locate Adult V and the children despite numerous visits to the home address; but the Police made a referral to Children’s Social Care and a social worker was allocated to carry out an Initial Assessment.     16Adult V and the children were staying with maternal grandmother and Adult V told the social worker that her relationship with Adult W (who was now in custody) was over. The Initial Assessment concluded that Adult V had taken appropriate action to protect the children and there was no further role for Children’s Social Care.  4.12. Children’s Social Care then received an anonymous referral in October 2005, suggesting that Adult V and Adult W were using and dealing in illicit substances at the family home; but when Adult V was seen, she stated that she and the children had been living at maternal grandmother’s home since 2004. Checks with other agencies raised no concerns and no further action was assessed as being required. 4.13. On 25.5.06 the Health Visitor made a home visit and received no reply from Adult V but found Child X (aged 5 years) home alone. After waiting 10 minutes at the home address the Health Visitor made a referral to Children’s Social Care and the Police. Prior to the attendance by the Police and Children’s Social Care Child Z (aged 11 years) returned to the property, about 40 minutes later, saying she thought her mother was visiting a neighbour and Child Z then took Child X to the neighbour’s house. The Health Visitor confirmed that the mother was at the neighbour’s house. Both Police and Children’s Social Care subsequently visited and spoke to Adult V after the Health Visitor had left. 4.14. A first day absence home visit (to maternal grandmother’s house) was made in April 2007 by the Home/School Liaison Officer in relation to Child X. 4.15. There was evidence of strained family relationships between Adult V and maternal grandmother (verbal altercations and Child X crying). Adult V seemed emotionally distressed and maternal grandmother was concerned that Adult V was using illicit substances again. The outcome was that the Home/School Liaison Officer reported to the school Child Protection Co-ordinator, who, in turn, spoke to the School Nurse about initiating a Common Assessment.     174.16. The Common Assessment Framework (CAF) Co-ordinator was consulted and recommended that a Common Assessment should be completed; and the school nurse was identified as the most appropriate person to do this. With Adult V’s consent, the School Nurse did so; submitted it to the CAF Co-ordinator and an initial Child With Additional Needs Meeting  (CWANM - see Glossary) was held on 5.6.07. Whilst it was agreed that Child X had no significant additional needs, it was identified that Adult V did need support regarding her substance misuse and mental health. According to the records, Family Group Conferencing and bereavement counselling were offered (but subsequently not taken up); and bereavement counselling had also been suggested by the GP. Comment There were no issues identified which would suggest that a referral to Children’s Social Care was required. Therefore this was an appropriate response and focus, demonstrating good practice. However, it should be noted that the decisions were based on Adult V’s self-reporting of her substance misuse. According to records it should also be noted that she did not access any of the additional services offered. However, in her interview with the Lead Reviewer, Adult V recalled having contact with someone whom she found to be very supportive and it is believed that this person was from the Family Group Conference Service. Interestingly, she also said in her interview that she did not receive support at the time of Child Y’s death. She could not remember the Social Worker visits (see paragraph 4.9); and she advocated the importance of counselling in these circumstances. 4.17. Adult V was present at this first CWANM but did not attend the review on 17.9.07. The home situation appeared more settled to those present and the school expressed no concerns about the care of Child X.  Maternal grandmother was providing good support and it was decided that there did not need to be any further meetings.    184.18. On 3.4.08 Adult V was arrested by the Police on suspicion of “possession with intent to supply” (a Class C drug); and she tested positive for opiates and Cocaine. She also admitted to the Police at that time to using Crack Cocaine and Heroin occasionally; and she had Methadone (55mgs) and Diazepam prescribed. She received a conditional discharge plus costs. The context for this incident is that Police Officers were on their way to interview Child Z about another matter when they saw Adult V in the street. Comment Whilst a Form 125 (see Glossary) was submitted in relation to Child Z, a separate Form 125 in relation to the adult substance misuse was not raised and should have been. This is a missed opportunity for consultation and communication between the Police and Children’s Social Care (and potentially other agencies) in order for them to exercise professional judgement on any risks to the children from parental substance misuse. 4.19. Nevertheless, a referral was made to Compass in the context of a Post-Arrest Referral. Compass have confirmed that they used an internal form to confirm they had contacted Children’s Social Care to ascertain whether the family was known. They were informed that the School Nurse was Lead Professional in a CAF.  4.20. A copy of the form was also sent to and filed by School Health, but there is no evidence that it was seen by the School Nurse (due to staffing levels at this time impacting on the reviewing and recording of information within the Health record). Comment There should have been a 2-way discussion between Compass and the School Nurse (as CAF Lead Professional) to ensure clarity re: follow-up. The particular form used by Compass has subsequently been altered to promote that clarity of information and expectations.    194.21. The Police notified Children’s Social Care of an incident in May 2009 in which Adult V had been causing a disturbance in the street (after drinking some vodka). She was arrested for a Breach of the Peace, and this was witnessed by Child Z and other family members close to the house. The CAF Co-ordinator later notified the School Nurse (as Lead Professional) of the disturbance.    20 5. KEY PRACTICE EVENTS AND EPISODES FROM NOVEMBER 2009 – JANUARY 2013 WITH SYSTEMIC LEARNING Context 5.1. This section now addresses events and episodes within the scoped period from November 2009 (when Adult V booked in with Child T’s pregnancy) to January 2013 (the death of Child T). From the beginning of this period Adult V and Child X were living in their newly-acquired tenancy, having moved from living with maternal grandmother.  The narrative will be broken down into key practice events and episodes.4 Key Practice Episode 1 – Antenatal contacts and joint working between professionals  5.2. Adult V was referred from her GP to Maternity Services when the pregnancy with Child T was 4 weeks; and she was seen on the same day as her booking appointment by the Obstetric Consultant (11.11.09). This is an enhanced service for substance misusing women and represents good practice as this Obstetrician takes a particular interest/specialism in substance misusing pregnant women, most of whom are booked under his care. A copy of the booking summary including information on Adult V’s substance misuse was sent to her GP and the Health Visitor and again this represents good practice. 5.3. In January 2010 the Substance Misuse Midwife shared information on Adult V with the Hospital Social Worker resulting in the family being discussed for the first time in this pregnancy at the next multi-agency Substance User Assessment Tool (SUAT) meeting (see Glossary for an explanation). This occurred on 13.1.10 and thereafter monthly through to May 2010 (i.e. 5 times) and on a 6th occasion in June after Child T had been born,  but before he was discharged.                                                               4 Some are designated as events, i.e. a very specific incident; others are described as episodes as they stretched thematically over a short period of time.    21                                                           5.4. Antenatally Adult V was described by professionals working with her as making good progress, i.e. a relatively low dose of Methadone and Diazepam prescribed by her GP. She self-reported that she used Cannabis. During the pregnancy she achieved a further reduction in her Methadone use from 50mgs to 25mgs.  5.5. She was offered 11 appointments with the Maternity Services. Being under the care of an obstetrician requires hospital attendance as well as antenatal care in the community; and this represents good practice. A Paediatric5 alert and a plan of care for the unborn Child T was made by the Paediatrician on 4.3.10 (i.e. 27 weeks gestation). The plan identified that Child T may be withdrawing from substances following delivery. 5.6. Initially Adult V’s attendance at antenatal appointments was slightly erratic (i.e. 2nd, 5th and 6th being failed attendances, the reasons were not recorded). 5.7. Latterly in the pregnancy Adult V attended on a regular basis. At no stage during the course of the pregnancy did the Hospital Social Worker consider that the threshold for a referral to Children’s Social Care was met; nor, indeed, at the point of Child T’s discharge as he did not require any special care withdrawal of substances. 5.8. However, the very significant information (both historic and current) relating to Adult W was missing and this was very relevant as Adult V had reported that although she and Adult W did not live together, he was the father of Child T and they had quite a lot of contact (as evidenced by the Police). It would have been productive for these meetings to discuss Adult W’s own substance misuse and the nature of his relationships with Adult V and the children.    5 Paediatric alerts are generated by a paediatric referral being made to a paediatrician if there is a potential concern for the unborn child, for example, maternal drug use/heart defect. The paediatrician then reviews the referral and if assessed as necessary writes a paediatric alert for the records which incorporates a plan of care which is filed within the maternity notes. A copy is also placed within the paediatric records for when the baby is born, (it can be seen as an example of good communication between departments within HEYHT).    22Systemic learning from Key Practice Episode 1 a. Due to time constraints and the volume of cases, cases are not discussed in great depth at the SUAT meetings and, it was reported at the Learning Event that, pragmatically, there is not sufficient time to discuss fathers/partners. Additionally, the Substance Misuse Services involved in the SUAT meetings expressed concerns about sharing such information on the men/fathers without consent. In the light of the historic information and the longstanding relationship, it would have been good practice to seek his consent to discuss relevant information about him, to aid an assessment of the impact of his needs on the family, and of his own parenting capacity.  b. The lack of knowledge and information on fathers/partners raises issues about potential unknown risks to other children in the household, to the new born and regarding staff safety (.e.g. the risk of lone home visiting).  c. There was no evidence of information-sharing between practitioners outside the meeting.  There was no documentation from the meeting within the Hospital Maternity records, or record of sharing information with the Community Midwives. This practice has now altered to ensure that information from the meetings is shared with Community Midwives and filed within the Hospital Maternity records so that practitioners involved with the maternity care in both the community and hospital settings are aware of the content of discussion from the SUAT meeting. d. At the time of Adult V’s pregnancy with Child T, the minutes of SUAT meetings were not recorded on Carefirst (i.e. the Children’s Social Care database) in cases where there were no safeguarding concerns about the unborn child. The minutes were distributed to the representatives of the agencies attending the meeting, who in turn were responsible for distributing them as appropriate within their agency.  The Hospital Social Worker also retained the minutes and was the point of contact for requests for information-sharing with Children’s Social Care (for example following a referral to CSC from another source).      23e. In mid-2013 this changed, and since that time all minutes from SUAT meetings have been recorded on Carefirst although clearly identified as for information only in circumstances where there are no safeguarding concerns about the unborn child.  f. Whilst the multi-agency SUAT meetings are clearly valuable in their own right (i.e. information-sharing), there has been no consistent use of a Common or an Early Help Assessment in a more structured and co-ordinated way. Moreover the meetings do not consider the views of the parents.  g. The Hull Safeguarding Children Board currently has a working group looking at Pre-birth Pathways; and one stream of work relates to the SUAT meetings. Consideration needs to be given to their scope, their practice, the recording by all agencies and the distribution of minutes.  Key Practice Episode 2 – Multi-agency working and decision-making under the Common Assessment Framework (CAF) 5.9. In addition to the substance misuse meetings (Key Practice Episode 1 above), on 24.3.10 Child X was the subject of a CWANM which was part of the CAF process at the time. It was chaired by a CAF Co-ordinator and attended by a Hospital Midwife, the Hospital Social Worker, a Health Visitor, the School Nurse, the Child Protection Co-ordinator for Child X’s school and by Adult V herself.  However, it is noteworthy that there was no representative present from the Substance Misuse Service. 5.10. The Common Assessment completed in relation to Child X in 2007 (with the School Nurse as Lead Professional – see para. 4.16) had been brought to the attention of the Common Assessment Team by the Hospital Social Worker when she was notified of Adult V’s new pregnancy with Child T and she felt it appropriate to review whether there was any need for any further help and support under the Common Assessment Framework.     245.11. The minutes of the meeting describe a positive picture both regarding Child X’s progress (no concerns expressed by school) and the needs of unborn Child T, e.g. good family support. Child X saw Adult W regularly; and, although reportedly not living together, Adult V and Adult W reportedly had a more positive relationship; Adult V supported Child X well at school and was attending her antenatal appointments. The conclusion was that Child X had no additional needs. The allocated Health Visitor had tendered her apologies and requested minutes of the meeting; but another Health Visitor had attended in her place. The allocated Health Visitor then carried out an antenatal contact with Adult V on 23.4.10. The outcome was that the level of need was Universal6 requiring only routine core contacts. 5.12. There is no specific learning from this episode, other than that there is evidence that key professionals considered the needs of Child Z and unborn Child T and reached a reasonable professional judgement that there were no unmet needs which required additional support. Key Practice Episode 3 – Child T’s Discharge  5.13. Adult V and Child T stayed as inpatients in the Maternity Hospital from birth to discharge 7 days later. Child T had health assessments on each day by the Advance Neonatal Nurse Practitioner or Paediatric Doctor due to the risk of Neonatal Abstinence Syndrome (i.e. withdrawing from substances). The plan had always been that Child T would stay in hospital for 5 days from birth for observation. Child T had a weight-loss of more than 10% on the fifth day so it was advised that Adult V and Child T would remain in-patients for a further 2 days, Adult V agreed to this plan.                                                               6 Health Visiting services are delivered in line with the national Healthy Child Programme 2010. This follows a model of a universal core programme of service delivery to all antenatal mothers and fathers progressing to a programme of care and service that meets different levels of need and risk (progressive universalism). The Assessment takes place at each contact with the service user. It takes into consideration identified current need and future risks which inform the level of service provided. The three service levels of need are: Universal which, as stated, is a core programme of care; Universal Plus, where a short time-limited increase in service is provided in response to an assessment of additional need, for example support with breast feeding; and Universal Partnership Plus programme of care which is provided where an assessment of health need has identified a child or their carer as having an additional health need, physical need and/or where there are safeguarding concerns around an unborn child or a young person (Health Visitor Implementation Plan, DoH 2011).    25This represents good practice by the Midwifery team and also shows Adult V being responsive to her baby’s needs. Key Practice Event 4 – First report to school 5.14. On 30.6.10, shortly after the birth of Child T, Child X reported to a member of school staff that Adult V had scratched her under her eye the night before. Child X stated that it was caused because she refused to come in. Information was passed to the Child Protection Co-ordinator who recorded they would contact Adult V. Although there are no records of the conversation with Adult V, the Child Protection Co-ordinator recalls having a conversation with Adult V. The Child Protection Co-ordinator is confident that if, during the conversation they had identified any concerns, she would have consulted and/or referred to Children’s Social Care. Key Practice Event 5 – Second report to the school 5.15. A further record was made by the Primary school on 16/9/10 after Child X disclosed to a member of staff during a 5-day residential school trip that when Adult V is asleep she (i.e. Child X) “does not recognise her” (i.e. Adult V) and that Child X looks after Child T. When asked how Child X looks after Child T, Child X said she gives Child T his dummy and bottle and changes his nappy. This information was passed on to the Child Protection Co-ordinator once the trip returned the following week. The Child Protection Co-ordinator recorded that they would speak to Child X. However, there are no recordings of this action taking place. Nevertheless, the Child Protection Co-ordinator recalls having the conversation with Child X, and is adamant that if they had had concerns they would have shared information with Child T’s Health Visitor with whom there was a strong working relationship. Systemic Learning for this particular school from Key Practice Events 4 & 5 5.16. It is unsatisfactory that on both occasions there is no recording of the outcomes. The Education Officer (Safeguarding) has addressed the issue of safeguarding recording in this school and shared her findings at the Learning Events as follows:    26i. Since 2010 the school Child Protection recording system has improved to ensure the system is more robust. ii. All Child protection files now have key information attached to the front cover, which clearly indicates the case status, a chronology sheet and a synopsis of events. The cross referencing on the front cover assists with easy navigation to relevant documentation in the file. iii. All records of Child Protection, safeguarding or behavioural concerns are forwarded to the Child Protection Co-ordinator in a timely manner for them to action accordingly. Having one contact point within the school ensures consistency in decision-making and enables the Child Protection Co-ordinator to have a complete overview of concerns raised. All records are shared and signed by the Headteacher as an additional measure to ensure appropriate actions have been taken. iv. The school acknowledges that there are never any guarantees that systems will not fail. However, they continue to maintain a self-critical approach in challenging their working practice by conducting internal audits to help identify and discuss decision-making. v. Previously domestic abuse incidents were not shared with the school (see Section 7).   However, practice has since changed and been strengthened, i.e. the school acts on information received as necessary; and therefore there are no specific recommendations for the school.  However, the Chair of the Hull Safeguarding Children Board will ensure learning from this review is communicated to all local schools. Key Practice Episode 6 – First Police call and resulting follow-up actions 5.17. On 9.10.10 the Police were called by Adult V following a verbal argument with Adult W whom she alleged had been kicking the door after she had locked him out; and he had a brick in his hand. The two children Child X and Child T were in the house at the time. He had remained outside the house for 2 hours.     27By the time the Police arrived Adult W had left and no damage or assaults had occurred. However, the attending Police Officers were told that Child X had shown signs of being distressed as a result of this incident. Both children were seen and appeared well. 5.18. A form F125 was submitted by the Police (i.e. a concern about a child); and a Case Administration Tracking System (CATS) record was created. This record confirms that Domestic Abuse Partnership (DAP) booklets were sent to Adult V offering support if she wished it. (For explanations of processes see Glossary of Terminology at Appendix iii.) The information from the CATS record was then shared with the Children’s Social Care Central Duty Team (CDT) and Health via City Health Care Partnership (CHCP) Safeguarding Team the following day (10.10.10). The CDT decision was that there was no need for Children’s Social Care involvement. 5.19. The Health Visitor and School Nurse were also notified of this incident and the Health Visitor made a follow-up home visit on 1.11.10 which generated a discussion with Adult V regarding the incident. From that discussion the Health Visitor had no safeguarding concerns but at the same time there was no particular challenge to the information regarding Adult W nor to the incident as described in the notification.  5.20. The School Nurse, having been notified of the incident, recorded that Child X had been distressed as a result of the incident. There is no evidence in records that this was followed up by gaining Adult V’s consent to speak to Child X. There is no evidence as to whether or not this incident was discussed between the School Nurse and the school. Systemic Learning from Key Practice Episode 6 a. The decision for no intervention by Children’s Social Care was a reasonable one, despite the children being present and the apparent distress by Child X over the incident.  Best practice would have been for Children’s Social Care to liaise with the Children’s Centre, the Health Visitor and the school as part of their decision-making.     28At the very least Adult V should have been advised of the services for wide-ranging support offered by the Children’s Centre. b. It was good practice by the Health Visitor to make a follow-up home visit following receipt of the domestic abuse notification.   Key Practice Event 7 – Second Police call 5.21. The Police were called by Adult V on 19.1.11 as Adult W was refusing to leave after he had stayed overnight. She claimed that he had hit her and smashed the TV and she was unsure whether he was under the influence of drink or illicit substances. When officers attended Adult W was still present and there was damage to the television but no assaults were reported and Adult W was removed from the property.  Child X was at school.  Child T was in the house but he was seen to be safe and well before the Police left the home.  Adult V was aware of domestic abuse support available.  5.22. There is no particular learning from this event. Key Practice Episode 8 – Third Police intervention 5.23. On 3.2.11 both parents were arrested for burglary and then released unconditionally, though Adult V was cautioned for possession of Cannabis. When searching the house in the context of the alleged burglary, the Police reported finding 40+ uncapped needles, spots of blood and bloodied tissues strewn around the house, including in the children’s bedroom. Police representatives attending the Learning Events highlighted that having possession of substance misuse paraphernalia does not in itself constitute an offence and no substances were found. Moreover, none of the children were present as they were with relatives.  Adult V’s Comment She was very disquieted by this description during her interview with the Lead Reviewer and she insisted that she has never used needles in the house.     29She is adamant that this description relates to the home of a couple living next door whose little girl was playing in their garden (see 5.25 below). 5.24. A Form 125 was submitted and a CATS record created; and the risk was assessed as medium. There was direct liaison between an officer from the Public Protection Unit and the manager of the Central Duty Team the following day (4.2.11). The decision was to proceed to a Section 47 enquiry on a single-agency basis by Children’s Social Care. 5.25. For this Serious Case Review the CSC author has reported that whilst a Social Worker visited unannounced the same day (4.2.11) neither the contact, referral nor consultation on the joint decision with the Police are recorded on the CSC database; and there is no record of an assessment of the children’s needs. The recording is limited to brief diary notes.   5.26. The Social Worker was present at the Learning and Recall Events and confirmed that there was no detailed recording but she could recall the visit in which Adult V was “very engaging”. The Social Worker saw Child T who was clean and well-presented. Adult V disputed the information given by the Police, i.e. a child’s name on the form was not related to this family; and she refuted the reference to uncapped needles. The Social Worker checked each room and there was no sign of any substance misuse paraphernalia.  5.27. The state of the house was good and there was food in the fridge and cupboards. Again in her interview, Adult V confirmed that Adult W was not living at the house and her explanation for any bloodied tissues found was that one of the children would have had a nosebleed. 5.28. The school Child Protection Co-ordinator was contacted by the Social Worker and reported back after Child X had been spoken to in school, stating that no concerns regarding Child X were identified. Additionally, the school Child Protection Co-ordinator described that they knew Adult V well and had a good relationship with her. The Substance Misuse Worker supporting Adult V was also contacted and reported no concerns.    305.29. A Children’s Social Care colleague updated the CATS record on 14.2.11, reporting that Adult W was living with paternal grandfather; and  Adult V and Child T were safe and well with Adult V reportedly accepting help from Domestic Abuse Partnership (DAP). From the Police perspective, the risk assessment was lowered to Standard and the incident was closed. 5.30. However, it has subsequently emerged when the records were checked that Adult V in fact declined DAP support. Systemic Learning from Key Practice Episode 8 a. Monitoring of progress of Children’s Social Care assessments did not work sufficiently well in this case, so that the absence of recording in relation to the referral and joint decision-making with the Police was not highlighted, and no assessment was completed. Given the length of time which has elapsed, it has not been possible to establish the cause of this situation, but the Learning Event heard that the likely context was a higher than average rate of new work into the Central Duty Team at that time and a particularly pressured period in terms of work demands for the individual worker involved. b. An immediate unplanned visit was made to the family in response to the referral from the Police, and contacts made with some other agencies, which provided no immediate cause for concern about the safety of the children. Nevertheless, an opportunity to undertake a full assessment of the children’s needs, together with an analysis of risk, was missed, and this was not good enough practice. The assessment work that was carried out was not formally recorded. These two dimensions (i.e. the lack of a full assessment and the lack of formal recording) meant that information which may have informed decision-making in respect of a subsequent contact about the family was not available. c. There is no evidence of robust challenge to the parents by the Police in response to them finding substance misuse paraphernalia. Also, in the process of lowering their risk assessment, there was a false assumption that Adult V was accepting DAP support (see Glossary).      31This information had come initially from Adult V herself and then through the Social Worker update of the CATS record. Key Practice Episode 9 – Fourth report to the Police  5.31. On 3.7.11 Child Z called the Police reporting that Adult V and Adult W were arguing with Child T present. On arrival at the house Police Officers confirmed that no offences had been committed and Adult W agreed to leave the address. Child T was seen to be happy, clean and well nourished. A Form 913 was submitted and the domestic abuse risk was assessed as medium. 5.32. The Police made another referral to DAP via a Form 913 on 9.7.11 because during the course of the home visit on 3.7.11, Adult V had told the Police Officers that Adult W was very controlling, by. making her wear a ring on her wedding finger even though they were living together and objecting to her going to a SureStart centre. A DAP Duty Worker made three telephone calls to the home (11th, 15th and 19th July) and on each occasion Child Z stated that Adult V was out or not available.  5.33. Meanwhile the DAP Social Worker brought the family for discussion to the Families Affected By Domestic Abuse (FABDA) panel meeting to be held on 19.7.11 (see Glossary). This meeting recommended that DAP try again to contact Adult V. When the attempt to contact Adult V failed again, DAP sent a letter and booklet later the same day (19.7.11). The case was then closed to the FABDA Panel and DAP informed the Police they have been unable to contact Adult V.  5.34. The record of the FABDA meeting was copied to the CHCP Health Safeguarding Practitioner who established that there were no actions for Health and then sent copies of the notes to the Health Visitor and School Nurse respectively for information. 5.35. There is no specific systemic learning from Key Practice Episode 9.    32 6. SYSTEMIC LEARNING IN RELATION TO DOMESTIC ABUSE (All the acronyms that are used in this section are expanded and explained at the Glossary – See Appendix iii) 6.1. Case Administration and Tracking System (CATS) forms are sent to the Central Duty Team (CDT) (which was established in May 2008) where a decision is made about the most appropriate response, for example, whether or not the child is in need under Section 17 Children Act 1989, or whether the threshold is met to initiate enquiries under Section 47 Children Act. During the period within the scope of this Review those domestic abuse cases assessed by the Police as high risk were directed to a Team Manager at CDT who liaised with a Police decision-maker about the response, in accordance with Child Protection Procedures. Medium-Lower risk cases were directed to a Senior Practitioner for a decision about whether to discuss the child and family at the FABDA panel. All notifications from the Police were inputted onto CareFirst (CSC database) as an initial contact by an administrator.  6.2. Copies of the CATS forms are also sent to Education where the Education Officer (Safeguarding) redirects them to the appropriate school; and the school involved in this case confirmed at the Learning Event that they found these notifications very important and useful in maintaining a child focus within the context of understanding the family. 6.3. Until November 2013, copies of the CATS forms were also directed to the City Health Care Partnership (CHCP) CIC Safeguarding Children’s Team and, when the incident involves pregnant women, a further copy is sent to the Hospital Midwifery Service. However, at governance level a decision was made (1.11.13) that Health (CHCP) could no longer receive the CATS forms as there were concerns about third party information being inputted into a child’s health record. Some of the issues raised are the consent of the subjects, confidential storage, and a considerable quality assurance exercise to confirm the accuracy of information received.    336.4. The inability of agencies across the partnership to resource full minute taking meant that the decision was taken in 2011 to stop providing full minutes of FABDA meetings and each agency present took their own notes. The operation of the FABDA panel was reviewed during the early part of 2014 in relation to its position within the partnership’s Early Help Framework. As a result the role of the Panel has been integrated into Early Help Action Meetings within each locality rather than operating as a standalone panel. This is an appropriate and positive development in that the partnership arrangements have changed and developed in the three years since FABDA was introduced.  Adult V’s Comment In her interview, Adult V was surprised that this report focuses on domestic abuse, claiming that her partner was not a violent man, that she had never been severely assaulted and that she invariably felt safe. Moreover, she described that he has always taken a keen interest in the children, including by being present at the birth of each child and accompanying them to appointments.    34 7. AN UNDERSTANDING OF THE SUBSTANCE MISUSE SERVICES AND SHARED CARE OFFERED TO THE PARENTS WITHIN THE SCOPED PERIOD 7.1. On the basis of the parents’ lifestyles and in particular the circumstances surrounding the death of Child T, it is important to understand the services that they received; albeit that much of the information contained here is based on self-reporting. 7a. Context 7.2 10 out of 57 GP practices in Hull have chosen to offer Shared Care. It means that when a patient has stabilised, they can receive the management of their prescribing and testing can be delivered by the GP in conjunction with the Substance Misuse Service who focus on psycho/social support. Adults V and W had separate GPs, both of whom offered Shared Care. There are many advantages, e.g. treatment locally and in the community and back into Primary Care services; less stigma; and the GP taking a holistic approach. There may be also some disadvantages, e.g. patients not engaging in group work activity and psycho-social interventions which J2R offer centrally.  Adult V’s view  In her interview she suggested that she found it better to receive the service in the community rather than mix with groups of substance misusers centrally, when, inevitably, there are risks and temptations. She feels that her own shared care worked very well. 7.3 Systemically there are issues in relation to recording, i.e. two separate systems being used in different GP practices (EMIS and SystmOne); and J2R workers not having access to either system for reading or recording purposes.    357.4 The respective Substance Misuse Worker and GP for Adult V worked closely together and the Substance Misuse Worker devised a practice whereby she would make her records available to the GP practice who would then scan them into the medical records. In the absence of Shared Care Monitoring Group meetings across the city (which used to take place), practice issues such as this good example are no longer shared – see Recommendation at Section 12. 7b. Adult V 7.5. From the point in September 2009 when Adult V became pregnant with Child T, she began to describe wanting to reduce her Methadone, not wanting her baby to be dependent on Methadone when born. Plans were made to reduce her Methadone and Diazepam during the second trimester. The assessment by the Substance Misuse Worker was that she engaged well and started to make positive changes in her lifestyle. The GP reports that multiple urine samples confirmed no other substances present. 7.6. Following Child T’s birth in May 2010, Adult V presented to Substance Misuse Services as being stable and free of illicit substances and she quickly established routines with the support of Adult W and maternal grandmother . At appointments she appeared relaxed and happy; and extra support was offered around the time of the anniversary of Child Y’s death which was, historically, a difficult period for her. 7.7. In January 2011 Adult V decided to concentrate on reducing her Diazepam with a view to detoxification during 2012. Generally throughout 2011 she was stable and she achieved her milestone of coming off Diazepam by January 2012. However, in November 2011 she was angry and upset with the GP who refused to prescribe Pregabalin. (This medication can lead to a high addiction and can be very problematic; see Health & Social Care Board (HSC) letter at Appendix v.)    367.8. She admitted to the GP that she had been using maternal grandmother’s  Pregabalin to manage lower back pain; but she declined the alternative offered by the GP. 7.9. Adult V’s attendance at J2R deteriorated in the early part of 2012, e.g. only attending 2 appointments instead of 4 between February and April 2012; though she maintained appointments with the GP and she did continued with her planned reduction of Methadone, gradually reducing down from 25mgs to 15mgs. In May 2012 the J2R worker made a no reply home visit in the light of continued failed appointments; and in June 2012 there is evidence of good communication between J2R and the GP and then with Adult V, discussing alternative plans if Adult V continued to fail appointments, e.g. to consider supervised consumption at the pharmacy. This prompted her attendance at her next appointment in June, but she felt that she had reduced too quickly and she was stabilised back on 20mgs of Methadone.  7.10. In July 2012 she asked her GP for sleeping tablets and this was declined. There was also evidence of good practice in the shared care between J2R and the GP by co-ordinating and bringing in line the issue of prescriptions and the J2R appointments, in order to counteract the pattern of failed appointments. This had the desired effect of improving her attendance from September 2012 to December 2012, i.e. 5 attendances out of 7. 7.11. There was a 3-way clinical review (J2R/GP/Adult V) in October 2012 at which she disclosed she had missed her collection of Methadone for 5 days due to illness; but she had used Adult W’s Methadone. It is noteworthy that Adult V had informed neither her J2R worker nor her GP of her failure to pick up her Methadone from the pharmacy; nor had the pharmacy informed the GP on the 4th day as per protocol. This would have allowed the GP to make a review, a result of which could potentially be a decision to stop the prescription, or to revert to supervised consumption.    377.12. Routine home assessments are carried out by J2R with service users who are parents and these were conducted with Adult V in October and November 2012 with no concerns raised. The purpose of these visits is to see the home and observe the environment in which the service user and children are living. They are not considered to be formal parenting assessments.  For this Serious Case Review it has been established that Adult V was provided with safe storage information (May 2012 and October 2012) and she was also issued with a lockable safe storage medication cabinet. 7.13. Adult V had been on Methadone for over 8 years and the treatment plan was to complete detoxification preparation work before Christmas 2012 with a view to entering an in-patient detoxification in early 2013. Hence she was referred to Compass (5.11.12) in order to undertake the Transitions Group work programme and to be offered 1:1 support (see Glossary at Appendix iii).  7.14. Adult V attended an induction meeting at Compass on 7.11.12 at which she reported occasional Cannabis use but she was confident she could abstain for the next 6 weeks in order to attend the group. She agreed to attend the group which was starting the following day  and the plan was for 6 x weekly group sessions. However, she did not attend. An agreement between J2R/Adult V/Compass confirming that the start date would be postponed by a week (i.e. commencing on 15.11.12) again led to a failure (she reported that Child T was clingy following an accident requiring hospital treatment). Despite telephone contact and texts to encourage her and also information-sharing with J2R, she then failed 3 further dates up to 3.1.13. Having not responded to communications, when she did not attend again on 3.1.13, she was discharged from the Compass programme. Reflection in the Learning Event identified that it would have been good practice to hold a 3-way meeting comprising Compass/Adult V/J2R to facilitate her engagement.      387.15. Meanwhile, two planned home visits by J2R were unproductive; Adult V changed the date of the first appointment and was out for the second; but when the J2R worker spoke to her on 2.1.13 she reported she had had a good Christmas and New Year; there were no concerns about her presentation and she had coped well with the build-up to the anniversary of Child Y’s death (end of December). A 3-way review (GP/Adult V/J2R) was planned for later in January. 7.16. Meanwhile, 3 days before the fatal event, Adult V had been given a 1 day prescription with a request that she come back into the GP surgery the following day to collect a 4 day prescription. She failed to do so. This Serious Case Review has explored whether GP surgeries could or should be proactive in “chasing” patients who have not collected their prescriptions.  The GP who was interviewed after the Learning Events considered that it was not proportionate or desirable to do so, partly due to limitations on resources and partly because assessing the motivation of the patient is crucial. This position is accepted. Adult V’s view Adult V believes that users should be tested weekly rather than fortnightly because there are many strategies for still misusing substances and yet at the same time producing “clean” samples. 7c. Adult W 7.17. From the point when J2R took over the contract in July 2011 (see Glossary) Adult W attended appointments with his Shared Care (J2R) worker focusing on his relationship with Adult V, his benefits, and seeking accommodation. He stated that he could not imagine coming down from the 100mgs of Methadone which he had been on for a long time; and he declined the offer of a referral for group work. He confirmed that he smoked Cannabis.     397.18. However, from November 2011 to March 2012 he failed many appointments, despite arrangements being changed so that he could be seen at the Shared Care Practice which would have been easier for him. He stated that he did not have a phone, so contact had to be by letter. Home visiting was considered but it was deemed not suitable as there was no current risk assessment regarding staff safety available.  7.19. In March 2012 Adult W’s J2R worker and Shared Care GP discussed Adult W and the GP agreed to adjust prescription dates to coincide with J2R appointments. This strategy was effective in that Adult W did attend an appointment with the J2R worker in April 2012, at which the main feature that was identified was that he was not taking his epilepsy medication and he was advised to speak to the GP about this. 7.20. In May 2012 a 3-way review was held (GP/J2R/Adult W) at which Adult W agreed to try a reduction of 5mgs and to recommence taking medication for a pre-existing medical condition. Additionally, he admitted that he was taking illicit Benzodiazepines occasionally and he had missed Neurology appointments. In July he was continuing to reduce his Methadone by 5mgs per month. After careful planning for a J2R worker to make a home visit (Adult V’s consent, the purpose, etc.) it was a no reply visit and Adult W later made clear his objection to a home visit despite J2R’s policy to undertake home visits for everyone with children. His Methadone reduction continued through the autumn and he appeared stable, reporting that he was enjoying the time he spent with Child T; he seemed brighter, more alert and stated he wished to explore detoxification options. 7.21. The key feature of the November 2012 appointment with his J2R worker was Adult W reporting that he was using acquired Pregabalin which had not been prescribed and about which there is significant concern (see Appendix v).     40He claimed that it helped his medical condition; but he was advised of the risks of doing this and it is noteworthy that he had asked the GP for Pregabalin 12 months earlier and had been refused. 7.22. The two J2R workers supporting Adult V and Adult W respectively liaised to discuss a home visit to which Adult V had agreed. Also at this time a safeguarding referral was considered by one of the J2R workers with a colleague; but, on balance, it was felt that there were no current risks to the children. At the time of Child T’s death, Adult W was on supervised consumption, and had been for the entire period of time covered by this Review. 7d. The Learning i. A J2R Did Not Attend (DNA) policy was introduced in November 2011 i.e. three consecutive Did Not Attend can lead to the suspension of treatment and discussions held to determine the appropriateness of continuing prescriptions and treatment in shared care, based on clinical risk and assessment. A review of possible options will form the basis of this such as a reversal back to supervised consumption may be considered.  ii. The Agency Author suggests that this policy should have been used with more rigour in relation to Adult V; but the J2R worker and the GP accepted that Adult V was generally a rather poor attender, with no increased risks identified; she was not demanding or manipulative; she was not a persistent substance-seeker; and her Methadone dose of 20mgs was considered as a low dose. iii. It was totally appropriate and commendable that the GPs in both practices did not accede to the requests for Pregabalin indicating that they recognised that this would potentially be detrimental to patient care. However, no overt description of this as substance-seeking behaviour was recorded; and there are no records of child safeguarding considerations having been made in relation to this.     41It may be significant that both parents were asking for this medication from their respective GPs at the same time (September-November 2011). iv. There were occasions when the pharmacy did not alert J2R or the GP if Adult V and Adult W independently failed to collect their Methadone doses; policies and practice are that when there are 3 consecutive failed collections, the pharmacy should inform J2R. v. In her interview with the Lead Reviewer Adult V gave an insight into the ease of availability of substances in her local area and in particular Pregabalin. She acknowledged that its “effects are weird”, i.e. potentially dangerous.    428. THE ROUTINE AND UNIVERSAL SERVICES OFFERED TO THE FAMILY WITHIN THE SCOPING PERIOD Introduction 8.1. Sections 5 and 6 of this report have described particular interventions and offered a commentary on them. Additionally, members of the family also received universal services within the scoping period and these are briefly summarised here. 8.a. Subject – Child T 8.2. Following discharge, 2 out of 4 Community Midwife appointments were kept and no adverse effects from the missed appointments were identified.  Adult V reported that she had been to the GP. 8.3. The Health Visitor had seen Adult V at an antenatal appointment at34+ weeks gestation based on the Health Visitor attending the CWANM (24.3.10). Following Child T’s discharge, the Health Visitor made a Primary visit when he was  12 days old; and another visit when he was aged 23 weeks, as a follow-up to a domestic abuse notification. 8.4. A Nursery Nurse visited 4 times (30.6.10, 13.7.10, 31.8.10, 5.7.12). The last visit comprised a 2-year development review. There were no health concerns, Child T had no unmet health needs, and his developmental assessment was age-appropriate. 8.5. Additionally, the GP conducted a routine postnatal review at 6 weeks old. Comment  At no stage were any health, development or safeguarding concerns identified. The relationship between Adult V and Child T was reported to be good; as also was the care she offered him. There is evidence of good interactions.     43Health Visiting services were delivered in line with standards and expectations within the Child Health Promotion Programme (2008) and the Healthy Child Programme (2010) – see footnote 6 under para. 5.11.  8.6. The only other intervention for Child T was on 10.11.12 when he was brought by Adult V to A&E. The history given was that he had been running around with a bottle in his mouth, had fallen over and cut his lip. He needed to stay in overnight for suturing under general anaesthetic by a surgical team. He was discharged the following day. No safeguarding concerns were raised because the explanation of the injury was reasonable and accepted. The hospital staff observation was that Adult V was meeting all of Child T’s needs while he was in hospital therefore there were no concerns identified about parenting at this time. 8.7. Procedurally, the A&E attendance and admission information and discharge letter were sent to and reviewed by the Health Visitor and again no safeguarding concerns were identified. However, there is no evidence of information or a discharge letter in the GP notes and therefore the GP could not undertake any follow-up (though of course the letter may have been sent and gone missing). 8.b. Child X 8.8. She presented as a happy, sociable child in Primary school where she made steady progress under School Action (see Glossary at Appendix iii). The only concerns centred on how she was collected from school and some absences. In her interview with the Lead Reviewer Adult V spoke warmly of the school and its consistency of the Class Teacher, good relationships and support. 8.9. Poor attendance in the first term at Secondary school (Autumn 2012) resulted in letters to Adult V and a home visit by a School Nurse on 19.11.12 (no reply) and another on 21.11.12 when she spoke to Adult V.     448.c. Adult V 8.10. Out of the 11 antenatal appointments offered by the Maternity Service, Adult V attended 8 and she received continuity of care from a core group of staff. On each of these 8 appointments she attended, she was requested to produce urine samples for the detection of proteinuria, but she actually only produced three. She claimed that the GP had tested the urine samples and the results were negative. However, at each antenatal appointment her current reported substance misuse and medication were described by Adult V and recorded in the maternity records; notably her reported reduction of Methadone from 50mgs to 25mgs during the pregnancy. Learning Urine samples will have been needed but for two different purposes and processes; testing for illicit substances and pre-eclampsia/diabetes. There is a risk that both professionals and patients could be confused without clarity and communication between all parties. The learning is for Midwives and GPs to be explicit and clear to women the purpose of particular urine samples.  Although the multi-agency SUAT meetings did represent one aspect of sharing information, professionals challenging information with parents and across agencies may be both necessary and appropriate. There will often be a need for separate and specific communication between agencies such as GP, Substance Misuse Services and the Maternity Service outside the SUAT meeting process.  8.11. The local Children’s Centre contacted Adult V three times in the first two months of Child T’s life, comprising an initial postnatal baby visit (30.6.10) and two further home and safety check visits (12.7.10 & 13.7.10).       45The visits were carried out by a Nursery Nurse based at the Children’s Centre and although Adult V was given information about services available in the local area, she did not access any Children’s Centre services, other than a holiday activity in July 2011.    46 9. CONCLUSIONS (including the specific Terms of Reference) 9.1. Is there evidence of disguised compliance? Defining disguised compliance as a deliberate attempt to draw attention away from potential harm to children, the analysis from this Serious Case Review is that this feature cannot be established. It is certainly evident from the preceding text that Adult V was, at times, reluctant to engage with services (e.g. DAP and Children’s Centre); that she failed appointments on many occasions (GP, J2R); and that she gave misleading information regarding the status of her relationship with Adult W. On several occasions, particularly following domestic abuse incidents, she said that the relationship was over or that he was not living at the family address, whereas it is clear that they maintained their sometimes volatile relationship. There was insufficient challenge by agencies at that time and also when Adult W was obviously present on many occasions at the family home (Police call outs and at the time of Child T’s death). Nevertheless, Adult V has consistently been described in the agency reports, at the Learning Events and indeed by the Judge, as a good mother. The agencies never assessed that the children (including child T) were at risk of significant harm. Her mis-information (e.g. stating that she was engaged with the Domestic Abuse Partnership which was not true) and keeping herself somewhat distant from agencies are much more likely to be related to her lifestyle and her involvement in illicit substances culture rather than deliberate attempts to draw attention away from any potential harm.    9.2. Is there evidence that for those agencies and services which are adult-focussed, they maintained a “think family/think child” agenda? There is good evidence that the two Substance Misuse Workers (who sometimes saw Child T at appointments) did record in their assessment work with both parents that they were considering the potential impact of parental substance misuse on Child T.    47Adult V and the children were registered with one GP practice and there is no evidence that there was not an appropriate child-focus. Indeed, in her interview the GP specifically commented on the good care Child T was receiving and on the close bonding and rapport between Adult V and Child T. Additionally, Adult V had reported to her Substance  Misuse Worker that she made strenuous efforts to give all three children (i.e. including Child Z) individual play-time and attention. 9.3. Is there any evidence that agencies heightened their thresholds or lowered their sensitivity, i.e. the “accommodation syndrome”? A careful study of all the agency reports and the debates (conducted over the two Learning Events) reveals much good practice and no evidence that sensitivity to safeguarding fell below expected standards, e.g. on all the Police call outs there were checks on the children and appropriate forms submitted; antenatal and postnatal services were of a high standard; the Health Visitor followed up the notification of a domestic abuse incident. However, the self-reporting from both parents (e.g. relating to their substance misuse and the status of their relationship) was not sufficiently checked or challenged by agencies. 9.4. Was there sufficient focus on and assessment of Adult W? There are several examples of occasions when agencies were insufficiently curious about Adult W’s role in the family and in the home in general, and when Adult W should have been contacted and his role should have been assessed. • The 3.4.00 allegation that Adult W assaulted Adult V while she was holding Child Z. Even though she had left to live with maternal grandmother, this could and should have been assessed by contacting Adult W. • Initial Assessments on Child X and Child Y in 2001. Parents had been mis-using substances for at least 5 years by this time and Adult V was indicating that Adult W planned to move in.    48                                                           • Initial Assessments regarding Child Z and Child X in 2004. This was an opportunity to make contact with Adult W and therefore assessments fell below required standards. • The February 2011 Section 47 investigation; a lack of contact and therefore a missed opportunity to assess strengths/risks in his relationships with Adult V and the children. • On 9.7.11 Adult V told Police that Adult W had a controlling influence over her but he was not included in any assessment and therefore the nature of their relationship was never explored and remained unknown. • Adult W was seen by a Health Visitor at the primary birth visit on 2.6.10; but when a Health Visitor visited on 1.11.10 Adult V reported that she and Adult W had been together for 20 years and that the incident had been taken out of context. There is no evidence of any exploration or challenge to this information. • Partners are not discussed in SUAT meetings. • There was never any assessment of Adult W as a significant other by any agency. • There is no evidence of Children’s Social Care making contact with Adult W’s Substance Misuse Worker to explore the implications of his substance misuse on his parenting capacity. • Adult W’s J2R worker was unable to complete a Home Assessment. This is a recurring theme in local and national enquiries7,8,9  7 There is a tendency for agencies to overlook the role of fathers/male partners/men both regarding the risk they pose and regarding the information they hold, in order to help understand the child’s situation. “This Serious Case Review highlighted the need for those working with children and their families to demonstrate how the role of fathers and men in households is considered in service provision and assessment.  This appears to still be an issue and requires further review.” Hull Safeguarding Children Board Serious Case Review Child F 2011     499.5. Was “the voice of the child” heard? There is good evidence that Child X was spoken to by a number of the school staff prior to the CWANM on 24.3.10. Therefore her views were conveyed to the meeting through the school Child Protection Co-ordinator. Child X was not seen by a Social Worker but was spoken to by the Child Protection Co-ordinator as part of the February 2011 Section 47 Enquiry. (NB: the Social Worker and the school had a very strong and trusting relationship and the decision for the Child Protection Co-ordinator to speak with Child X rather than the Social Worker was a considered and appropriate one.) Throughout the period described in this Serious Case Review there is no evidence of Child X or Child Z being spoken to other than in school; but the study and analysis that has been undertaken does not identify that any other professional should have done so. Key Practice Episodes 4 and 5 have identified that again Child X was spoken to directly in school on the basis of the concerns which were raised. The observations of mother/child relationships, and particularly the interaction between Adult V and subject Child T, come mainly from Health (GP, Special Care Baby Unit, home visits by Health Visitor and Nursery Nurse). Additionally, it is noteworthy that J2R workers made records which were scanned into the GP notes referencing observations on Child T. Also, the brief record of the Social Worker’s home visit on 4.2.11 does comment on the presentation of Child T, although not on the mother/child interaction.                                                                                                                                                                                           8 An Ofsted report identified gaps in Serious Case Reviews where information from or about fathers, whether living at home or elsewhere, and other adults living in the home might have contributed to a better understanding of the children and their families. Learning Lessons from Serious Case Reviews 2009-10 (Ofsted 2010)  9 There was, yet again, scanty information about men in most reviews, particularly in relation to an understanding about past history. This pattern reflects the wider problem of the lack of information about and lack of engagement with men in child health and welfare more broadly (Haskett et al 1996).  The information that was available sometimes highlighted the tentative engagement by and with men and fathers. Understanding Serious Case Reviews and their impact – Biannual Analysis 2005-2007 Department for Children, Schools and Families – June 2009     509.6. Is there evidence of both compliance with expected practice and of good practice? There are several examples in the text of sections 3-7 which are highlighted as comments. Additionally, there are some further examples highlighted below: • The Police policies and procedures were followed in response to domestic abuse incidents. • The Domestic Abuse Partnership (DAP) and Public Protection Unit have a good internal working relationship and worked well with partner agencies. • J2R’s effective individual case management of their respective clients and perseverance helped support the parents to move from hectic and chaotic lifestyles and ambivalence, to change and want to reduce their dependency. • J2R were aware of vulnerability around the anniversary of Child Y’s death and proactively offered extra support. • Effective inter-agency communication and work between school and School Nurse at the point of initiating a CAF in June 2007.  • The meeting between Primary and Secondary Child Protection Co-ordinators prior to transfer in order to share background information, notably the CAF. • Social Workers visiting the family shortly after the death of Child Y in 2001 to offer support. • There is evidence to support that Adult V was asked the Routine Enquiry Questions by her Health Visitor and her responses were recorded appropriately.    51• An additional visit to Child T was completed by the Health Visitor for further assessment following the receipt by the Health Visitor of the DV report from the Police on 1.11.10. • The early referral to a consultant-led clinic for women misusing substances during pregnancy by midwifery. • The fast-tracking of children in the A&E unit who require plastic surgery.  • Both GPs recognising the risks of prescribing Pregabalin. 9.7. Is there evidence of effective multi-agency working together? Again there are several examples commented upon in the text of this report. Additionally: • The system of Police Form 125 and CATS being shared with Children’s Social Care Central Duty Team works well in general and did so in this case. • It was confirmed in the Learning Events that the system of Police Form 913 being screened by Domestic Violence Co-ordinators and then the links to the multi-agency FABDA meeting was effective in this case. • The multi-agency SUAT meetings are a good example of early intervention and the co-ordination of planning (see Key Practice Episode 1). • When Adult V was admitted to the antenatal ward the Midwife contacted the Hospital Social Worker to inform her of Adult V’s admission. • The pre-birth plan from the hospital was filed in the maternity records (6.5.10); and a copy of the plan was shared with the Community Midwives and Health Visitor and placed in the unborn Child T’s records.  • Hospital Social Worker was informed of the discharge of Adult V and Child T on 27.5.10 (in accordance with the pre-birth plan and the Paediatric alert).    529.8. Are there practices and procedures described in this report which reveal that there are Areas for Development and Learning Opportunities? i. In conducting the review of Adult W’s records, the author of the agency report covering GP services has become aware that there is an issue of significant over-prescription of addictive medication by the practice to Adult W. This extends back for at least one year prior to Child T’s death and therefore he received more potentially addictive, and other prescribed, medication than was intended. Poor prescription control practices in the surgery have been raised by the Agency Author.  This was raised and addressed by the agency report author.   ii. J2R did not establish links with the Health Visitor or the school in order to triangulate information or share assessments of the parents’ functioning. Conversely, the Health Visitor did not initiate any contact with J2R for similar purposes. Although the two J2R workers (managing each parent individually) did exchange information frequently, they might have attempted to manage both parents and their potential risks more collectively. Substance Misuse Service assessments must consider the individual in the context of them being a parent/carer for children. iii. Adult V received antenatal care from the Substance Misuse midwives and Obstetric medical staff, with the shared care arrangements managing the reduction of Methadone programme. The midwives relied upon self-reporting from Adult V (on substance use and the results of urine samples) rather than seeking  validating information from the GP and Substance Misuse Service before entering the information into recording systems. iv. Although Compass only saw Adult V on one occasion, they could and should have explored and recorded the risk assessment question on DV which was answered in the affirmative. Compass might also have checked whether Adult V required childcare support to obviate her failed appointment. Compass’ Safeguarding children and Safeguarding adults policies have both been reviewed and were distributed in July 2014.     53Compass single agency training has been delivered to staff around the new policies, and processes relating to safeguarding have also been reviewed with staff. This will include the expectation that Children’s Social Care will be contacted when it has been identified that a service user has children/is residing or has significant relationships with children under 18 years, to check the status of the child/service users/family. v. There were no clear national or HEYHT guidelines for substance misusing pregnant women in place in 2009. As a result, the package of midwifery care received by Adult V would appear to be basic with no identifiable enhanced midwifery care or effective enhanced communication with partner agencies. There was no documentation of an assessment of Adult V’s awareness/understanding of potential problems for her unborn baby in regard to her substance misuse. There was no record of any conversations regarding coping strategies in respect of caring for new born and other children whilst still using substances. There was no record of any discussion regarding the safe storage of medication to prevent accidental ingestion by any of the children in the household. The Serious Case Review has been informed that a new dedicated 15 hour per week Substance Misuse Midwife post became operational from 8.9.14. Additionally, a draft job description for a full-time post is under review and will be completed by 1.12.14. vi. There is no evidence of enquiry into domestic abuse within the Maternity records for Adult V. During 2009 to 2010, ‘routine enquiry’ on whether a woman was experiencing domestic abuse was a recommendation from the Department of Health, Responding to Domestic Abuse (2005) and the HEYHT Individualised Antenatal Care for Pregnant Women guideline (2008). The ‘routine enquiry’ did not occur in this case, and the authors are unable to ascertain why this was so. The HEYHT Children and Domestic Violence Guideline (2012) states that domestic violence data is to be collected by all midwives, health visitors and A&E staff.     54Routine enquiry is asked by all midwives and health visitors when they come into contact with a woman. Ideally this should be done antenatally and between 1-3 weeks postnatally. The practitioner must also ask routine enquiry (if deemed safe to do so) if he/she suspects or has evidence of domestic abuse. Yearly training on routine enquiry is now mandatory for all midwives. Compliance with recording routine enquiry is monitored via the supervisors of midwives spot check which is done on a monthly basis. The HEYHT key performance indicator (KPI) target is 80% for this being recorded, with exception reporting to NHS Hull Clinical Commissioning Group (CCG) if the compliance rate falls below 80%. Compliance from August 2013-August 2014 has been between 80-100% with the exception of 1 month (June 2013) at 70%. This has been investigated and no trends were identified. Subsequently, the following month audit showed 100%. The figures for routine enquiry are reported to the HEYHT Children’s Safeguarding Committee and the maternity managers on a monthly basis and also to the Hull Safeguarding Children Board Serious Case Review Sub-Committee. This process has implications for the Police. If a Health Visitor or Midwife is asking a victim “Who is responsible for assaulting you?” and possibly even the circumstances and mechanism of any injury, and then making a record of this conversation, the Police may need to seek access to such records and also take a statement from the Health professional.  As a result of this Serious Case Review the Police intend to inform all their staff of this process via the Force Intranet and through safeguarding training.  vii. In relation to the learning from key practice episode 8 (the Section 47 Enquiry in February 2011), Children’s Social Care has subsequently embarked on a ‘whole systems review’ of social work.  This review is known as ‘Reclaiming Frontline Practice’.  With effect from January 2014 the Central Duty Team is now known as the Access & Assessment Team.      55As part of the overall changes there has been a substantial increase in the number of social workers within ‘Access & Assessment’ together with a restructuring so that social workers work within small units (known as pods) led by a Consultant Social Worker.   Each pod is supported by a Pod Co-ordinator with responsibility for business support and administration.   One pod is responsible for the initial receipt of, and decision making about, all referrals, and this has introduced a high degree of consistency and monitoring of referrals when compared to previous arrangements.   viii. The principle of shared responsibility within each pod for a number of assessments is important for ensuring that ongoing assessments remain ‘live’ and that there is support for joint working to minimise the overload of any individual worker. In addition, assessment practice has been improved through the introduction of a Children’s Social Care single assessment, which replaces previous systems of initial and core assessments from January 2014 onwards. ix. At the time under review Health Visiting and School Nursing worked with paper-based records and they had no system for determining which children lived together within a family, especially if children had different surnames or had transferred from Health Visiting to the School Nursing service before the next child was born.  With the implementation of the electronic Health Care record (SystmOne) for School Nurse services in September 2012 there has been a considerable improvement in the recording of the groups and relationship of significant others within a child’s records. From February 2014 Health Visitors now use the same system and gain the same advantages.  x. Within the time period of this report universal core contacts could be delivered by Health Visitors, Community Staff Nurses and Nursery Nurse within the team. This practice was revisited in March 2012 following the Health Visitor Implementation Plan (2012) and was fully implemented by October 2012. Assessments at 6-8 weeks, 7-12 months and 2 years are now completed by the Named Health Visitor.     56In addition, children assessed as requiring a universal service provision are now routinely offered two appointments. If they fail to attend they are followed up by the Named Health Visitor.   xi. There is no record of an assessment of Adult V’s emotional wellbeing during the postnatal period. The current HEYHT Perinatal Mental Health Guideline (2012) now advises enquiry into maternal mental health at both antenatal and postnatal assessments. There is no HEYHT record of assessment of emotional attachment within the postnatal period as suggested in NICE Guidance for Routine Postnatal Care of Women and their Babies (2006), this area of practice was identified as collateral learning within a local Serious Case Review in 2013.  Midwives are to receive additional training regarding maternal mental health, within the “Caring for the Vulnerable Women” training and an explanation of the need to implement enquiry into maternal mental health: The programme includes • Honour-based Violence and Domestic Abuse (DAP) • The Emotional Impact of Pregnancy on the Vulnerable Woman  • Substance Misuse (ReNew) • Female Genital Mutilation (FGM) • Asylum Seekers. Refugees   Six sessions will be available through the Autumn of 2014. The recording of enquiry into maternal mental health will be audited in May 2015 when all midwives have received the above update and the Maternal Mental Health enquiry will have been embedded in practice.     57xii. Systems to enable earlier engagement by Children’s Centres with pregnant women from more vulnerable groups have also been established. During 2013 an information-sharing protocol was agreed between Hull City Council and the Hull and East Yorkshire Hospitals NHS Trust. The purpose was to facilitate liaison between the hospital and the Children Centres. The process is that, with written consent from women at the point of the booking of a pregnancy, information is shared with their local Children’s Centre at the 16th week of pregnancy, so that early contact can be made and additional support offered to potentially vulnerable women. However, this Review has also highlighted the need for more routine feedback to the multi-agency substance misuse meeting at the Women and Children’s Hospital as to whether individual women have engaged with their local Children’s Centre.  xiii. The issue of the dissemination of CATs records to Education and Children’s Social Care but not Health agencies was recognised at the Learning Event as a significant information-sharing and governance issue for wider discussion, including partner agencies and the Hull Safeguarding Children Board.  Two multi-agency meetings have been held with future meetings planned. Initial agreement has been reached that the Police will no longer share the CATS records and will use the 913 forms.  City Health Care Partnership will review the information received in the first instance via an audit which will be reported to the next meeting. Information governance leads will work together on an information-sharing protocol. Further meetings, convened by the Clinical Commissioning Group, will review sharing with other agencies including health organisations and education. xiv. On 18.8.14 a well-attended multi-agency meeting was held to begin to develop a Pre-birth Vulnerability Assessment Pathway. A draft pathway description and diagram have already been prepared for further consultation.    5810. AN OVERVIEW a. Serious Case Reviews should attempt to identify whether the tragedy could have been predicted or prevented. b. Sections 3 and 4 of this Report have analysed the family history and the key events up to 2009. Whilst there were some significant substance misuse-related and domestic abuse incidents, that period concluded with Child X being the subject of a CAF.  c. The scoped period from November 2009 is characterised by multi-agency working antenatally and postnatally (Child T), three further reports of domestic abuse and one Section 47 enquiry; together with ongoing substance misuse services to both parents. d. It is now clear from information revealed during this Serious Case Review that Adult W was in fact living at the family home consistently over the last 18 months of Child T’s life; but he chose to identify another address for official purposes. However, there is no evidence that the earlier dishonesty of Adult V saying that the relationship with Adult W was over and then him remaining a constant feature in her life, or her reluctance to engage with agencies, had any direct or major adverse effect on the children. e. The last involvement of Children’s Social Care/Police/Domestic Abuse Partnership/FABDA was in July 2011, i.e. 18 months before Child T’s tragic death. For the remaining services involved with the family during that 18-month period (Nursery Nurse, GP, two J2R workers) no concerns about Child T in his own right, nor about the parents’ care or handling of Child T ever emerged. Indeed there are reports of good interaction between Adult V and Child T; and this reinforces the Judge’s comments quoted at Section 1.1.  Additionally, there were no significant concerns from the school in relation to Child X.  f. Adult W was reported to be “hands on” with all three children.  The home environment and the parents themselves appeared more settled.     59Indeed, the 18-month period prior to Child T’s tragic death was the most stable period in the parents’ adult lives. Therefore the J2R workers’ decision that there were no safeguarding issues to justify a referral (see para. 7.21) was a reasonable and defensible one. g. Based on the levels of need and risk identified in the Child Health Promotion Programme (2008) and later the Healthy Child Programme (2010), Child T was always assessed as needing health visiting services at the Universal level, i.e. the core programme. This was an appropriate assessment in the circumstances. h. Despite the long history of mis-use of controlled substances, a history of low level dealing, and other risk factors such as domestic abuse and other health complications, up to Child T’s death there is no evidence that the children were ever subjected to significant harm by the parental substance misuse. i. Whilst this Serious Case Review has identified some learning, the conclusion is that the fatal incident could not have been predicted and therefore could not have been prevented.    60 11. FINDINGS FOR THE HULL SAFEGUARDING CHILDREN BOARD 11.1. The assessment and management of substance use in pregnancy The current guidelines under the auspices of Hull & East Yorkshire Hospitals NHS Trust, Hull City Council Social Services Department, and Hull & East Riding Community Health are dated April 2000.  However, in addition, there is detailed guidance issued by the Hull Safeguarding Children Board  entitled “Substance Misuse in Pregnancy” (Section 7.13). This includes communication and confidentiality, SUAT meetings, record keeping, etc. At Key Practice Episode 1 and at 9.8(xiv) of this report reference is made to work that the Hull Safeguarding Children Board is currently undertaking on Pre-birth Vulnerability Assessment Pathway. In the light of the findings of this Serious Case Review, the Hull Safeguarding Children Board will want to be reassured that this stream of work is robust. In particular reassurance will be needed that the ownership and effectiveness of Multi-agency Vulnerability Meetings (previously SUAT Meetings) is established. The HSCB accepts this finding and is leading on work to develop a comprehensive pre-birth vulnerability pathway. This work will be concluded by 31st March 2015.  11.2. Overlooking the role of fathers/men/significant others “If professionals do not enquire about or assess the role of fathers, possible risk factors and possible protective factors could be missed.”10                                                              10 Hull Safeguarding Children Board Serious Case Review Child F 2011     61The Hull Safeguarding Children Board will want to assure itself that assessments, ongoing work, and professional curiosity with children and families maintains an appropriate focus on and engagement with fathers/men/significant others (e.g. grandparents) both in relation to the risk they may pose and/or in relation to the information they may hold. The HSCB accepts this finding and recognises that a lack of focus on the role of fathers/men/significant others has been a feature of other local and national serious case reviews and local learning from practice. The HSCB will lead on a focused piece of work with partners to understand the issue and identify the most effective means of improving local practice. This work will be concluded by 31st March 2015.  11.3. Information-sharing relating to domestic abuse and child concern The current guidance issued by the Hull Safeguarding Children Board is entitled “Considerations when contacting another agency/service” (Section 8.1). In the light of this Serious Case Review the Hull Safeguarding Children Board needs to oversee, scrutinise and challenge how information is effectively shared: i. the dissemination of CATS records to Education and Children’s Social Care but not Health and the governance and duty of care implications that lie behind this decision (although this is currently being discussed see 9.8 [xiv]) ii. the current guidance does not constitute a multi-agency information-sharing protocol. This has been recognised locally and work is underway to develop a specific protocol for sharing domestic abuse notifications. The HSCB accepts this finding and is leading on work to develop an information sharing protocol in relation to domestic abuse. This work will be finalised by 31st January 2015.     6211.4. The Lead Reviewer is satisfied that single agency recommendations and action plans, which agency authors identified, are accurate and reflect the internal findings and learning. The Hull Safeguarding Children Board  will monitor the implementation and impact of these single agency recommendations.    63 12. RECOMMENDATIONS  There are four specific recommendations which have emerged from the work of this SCR:  i. That the Independent Chair of HSCB should write to all local Head Teachers informing them of the learning from this and other reviews about the need for accurate recording in relation to safeguarding issues - by 15th November 2014  ii. That a forum is established by the Strategic Substance Misuse Manager to enable General Practitioners involved in delivery of shared care arrangements to come together and identify areas of concern or barriers to effective joint working and also to share current best practice - by 31st January 2015  iii. That the local Public Health Service should undertake a targeted public awareness raising campaign highlighting the risks associated with consuming a mixture of substances - by 31st March 2015  iv. That the Strategic Substance Misuse Manager should write to  pharmacies and substance misuse service providers reminding them of the need for clear communication about repeated failure to collect prescriptions – by 31st December 2014    Appendix (i)                                                                        Terms of Reference and Project Plan   HULL SAFEGUARDING CHILDREN BOARD   TERMS OF REFERENCE & PROJECT PLAN SUBJECT :  Child T D.O.B.  20.05.2010 D.O.D.  05.01.2013    64 Appendix (i)                                                                        Terms of Reference and Project Plan   651. Introduction The 2½ year old male child was pronounced dead shortly after he arrived at hospital on 5.1.13. An ambulance had been called by the child’s father when the child had been found floating face down in a bath of very hot water. There  has  been  a  delay  in  making  a  decision  regarding  a  Serious  Case Review  (and  the  methodology  to  be  used)  due  to  awaiting  toxicology reports on both of his parents (in relation to drugs) and on the outcome of further tests and enquiries in the police investigation. The Chair of the Hull Safeguarding Children Board, in consultation with members of the Serious Case Sub‐Committee, has decided to invoke a Serious Case Review and to use SILP methodology; and the Department of Education and Ofsted have been advised accordingly. 2. Purpose The  purpose  of  a  SILP  remains  the  same  as  that  for  a  Serious  Case Review, namely: • To establish what lessons are to be learned from the case about the  way  in  which  local  professionals  and  organisations  work individually and together to safeguard and promote the welfare of children • To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • Improve intra‐ and inter‐agency working and better safeguard and promote the welfare of children. (Working Together to Safeguard Children, March 2010)  Appendix (i)                                                                        Terms of Reference and Project Plan   663. Framework Serious Case Reviews and other case reviews should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks  to  understand  precisely  who  did  what  and  the  underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings (Working Together, para. 10, March 2013) 4. Specific Scope The subjects: • the deceased child     ‐ Child T • both parents     ‐ Adult V (mother)         ‐ Adult W (father) • the younger sibling     ‐ Child X (collectively as Family U) The time period – from 4th November 2009 (antenatal dating scan) up to 4th  January  2013  23:00pm  (date  and  approx.  time  emergency  services were called to the family home).  Appendix (i)                                                                        Terms of Reference and Project Plan   675. In addition Agencies  are  asked  to  review  and  report  on  significant  events  and safeguarding  issues  on  both  parents  and  children  prior  to  November 2009, eg. domestic violence episodes, substance misuse and treatment, referrals to Children’s Social Care, the use of CAF, etc. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points. 6. Agency Reports Agency reports will be commissioned from: • City Healthcare Partnership CIC for Health Visiting and School Nursing • Hull  &  East  Riding  Hospitals  NHS  Trust  for  Midwifery  and  Acute services  • North Yorkshire & Humber Area Team, NHS England for GP services • Journey to Recovery and Compass for substance misuse services • Humberside Police • Adults, Children and Family Services: o Children’s Social Care (to include an overview of involvement with CAF, FABDA and the Children’s Centre) o Learning & Skills (Primary school involvement with sibling) • Domestic Abuse Project  7. Generic Analysis 7.1. Critically  analyse  and  evaluate  the  events  that  occurred,  the decisions made and the actions taken or not. Were there missed opportunities or episodes when there  was sufficient  information to  have  taken  a  different  course?  Were  assessments  conducted effectively and appropriate conclusions drawn?  Appendix (i)                                                                        Terms of Reference and Project Plan   687.2. Where  judgements  were  made  or  actions  taken  which  indicate that  practice  or  management  could  be  improved,  try  to  get  an understanding not only of what happened, but why. 7.3. Demonstrate  whether  your  agency/service  heard  and  responded to the child’s voice. 7.4. Identify  and  explain  if  your  agency/service  believes  that  other agencies/services should have been sought and/or provided. 7.5. Identify good practice. 7.6. Were professionals proactive in escalating concerns and effecting challenge where appropriate? 7.7. From an inter‐agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other?  7.8. Did  your  agency  identify  any  issues  of  ethnicity,  diversity, language,  culture  (e.g.  poverty)?  If  so,  how  did  your  agency address these issues?  8. Particular Areas For Consideration 8.1. Was there evidence of disguised compliance on the part of parents in their dealings with agencies and services? 8.2. Is there evidence of “Think Family/Think Child” in the way adult‐focused agencies and services conducted their management of the case? 8.3. Is  there  evidence  of  “an  accommodation  syndrome”,  i.e.  an acceptance  of  normality  and  high  thresholds  in  responding  to substance‐misusing parents?    Appendix (i)                                                                        Terms of Reference and Project Plan   699. Engagement with the family A letter will be sent from the Chair of the Board informing parents of this Review and its purpose. A little while later Paul Tudor will write to them again as a follow‐up and invite them to participate in the form of a home visit/interview/correspondence/telephone conversation. Their contribution will be woven into the text of the Overview Report; and they will be given feedback at the end of the process. We will keep an open mind regarding siblings and significant others. Hopefully any interviews will take place prior to the Learning Event so that their voice will be heard at the Learning Event. 10. Documentation The “bundle” for the Learning Event will comprise: • Integrated  Chronology  (prepared  from  CDOP  information  and updated with SCR agency report information) • Agency reports • Any minutes of meetings (FABDA, CWAN, etc.) 11. Timetable w/c 18 November 2013  Commissioning  letters  to  agencies  for Authors 22 November 2013 11am‐12pm Brunswick House (HQ‐Adults, Children & Family Services) Briefing for Agency Authors by Paul Tudor By 10 January 2014 Deadline for Agency Reports  13/14 January 2014 Quality  assurance  of  Agency  Reports  by Paul Tudor/Neil Colthup   Appendix (i)                                                                        Terms of Reference and Project Plan 16 January 2014  Distribution  of  Agency  Reports  and integrated chronology for Learning Event 24 January 2014 9am – 3:30pm Brunswick House Learning Event   12 February 2014 10am – 12pm Brunswick House  Reference Group/SCR Sub‐Committee 28 February 2014 9am – 3:30pm Brunswick House Recall Day   19 March 2014 Presentation  of  report/sign  off  at  HSCB meeting 8 April 2014 Deadline  for  completion  of  Overview Report/submission  to  Department  for Education  (subject  to  conclusion  of  any criminal proceedings)     70  Appendix (ii)                                                                                    Agency Author Report Template   HULL SAFEGUARDING CHILDREN BOARD  AGENCY REPORT (*Name of the agency*)  SIGNIFICANT INCIDENT LEARNING PROCESS SUBJECT : Child T      71  Appendix (ii)                                                                                    Agency Author Report Template 1. Please see Terms of Reference and Project Plan document for: • Introduction • Purpose • Framework 2. Specific Scope The subjects: • the deceased child     ‐ Child T • both parents     ‐ Adult V (mother)         ‐ Adult W (father) • sibling       ‐ Child X (collectively as Family U) The time period – from 4th November 2009 (antenatal dating scan) up to 4th January 2013 23:00pm (date and approx. time emergency services were called to the family home).  3. In addition Agencies  are  asked  to  review  and  report  on  significant  events  and safeguarding  issues  on  both  parents  and  children  prior  to  November 2009, eg. domestic violence episodes, substance misuse and treatment, referrals to Children’s Social Care, the use of CAF, etc. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points.      72  Appendix (ii)                                                                                    Agency Author Report Template 4. Within the Scoping period (4.11.09 – 4.1.13 11pm) a. Summarise in narrative form the key information on the child and parents from your agency/service. b. Summarise the services offered and/or provided to the child and parents; and the decisions reached. 5. Generic Analysis 5.1. Critically  analyse  and  evaluate  the  events  that  occurred,  the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to  have  taken  a  different  course?  Were  assessments  conducted effectively and appropriate conclusions drawn? 5.2. Where  judgements  were  made  or  actions  taken  which  indicate that  practice  or  management  could  be  improved,  try  to  get  an understanding not only of what happened, but why. 5.3. Demonstrate whether your agency/service heard and responded to the child’s voice. 5.4. Identify  and  explain  if  your  agency/service  believes  that  other agencies/services should have been sought and/or provided. 5.5. Identify good practice. 5.6. Were professionals proactive in escalating concerns and effecting challenge where appropriate? 5.7. From an inter‐agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? 5.8. Did  your  agency  identify  any  issues  of  ethnicity,  diversity, language,  culture  (e.g.  poverty)?  If  so,  how  did  your  agency address these issues?    73  Appendix (ii)                                                                                    Agency Author Report Template 6. Particular Areas For Consideration 6.1. Was  there  evidence  of  disguised  compliance  on  the  part  of parents in their dealings with agencies and services? 6.2. Is there evidence of “Think Family/Think Child” in the way adult‐focused  agencies  and  services  conducted  their  management  of the case? 6.3. Is  there  evidence  of  “an  accommodation  syndrome”,  i.e.  an acceptance  of  normality  and  high  thresholds  in  responding  to substance‐misusing parents? 7. Key Learning Points 7.1. What did we do well which we need to keep doing? 7.2. What didn’t we do so well that needs to stop? 7.3. What things need to be done differently to lead to improvements and how should this be done? 7.4. What is to be learnt about improving multi‐agency working? 8. Recommendations You  may  make  in‐house/single  agency  recommendations  (but  are  not obliged to do so). If you are making recommendations please make them SMART, i.e.  Specific Measurable Achievable Realistic Timely     74  Appendix (ii)                                                                                    Agency Author Report Template 9. Sign‐Off (Neither  the  reviewer  nor  senior  sign‐off  person  has  had  any  direct involvement with this case prior to the death of the child.) Agency Reviewer: Date:  The reports of all reviews must be signed by the relevant senior officer, indicating that the review has been: • carried out to the required standard and • the learning points are accepted by the organisation • the recommendations/action plan will be implemented  The Senior Officer accepts that: • The review has been carried out to the required standard. • The learning points reached in the review are accurate. • The recommendations/action plan will be implemented.   Senior Officer:  Job Title:  Date:  On  completion,  please  send  or  deliver  the  completed  report  by  10th  January 2014 at the latest to: Cathy Eccersley Hull Safeguarding Children Board Midmere Centre Dorchester Road Hull  HU7 6BD or cathy.eccersley@hullcc.gcsx.gov.uk  75  Appendix (iii)  Glossary of Terminology CAF Co-ordinator With the introduction of the Common Assessment Framework (CAF) in Hull in 2006, a number of CAF Co-ordinator posts were established by the Children and Young People’s Strategic Partnership to work in local areas in the City. Their role was to work alongside and support agencies to develop the use of the CAF, to support decision-making and to provide training across the partnership. CAF Co-ordinators also acted as Chair for more complex Child With Additional Needs Meetings as part of the CAF arrangements. The role of CAF Co-ordinator was deleted in 2011. Case Administration and Tracking System (CATS)  Humberside Police use a system called CATS for the recording of all information sharing; F125s, Section 17 and Section 47 referrals. Not all F913s are recorded on CATS, i.e. as some parties involved in domestic incidents may not have children. The CATS system can create a computer generated form from information contained within a CATS record. Humberside Police have used CATS since 2008. City Health Care Partnership Community Interest Company (CHCP)  City Health Care Partnership CIC (CHCP) provides community health services to the City of Kingston upon Hull and surrounding areas. City Health Care Partnership CIC (CHCP), previously NHS Hull provider services, officially formed on 1st June 2010 as an independent health services provider separate to the commissioning organisation, NHS Hull.  Amongst other services, CHCP provides community paediatric nursing, health visitors, school nurses, dentistry, public health and GP practices in a community setting. Compass (Compass Open Access and Harm Reduction Service) A service which will take referrals from professionals and also self-referrals.  CWAMN  Child With Additional Needs Meeting (CWANM). As part of the implementation of the CAF framework in Hull, the title given to a multi-agency meeting to discuss the co-ordination of support to a child and family following a CAF assessment. National guidance referred to such meetings as Team Around the Child (TAC) meetings, and with the development of whole family approaches Team Around the Family (TAF) is now the commonly used terminology.   76  Appendix (iii)  Glossary of Terminology  Domestic Abuse Partnership (DAP) This is a multi-agency partnership which is co-located in a Police Station. Staff are seconded from Police (Domestic Violence Co-ordinators and MARAC Administrator), Children and Young People Services (social workers), Women’s Aid (DAP Manager), Housing (Housing Officer), CHCP (Health Practitioner and administrator), J2R (Addictions Workers and Citysafe), 7 Domestic Violence Support Workers and Men’s Worker. The Domestic Abuse Partnership sits in the same office as the Police Public Protection Unit and those cases screened as high risk will automatically be passed to DAP for a secondary risk assessment and consideration of a MARAC. Any consideration of victim consent will be overridden in these cases. Drug Intervention Programme (DIP)  From 2006 Compass was responsible for most of the programme. This comprises key elements such as resettlement, Housing support, Clinic, needle exchange, Choices, Outreach. In 2008 another service became involved in parts of the programme, i.e. City Health Care Partnership. Prior to July 2011 Substance Misuse Services were provided by two providers, Humber Foundation Trust and CHCP CIC. The services provided by CHCP CIC used a tiered approach to provision from complex to less complex patients/presentations. The services provided a mixture of substitute prescribing options alongside psychological interventions. Families Affected By Domestic Abuse (FABDA)  A multi-agency forum for case discussion in relation to children and families affected by low level domestic abuse. The purpose of the meeting was to co-ordinate an early response in those cases which did not meet the threshold for a response by Children’s Social Care or MARAC. During 2014 the FABDA panel was discontinued and low level domestic abuse contacts are now discussed at multi-agency Early Help Action Meetings which take place in each locality of the city. Form 125 Juvenile Report  For Police Officers to complete where any contact with a child under 18 raises concerns of a safeguarding nature; in circumstances of being a victim, a witness, an offender or “of interest or concern”. The form is to be submitted to the Public Protection Unit.  The Officer submitting the form is required to complete a risk assessment grading and selecting the relevant category Standard/Medium/High.     77  Appendix (iii)  Glossary of Terminology Form 913  For Humberside Police the definition of domestic abuse is: “Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological, physical, sexual, financial and emotional.” It is Force policy that when Police Officers or staff attend a domestic abuse incident where one or both of the parties are 16 years or older a F913 form submission is required. The form includes a risk assessment for the Police Officers to complete. The form is sent through to a Domestic Violence Co-ordinator located within the Public Protection Unit where a secondary risk assessment takes place. For the Police, Form 913 is the recording tool for all officers to submit a record of incidents of suspected or actual domestic abuse. For Hull alone, Humberside Police attend approximately 500 per month. These are initially screened using a national risk assessment code. The Form 913 is sent through to a Domestic Abuse Co-ordinator within the Public Protection Unit for a secondary risk assessment.  Journey to Recovery (J2R) A non-criminal justice service to assess and assist individuals for both prescribing and structured interventions to support and enhance individuals with substance related problems becoming free of illicit substances and maintaining recovery. J2R took over from CHCP in July 2011. School Action  School Action of the Special Educational Needs Code of Practice (2001) is provided when a child has been identified as making little or no progress despite a differentiated curriculum. Children are given extra support using internal resources, and progress is monitored via an Individual Education Plan.   78  Appendix (iii)  Glossary of Terminology  School Health Plus  The universal school health service delivers the service required by the Government following the Healthy Child Programme. School Health Plus is an enhanced service provided by three City Health Care Partnership (CHCP) School Health Teams which can be procured by individual schools, bespoke to their needs or by a cluster group of schools collaboratively. Enhanced support packages include: attendance booster; emotional health support package; sex and relationships education programme; personal health and social education support and individually tailored programmes to a child or family’s needs. In this case the School Nurse undertook home visits to encourage parents to improve their child’s attendance. SUAT Meetings  Hospital Social Workers employed by Children’s Social Care have been located within the Hull Women and Children’s Hospital for the last 13 years; and they have co-ordinated, chaired and recorded monthly substance misuse multi-agency meetings, which are held in the hospital. They are known as SUAT meetings as they use a Substance User Assessment Tool. Attendance at the SUAT meeting can include Compass, DIP, SCBU, two Safeguarding practitioners (representing Health Visiting and Hospital Trust respectively), Substance Misuse Midwives (when in post), Postnatal Ward Midwifery Sister; and more recently J2R.The purpose is to share information on pregnant substance misusing women and to ensure that support and intervention in individual cases is appropriate to the needs of the unborn child.           79  Appendix (iv)  Drug Treatment System Referral Guidance   80  Appendix (v)  HSC letter to all GPs regarding Pregabalin   81  Appendix (v)  HSC letter to all GPs regarding Pregabalin     82 