Death of a 9-week-old girl in January 2018. Following the conclusion of the inquest it was confirmed that Child A died from unknown causes following unsafe sleeping environments at her home. Learning includes: children's social care assessments should ensure historical concerns including home conditions and suitable sleeping arrangements for children are explored during re-assessment; risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services as this may indicate an ongoing, abusive relationship; retractions of statements regarding domestic abuse may be indicative of ongoing contact between the victim, the perpetrator and their children; social workers should speak directly to children being 'programmed' by their parents, without the presence of their parents, to explore their wishes and feelings; perpetrators of domestic abuse should be directly spoken to about the impact of their abusive behaviour on children and included in the assessment process or safety plan for children; consideration should be given to de-escalating to a team around the family plan if low level concerns still need to be addressed when child in need plan is closed; written agreements are not effective tools for managing risk and their use should be avoided; managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information. Recommendations are embedded in the learning. Please note that this report was written in October 2020 but was published in 2022.
      
 Title:  Safeguarding practice review: Child A: version 5 October 2020. LSCB: Kirklees Safeguarding Children Partnership Author: Kirklees Safeguarding Children Partnership Date of publication: 2022  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.                                                               SAFEGUARDING PRACTICE REVIEW CHILD A Version 5 October 2020  Independent Person from KSCP Partnership Review Author  i Table of Contents GLOSSARY  ___________________________________________________________________ 1 1. INTRODUCTION ___________________________________________________ 3 2. REVIEW PROCESS _________________________________________________ 4 TIMESCALE FOR THE REVIEW _____________________________________________________________ 4 3. OVERVIEW OF AGENCY INVOLVEMENT WITH THE FAMILY _________ 5 FAMILY COMPOSITION __________________________________________________________________ 5 SYNOPSIS OF AGENCY INVOLVEMENT _____________________________________________________ 5 4. KEY PRACTICE EPISODES _________________________________________ 10 KPE 1:  CLOSURE OF CHILD IN NEED PLAN – JANUARY 2016 ________________________________ 10 KPE 2:  SUPPORT FOR SIBLING 2 _______________________________________________________ 12 KPE 3:  MULTI-AGENCY RESPONSE TO HIGH RISK DOMESTIC INCIDENT ________________________ 16 KPE 4:  HOME CONDITIONS ____________________________________________________________ 24 KPE 5:  PREGNANCY WITH CHILD A – MAR 2017 TO NOV 2017 _____________________________ 26 KPE 6:  POLICE CALLOUT 01:00 ON 01/01/18 ___________________________________________ 29 5. CONTRIBUTION OF FAMILY _______________________________________ 30 CONTRIBUTION OF SIBLINGS ___________________________________________________________ 30 6. ANALYSIS ________________________________________________________ 30 IMPACT OF DOMESTIC ABUSE ON CHILDREN _______________________________________________ 31 SUFFICIENT FOCUS ON FATHER __________________________________________________________ 33 TO WHAT EXTENT WERE AGENCIES AWARE OF THE HISTORY OF NEGLECT OF THE CHILDREN AND DOMESTIC ABUSE WITHIN THIS FAMILY? __________________________________________________ 34 EVIDENCE OF ONGOING NEGLECT OR DOMESTIC ABUSE WITHIN THE FAMILY ____________________ 35 WAS FAMILY HISTORY GIVEN APPROPRIATE CONSIDERATION DURING DECISION-MAKING? _______ 38 QUALITY OF ASSESSMENTS AND DECISION-MAKING DURING THE SPECIFIED PERIOD – SPECIFICALLY RELATING TO FAMILY ENGAGEMENT? _____________________________________________________ 39 WAS CONSIDERATION GIVEN TO WHETHER OR NOT A PRE-BIRTH ASSESSMENT WAS INDICATED PRIOR TO CHILD AS BIRTH? __________________________________________________________________ 44 7. CONCLUDING REMARKS __________________________________________ 44 8. REFERENCES _____________________________________________________ 45 9. BIBLIOGRAPHY __________________________________________________ 46 APPENDIX ONE:  FULL TERMS OF REFERENCE ________________________________________ 2  ii APPENDIX THREE:  LIST OF LEARNING POINTS ______________________________________ 6     1 Glossary Common Assessment Framework The Common Assessment Framework (CAF) was the standardised approach to conducting assessments of children’s' additional needs and deciding how they should be met.  It has been replaced in Kirklees by the Single Assessment framework. Child in Need (CiN) Defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Contact Agreement Written agreement signed with parents to clarify expectations by social care for child contact.  It is not legally binding. Contract of Expectations Written agreement signed with parents to clarify expectations by social care.  It is not legally binding. Domestic abuse Home Office definition: 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 or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological; physical; sexual; financial; emotional  Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.  Coercive behaviour is a continuing act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. Multi Agency Risk Assessment Conference (MARAC) A meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the area and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality Neglect Defined in Working Together as “The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:  • provide adequate food, clothing and shelter (including exclusion from home or abandonment).  • protect a child from physical and emotional harm or danger. • ensure adequate supervision (including the use of inadequate caregivers); or  2 • ensure access to appropriate medical care or treatment.  It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs”.  Residence Order Replaced by ‘Child Arrangement Orders’ in 2014.  Stipulations where children are to reside and in whose care. Section 47 Children Act enquiry Children’s Social Care must carry out an investigation when they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer significant harm”. The enquiry will involve an assessment of a child’s needs and those caring for the child to meet them. CAMHS Child and Adolescent Mental Health Services ADHD Attention deficit hyperactivity disorder Single Assessment The Single Assessment replaces the EHA (Early Help Assessment), the Initial Assessment and the Core Assessment.  It is intended to assess a child who appears to have additional needs and/or require extra help to support them in the following areas: • The child's developmental needs. • The parents' or caregivers' capacity to respond appropriately to those needs; and • The wider family and environmental factors Victim Personal Statement The Victim Personal Statement (VPS) gives victims a voice in the criminal justice process by helping others to understand how a crime has affected the victim. Multi-Agency Safeguarding Hub Is now referred to as the Duty and advice Team.  The ‘front door’ to children’s services in Kirklees Council. Strategy Discussion A Strategy Discussion (sometimes referred to as a Strategy Meeting) is normally held following an Assessment which indicates that a child has suffered or is likely to suffer Significant Harm.  The purpose of a Strategy Meeting is to determine whether there are grounds for a Section 47 Enquiry.  Non-molestation Order A non-molestation order is, in English law, a type of injunction that may be sought by a victim of domestic abuse against their abuser. PDVG Pennine Domestic Violence Group KNH Kirklees Neighbourhood Housing    3 1. Introduction 1.1. Local Child Safeguarding Practice Reviews are commissioned by Kirklees Safeguarding Children Partnership (KSCP) when partner agencies identify cases that raise issues of importance for safeguarding children in the area. 1.2. This Review was triggered by the death of Child A, who was nearly nine weeks old when she was found lifeless in her parent’s bed.  Following the conclusion of the inquest it was confirmed that Child A died from unknown causes following unsafe sleeping environments at her home.  Following the post-mortem, mother was convicted of four offences of cruelty to person under 16 years and sentenced to a Community Order. 1.3. Child A’s family were previously known to local statutory agencies for incidents of domestic abuse between parents and neglect of older siblings.  As a result, the KSCP took the decision to conduct a Local Child Safeguarding Practice Review to identify learning for local agencies.   1.4. This Child Safeguarding Practice Review has not identified any actions that may have been taken by professionals to prevent Child A’s death.  It is therefore not intended to hold individuals to account for their practice, as there are other processes that may be used for that purpose if required (such as disciplinary procedures, professional regulation, and in exceptional cases, criminal proceedings).  Rather, this review provides an opportunity to reflect on professional practice to gain an understanding of what happened and why, and identify lessons that can improve the response to children and families in Kirklees.   1.5. This report provides: • An overview of the process for conducting the review. • A brief synopsis of local agency records on the family from 2012 onwards.  This includes information recorded about Mother and Father’s own childhoods. • An overview of agency involvement with the family during the review period. • A detailed analysis of six Key Practice Episodes, identified by the independent reviewer as those incidents and/or recurring issues that had a significant bearing on how the case developed and was handled by local agencies. • An analysis of key issues identified by the KSCP in the terms of reference; and • A summary of lessons learned during the review process, to enable the KSCP to work with local partners to improve local safeguarding practice.  1.6. This report has been prepared by an independent member of staff from a KSCP partner agency, with support from staff within the KSCP.  The KSCP consider this person to be sufficiently independent of this case and the agencies that were directly involved in supporting the family.        4 2. Review Process 2.1. In light of changes to the statutory guidance that sets out the rules for conducting Child Safeguarding Practice Reviews (formerly referred to as Serious Case Reviews)1, the KSCP developed a new approach to streamline the process for conducting reviews and maximise opportunities for learning lessons in a timely way. 2.2. This approach includes: • Asking partner agencies to complete an initial information gathering tool to enable the KSCP to make an informed decision about whether to conduct a review, and to establish clear terms of reference for the conduct of the review.   • Asking those agencies that had a significant involvement with the family during the review period to compile their records into a comprehensive chronology.  • Seeking an independent reviewer from within existing partner agency staff that is sufficiently independent of the case and the agencies that were directly involved in supporting the family. • Conducting a practice learning event with professionals that worked directly with the family to provide an opportunity for the reviewer to clarify any inaccuracies or inconsistencies in agency records and understand the context of decision-making during the review period. • Meeting with managers of involved agencies to discuss learning that emerged from the practice learning event and identify early opportunities to implement improvements. • Drafting a review report that considers professional practice in this case; highlights relevant research and best practice; and identifies learning points for the KSCP, and its partner agencies, to determine how best to translate this learning into tangible improvements in safeguarding practice; and • Presenting the review report to the Serious Case Review Workstream for external challenge and scrutiny. 2.3. The review author identified some learning for the KSCP in using this approach for conducting CPSRs and for individual agencies about improving the quality of their contribution to the review process.  This has been provided in a separate report to the Board.   Timescale for the review 2.4. The review considers agencies’ involvement with this family from 01/01/2016 until the death of Child A on 01/01/2018.  Agencies were asked to provide a chronology and analysis of significant events between these dates, and a summary of significant interventions prior to 01/01/2016.   1Working Together to Safeguard Children is the statutory guidance, it was open for consultation during the period when this review was conducted and published on 5 July 2018  5 3. Overview of agency involvement with the family Family composition              Synopsis of Agency Involvement  Prior to the Review Period (before 01/01/2016) 3.1. Father does not appear to have significant contact with statutory agencies as a child/young person.  Records indicate that he was exposed to parental domestic abuse and parental substance misuse as a child.   3.2. Mother similarly does not appear to have significant contact with statutory agencies as a child/young person.  Records indicate that she was subject to a custody battle between her parents, and she reported to agencies that she was asked to leave her mother’s address when she was about 13 years old.  When she became pregnant with her first child at 15, she reported that Maternal Grandfather asked her to leave the property as he did not approve of the pregnancy and the house was already overcrowded. 3.3. It is not clear from the records when Father’s relationship with Mother began, but we do know that he was 19, and she was 16, when their first child was born.   3.4. Local agencies recognised indicators of low-level neglect from when the eldest child, referred to in this report as Sibling 1, was three months old.  Low level domestic incidents were also reported to police in the first year of Sibling 1’s life.  Mother and Father had another baby, Sibling 2, when Sibling 1 was 10 months old.   3.5. The family were referred to Children’s Social Care when Sibling 2 was around six months old.  There were concerns about leaving children unattended and poor home conditions.  The case was assessed as reaching the threshold for Child in Need and professionals noted significant improvements under the Child in Need plan.  The case was then de-escalated to a Common Assessment Framework (CAF) and managed by a Multi-Agency Support Team (MAST).   3.6. In the first six months of 2012 there were four low-medium level domestic incidents.  Father was noted to be under the influence of alcohol and/or other drugs in two of these incidents.   3.7. In August 2012, Father assaulted Mother causing visible injury.  The assault included being thrown across the room, being grabbed around the throat and being hit across the head with an object.  The MAST also raised concerns with social care about neglect of the children.  As a result, social care undertook an assessment which noted poor home conditions including the state of the children’s bedroom.  The children were placed under a Child Protection Plan under the category of neglect.  Father signed a contact agreement, which stipulated that contact with the children must be supervised by his grandmother. Mother DOB 1993Sibling 1DOB 2010Sibling 2DOB 2011Sibling 3DOB 2014Child ADOB 2017Father DOB 1991 6 3.8. Following six months on the CP plan, the case was de-escalated to Child in Need as the risk was considered to have been reduced and the family were working with professionals.  Mother reported that she wanted to resume the relationship and let Father have more contact with the children.  Work was done with Mother to highlight the impact of domestic abuse on children and the case was subsequently closed to social care. 3.9. In August 2013, Mother was charged with an assault on Sibling 1, who was three years old, after she lowered the child out of an upstairs window onto a flat roof.  The children were subsequently placed with maternal great grandparents.  Following a positive risk assessment undertaken by social care, Mother was granted unsupervised contact with the children.  Mother signed a Contract of Expectations to confirm that Father was not allowed to be at the home address.   3.10. Mother was pregnant with twins at this time, and, given the recent concerns identified by professionals, a pre-birth assessment was completed by social care.  Sadly, Mother was advised that one of the twins had died and Sibling 3 was born following an emergency caesarean section in February 2014.  Sibling 3 was discharged to the home address in his mother’s care. 3.11. Due to ongoing concerns that Mother was still in a relationship with Father, an Interim Supervision Order was imposed in June 2014.  A non-molestation order was also granted during this period.  The Supervision Order was de-escalated to a Child in Need in June 2015.  In November 2015, professionals noted that Mother was living independently (she had been living with Maternal Great Grandmother) and although engagement with professionals had been intermittent, significant improvements had been made and Mother appeared to have addressed concerns around behaviour management and routines.   7 Key Incidents/Interventions (April 2010 – December 2015) Year/ period Child Born Notification to CSC/ request for advice Referral to CSC Early Help Child in Need Plan Child Protection Plan Interim Supervision Order Orders 2 0 1 0 Apr-Jun  Sibling 1        Jul-Sep   HV request for advice       Oct-Dec   DV incident       2 0 1 1 Jan-Mar          Apr-Jun  Sibling 2        Jul-Sep          Oct-Dec    Poor home conditions      2 0 1 2 Jan-Mar   DV incident       Apr-Jun   DV incident Escalated by MAST      Jul-Sep   DV incident, significant assault      Father - supervised contact order Oct-Dec          2 0 1 3 Jan-Mar          Apr-Jun          Jul-Sep    Assault on child     Mother – contract of expectations Oct-Dec   Pregnancy/ pre-birth assessment       2 0 1 4 Jan-Mar  Sibling 3       PLO letter issued Apr-Jun   3 x DV incidents      Non-molestation order issued Jul-Sep          Oct-Dec          2 0 1 5 Jan-Mar          Apr-Jun          Jul-Sep          Oct-Dec           Agency involvement during review period (Jan 2016- Jan 2018) 3.12. At a Child in Need meeting in January 2016, there was a unanimous decision to close the Child in Need plan that had been in place since June 2015.  Mother was recorded to have made significant progress and was meeting children’s needs, although her engagement with agencies was sporadic.  She agreed to make an appointment for sibling 2 to attend the GP.  Father’s contact with children continued to be supervised, and professionals agreed that concerns would be raised if it appeared that relationship resumed.   (KPE1) 3.13. Mother took Sibling 2 to the GP a few days later with concerns about developmental delay, challenging behaviour and self-harm.  As a result of this visit, Sibling 2 was referred to a paediatrician to determine if there was a medical cause for his behaviour.   3.14. At a routine screening in April 2016, a school nurse noted concerns regarding Sibling 2’s appearance and referred the case to social care.  From the health record, it would appear that social care conducted a home visit and identified no concerns with Mother’s care of the children (although there is no corresponding record from social care).    8 3.15. At their appointment with Sibling 2 in May 2016, the paediatrician reported that the physical screening detected no abnormalities and provided some advice to Mother around behaviour management.  In June, September and October 2016, Mother took Sibling 2 back to the GP as she was continuing to struggle with managing his behaviour and wanted medication to help him sleep.  In December 2016, Mother requested to speak with school about Sibling 2’s behaviour, reporting that he had been diagnosed with autism and ADHD. (KPE2) 3.16. In September 2016, Mother reported to Police that Father had verbally abused her; woken Sibling 1 and told her that her mother was a ‘slag’ and ‘didn’t care about her’; grabbed Mother by her hair, ragged her to the floor and stamped on her head and back as she lay on the ground.  As a result of this incident, the case was discussed at the Multi-Agency Risk Assessment Conference (for high risk victims of domestic abuse) and there was a child protection enquiry, which concluded that the family could be supported via Child in Need.  This offer of support under a Child in Need plan was declined. (KPE3) 3.17. Poor home conditions were noted prior to the review period and again as part of social work assessment in September 2016.  In early November 2016, KNH had commenced an anti-social behaviour case for condition of the garden.  By mid-December 2016, a legal notice was served on Mother to address the rubbish in the garden.  By the end of February, Mother had cleared the rubbish and the ASB case was closed. (KPE4) 3.18. In March 2017 Mother attended hospital and a pregnancy was confirmed.  She had an antenatal booking appointment in June, where she advised the midwife that the pregnancy was the result of a one-night stand and the father would not be involved.  She denied that there was any domestic abuse in her relationship with the father.   3.19. In June 2017, Sibling 2 was seen again in Paediatric Clinic as Mother was still concerned about his behaviour and reported that it was worse than before. 3.20. Father was arrested for failing to provide a specimen for a roadside breath test in July 2017, and subsequently sentenced to a12-month Community Order, supervised by Probation CRC.  Probation contacted social care to determine if Father had contact with his children, and was advised that they had previously been involved with the children due to concerns about parental domestic abuse and substance misuse, but the children were no longer subject to child protection. 3.21. Mother attended hospital a number of times in September and October, reporting that she had spontaneous rupture of membranes, reduced foetal movements and pelvic pain.  All scans, tests and observations returned normal.  She was asked about mood and anxiety and referred to Single Point of Access for support with managing her anxieties.  However, she did not keep her appointment and was discharged from the service.  (KPE5) 3.22. In September 2017, Kirklees Neighbourhood Housing attempted to access the property to service gas appliances.  By the end of October, following a comprehensive process, KNH made a final attempt to service gas appliances.  At this point the gas was capped at Mother’s request and there was no gas supply to the address from this point onwards.  3.23. Child A was born at the end of October by a planned caesarean section.  Mother and baby were discharged home and there were a number of home visits conducted by the midwife and the health visitor.   3.24. Police were called to a domestic incident at 01:00 am on 01/01/18 after Father reported that his brother was in drink and refusing to leave the property.  Officers responded quickly and determined that no offences had been committed and removed Father’s brother.  Attending officers were not aware of the domestic history between Mother and Father. (KPE6)  9 3.25. Police records note that an ambulance was called to Mother’s address at 5:58am on the morning of 01/01/18.  Child A was found lifeless by father in mother’s bed and taken to hospital via ambulance.  Child A was pronounced dead in hospital shortly afterwards.  Key Incidents/Interventions January 2016 – December 2017 Year/ period Child Born CSC notification or request for advice Referral to CSC Assessment S47 enquiry Child in Need Order 2 0 1 6 Jan       CiN closed  Feb         Mar         Apr   Referral by school nurse Assessment, NFA    May       Jun        Jul   Referral, no clear source  Assessment, not able to complete    Aug        Sept   High risk DV incident  S47 enquiry   Oct    S47 downgraded to single assessment  Offer of CiN, Mother declined  Nov       ASB process for state of garden Dec  DV incident      2 0 1 7 Jan         Feb        Garden cleared and ASB case closed Mar        April        May        Jun        Jul  Probation check with CSC if Father has children       Aug        Sept        Oct Child A      Gas service to property capped, no gas supply from this point on Nov       Dec  DV incident         10 4. Key Practice Episodes 4.1. Key Practice Episodes (KPE) are identified during the review process to capture key incidents and/or ongoing issues that warrant further analysis.  These episodes are usually times when an incident triggers the involvement of a number of professionals; there is an event that is significant to understanding the way that the case developed and/or was handled; and/or there is a recurring issue for the family.    4.2. In this case, the independent reviewer identified seven key practice episodes that warranted further exploration: 1. Closure of the Child in Need plan – January 2016. 2. Support for Sibling 2 – January 2016 to June 2017. 3. Multi-agency response to domestic abuse incidents – September to October 2016; December 2016; December 2017 4. Home conditions – September 2016 to February 2017; and January 2018. 5. Pregnancy with Child A – March to October 2017. 6. Police incident at 1:00am on 01/01/18.  KPE 1:  Closure of Child in Need plan – January 2016 4.3. Child A’s three elder siblings were subject to a Child in Need Plan when the review period commenced in January 2016.  The plan had been in place since an Interim Supervision Order ceased in June 2015.   4.4. There were no domestic incidents between Mother and Father reported to Police and no recorded concerns about the children from other agencies whilst the Child in Need plan was in place (from June 2015 to January 2016).  Professionals noted that while Mother’s engagement with professionals and services had been intermittent, she had addressed concerns regarding behaviour management and routines whilst living with her grandmother and appeared to have more insight into potential risk and concerns for her children.  Professionals noted that Mother was continuing to meet the children’s needs following her move to her own accommodation in October 2015.   4.5. A Child in Need meeting was held on 08/01/16.  The meeting was attended by Mother, the health visitor, social worker, family support worker and vice principal of the children’s current school.  School professionals note that the children had moved to the school on 16/12/2015 and therefore had only attended for eight days prior to the meeting.  At that time the school had not received the children’s records from their previous school but had phone contact with the previous school and advised the meeting that they felt they knew all they needed to know.  There was no representative from Kirklees Neighbourhood Housing at the meeting.  4.6. Mother reported that she felt she had ‘come a long way’ and felt a lot better in herself, reporting that she ‘felt like an eight’ (on a scale of one to ten – with ten being the best).  She commented on using positive praise and incentives to encourage good behaviour with Sibling 2, when she used to just shout at him.  The social worker reported positively that this meeting was the first time that Mother had been able to identify professionals that she could turn to if she needed support.  11 4.7. The CiN closure summary notes that there had been a significant amount of domestic violence perpetrated by Father, and, although it was agreed that he should have a risk assessment prior to having unsupervised contact with his children, he failed to engage with social care to undertake the assessment. 4.8. At the meeting, a unanimous decision was taken to close the Child in Need plan.  All professionals agreed that concerns would be raised if Mother recommenced a relationship with Father and social care were clear that they would become involved if there were any further incidents of domestic abuse. 4.9. Notes from this meeting suggest that Father’s contact with the children would continue to be supervised by family members (but not Mother) due to concerns around domestic abuse.  Mother was advised that she would receive information about supervised contact arrangements in the post.  Mother was to register the children with a dentist and make an appointment with the GP to discuss Sibling 2’s behaviour.    Analysis 4.10. The decision to close the Child in Need plan may have been appropriate, given the stability that the family had achieved.  Mother appears to have demonstrated to professionals that her relationship with Father was over, and that she recognised the impact of domestic abuse on her children.  Furthermore, professionals at the meeting noted marked improvements in behaviour management and establishing consistent routines.   4.11. However, it may have been prudent to either invite the previous school to the meeting or keep the Plan open until the current school had received relevant records from the previous school and had time to get to know the children and consider their behaviour in the context of their history.  It is also unfortunate that no one from Kirklees Neighbourhood Housing was invited to attend the meeting, despite requests from the allocated Stronger Families Consultant to be involved in any multi-agency meetings around the family.   Learning Point 1: If children have recently moved schools, the previous school should be invited to multi-agency discussions around safeguarding children.  Learning Point 2: Relevant housing providers should be routinely invited to multi-agency discussions around safeguarding children.  4.12. Attendees noted that there continued to be some concern around Sibling 2’s behaviour and suggested that Mother discuss this with her GP.  It is not clear what the rationale for this advice was.  The concerns that are recorded in the subsequent GP visit relate to developmental delay, self-harm and challenging behaviour, all of which could be attributed to early exposure to domestic abuse and lack of consistent boundaries and routines.   4.13. Furthermore, these issues could have been managed by the professionals attending the Child in Need meeting (i.e. the health visitor) via referrals to appropriate services.  Given Mother’s later insistence on securing a diagnosis for ADHD and/or autism (see Key Practice Episode 2), advising Mother to approach the GP, which suggests an underlying medical cause for his behaviour, may have been problematic in that it potentially provided Mother with an alternative to good, consistent parenting.   4.14. The social worker noted that Mother was engaging well with services and could, for the first time, identify professionals that may assist her if she needed support.  It may have been prudent to keep the Plan open or de-escalate to a Team Around the Family (TAF) plan to  12 ensure that this engagement with agencies was sustained.  This is particularly relevant in light of the ongoing concerns regarding Sibling 2.     Learning Point 3: Consideration should be given to de-escalating to a Team Around the Family plan if low level concerns still need to be addressed when a decision is made to close a Child in Need plan  4.15. It appears professionals at the Child in Need meeting clearly communicated that Father was to continue to have supervised contact with his children.  Professionals attending the meeting agreed that social care would conduct a further assessment if Mother recommenced a relationship with Father or if there were any further incidents of domestic abuse.  There did not appear to be a discussion about how professionals should flag this on their records and/or advise social care if they had any concerns that the relationship had resumed.  There was no reference to previous written agreements (Father’s contact agreement in 2012; Mother’s contract of expectations in 2013) that parents had signed in respect to expectations about Father’s contact with children, so it is not clear if these agreements were still in force.   4.16. The multi-agency chronology of professional involvement with this family shows some ambiguity about contact arrangements (see analysis at s6.24 to 6.28 for further detail about this ambiguity), and not all practitioners at the practitioners’ forum were aware that Father was only supposed to have supervised contact with his children and/or the appropriate way to report any breaches.   Social Care Managers confirmed that there is no current process for flagging the relevant children’s file to ensure that concerns of this nature can be responded to appropriately; all concerns are referred via the normal referral route to social care and assessed in light of the information provided by agencies and relevant history.   Learning Point 4: Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals.  This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to agreed contact arrangements.  KPE 2:  Support for Sibling 2  4.17. Throughout the review period, Mother expressed concern about Sibling 2 and the difficulties she had in managing his behaviour.  She primarily sought support via her GP, but also sought support from other agencies for his behavioural problems.  Contact with Health Services to secure a diagnosis for Autism and Attention Deficit Hyperactivity Disorder (ADHD) 4.18. At a Child in Need meeting in January 2016, Mother was advised to take Sibling 2 to the GP.  They attended the GP three days later with concerns about challenging behaviour, self-harm and developmental delay.  As a result of this visit, Sibling 2 was referred to a paediatrician.   4.19. Sibling 2 was seen by the paediatrician in May 2016.  The paediatrician reported that the physical screening detected no abnormalities and provided some advice around behaviour management.  In June, September and October 2016, Mother took Sibling 2 back to the GP as she was continuing to struggle with managing his behaviour and wanted medication to help him sleep.  In December 2016, Mother requested to speak with school about Sibling 2’s behaviour, reporting that he had been diagnosed with autism and Attention Deficit  13 Hyperactivity Disorder (ADHD).  The following year, Mother attended the GP requesting a letter to confirm Sibling 2’s diagnosis and seeking a further prescription to help him sleep.     4.20. In June 2017, Sibling 2 was seen again in Paediatric Clinic as Mother was still concerned about his behaviour and reported that it is worse than before.  The GP record of this appointment notes that Mother was advised that school should refer Sibling 2 for an ADHD assessment; and Sibling 2 was also referred to the Children’s Emotional Wellbeing Service.  The GP record also notes that Sibling 2 was seeing Father more frequently.   4.21. Following this appointment, School considered making a referral to CAMHS for an ADHD assessment of Sibling 2, but had previously been advised that CAMHS would not consider this assessment for a child that has been exposed to domestic abuse in the last two years.  The rationale for this is believed to be that children exposed to domestic abuse may display behavioural and emotional problems that are not caused by an underlying medical illness, which can make diagnosis difficult.   4.22. Following a high-risk domestic incident in September 2016 (further detail provided in KPE3), a s47 assessment undertaken by social care noted that Sibling 2 was alleged to have ADHD and Autism and was observed to struggle with verbal interaction.  The assessment went on to note that Sibling 2 refused to speak to the social worker.  The assessment later states that all children were seen and spoken to together because of their ages and learning needs.  This assessment also notes that Mother spoke to Sibling 2 ‘differently’, and that this was the strategy she had been given to manage his diagnosis within the autistic spectrum.  She advised that social worker that she was attending a group for the parents of autistic spectrum children, and she particularly liked it as the parents swap advice.  Analysis 4.23. Professionals at the practitioner forum agreed that Sibling 2 did not have ADHD and/or autism.  This was explored by the paediatrician, who was initially quite clear that Sibling 2’s difficulties were behavioural and provided advice around clear, consistent boundaries.   4.24. Mother was given advice regarding behaviour management from the paediatrician, health visitor, GP and school and it would appear that this advice was not followed.  Sibling 2 was also referred to the Children's Emotional Wellbeing Service, but there is no evidence that any appointments were attended.  Instead, Mother was intent on securing a diagnosis for Sibling 2 and a medical remedy for his behavioural problems.   4.25. Parents usually find it difficult to accept a diagnosis of autismi.  Accordingly, Mother’s persistence in obtaining a diagnosis should have triggered some professional curiosity about what motivated this persistence i.e. did Mother perceive there to be some benefit to a medical diagnosis or was she seeking an easier alternative to good, consistent parenting?  It may also be that this focus on a medical cause for Sibling 2’s behaviour sought to distract professionals from other issues in the family and/or potential causes for his behaviour.  The Triennial Analysis of Serious Case Reviews identified a case where “[The mother’s] insistence on a specific medical diagnosis for the children’s difficulties seems to have served in many ways to dissipate any consideration of other family and environmental features of their lives – in particular the quality of the parenting they received.”ii  Learning Point 5: some parents may be intent on securing a medical diagnosis for a child’s behavioural problems and consequently ignore advice from professionals about behaviour management.  A consistent, multi-agency response should be given to parents in these cases to ensure that children receive an appropriate, authoritative parenting approach.  14  4.26. It is also not clear if professionals considered the impact of Mother’s behaviour on Sibling 2 – he was taken to a variety of appointments and treated differently to his siblings due to Mother’s understanding of the causes of his behaviour.  However, it is considered likely that singling Sibling 2 out will have compounded his behavioural difficulties.   4.27. A social worker noted that Mother used a more authoritarian style of parenting with Sibling 2 and, when questioned about this, Mother reported that she treated him differently due to this Autism/ADHD, and she was not challenged on the appropriateness of using an authoritarian parenting style to manage his behaviour.  Research suggests that authoritarian parenting, which is characterised as low in warmth and nurturance, is likely to exacerbate behavioural problems in children.iii  Learning Point 6: An authoritarian parenting style is likely to exacerbate behavioural problems in children    4.28. It is not clear if professionals understood and clearly communicated to Mother that Sibling 2’s difficulties were likely to be the result of early exposure to domestic violence and inconsistent parenting.  Children exposed to domestic violence demonstrate greater behavioural and emotional problemsiv, learning problemsv and less secure attachments to their caregiversvi. This is largely because children depend on cues from caregivers to regulate distress and, if caregivers are absent and threatening or being threatened during times of acute distress, it can affect the way children regulate emotions, respond to fearful stimuli, and develop trusting relationships with othersvii.  Accordingly, Sibling 2’s difficulties in managing his temper, self-harming and difficulties in sleeping are likely to stem from earlier experiences of living in a volatile environment, feeling frightened and not having a consistent source of support to help him manage his distress.     Learning Point 7: exposure to domestic abuse may cause behavioural and emotional problems in children.  Professionals should clear about the research that supports this and evidence the work done with parents to increase their understanding of the impact of domestic abuse on their children.  4.29. It is not clear from agency records if the process for obtaining a diagnosis of autism was clearly understood by professionals and/or clearly communicated to Mother.  The independent reviewer understands that, since the period under review, there has been concerted efforts by the Child and Adolescent Mental Health Services to raise awareness about ‘ASK CAMHS’, the initial point of contact for those who have concerns about a child or young person’s emotional or mental health.  This should assist professionals in providing clear, consistent advice to parents about obtaining appropriate support for children. Learning Point 8:  ‘ASK CAMHS’, the initial point of contact for those who have concerns about a child or young person’s emotional or mental health, should assist professionals in in providing clear, consistent advice to parents about obtaining appropriate support for children  Offers of Support from Early Help 4.30. At a routine screening in April 2016, a school nurse noted that Sibling 2’s clothes and ears were dirty, and Sibling 2 advised that he had not eaten breakfast and there was no food in the house.  The school nurse had worked with the family when they were subject to a Child in Need plan and, given historic concerns regarding neglect, contacted school to discuss her concerns and referred the family to social care.  The school nurse recorded that the case had  15 been allocated to a social worker.  It does not appear that Mother was advised that a referral was being made.   4.31. There is no record from social care about this referral or subsequent assessment, but health records indicate that Mother attended school angry that a social worker had visited her home and wanted to know if school had referred.  From the health notes, it would appear that the school safeguarding lead advised Mother that social care was contacted by health as a result of what Sibling 2 had said during the routine check. 4.32. From the health record, the social worker advised the school nurse that the social worker, and the family support worker that had been involved with the family during the Child in Need plan, attempted a joint visit with Mother but she had refused access.  Two weeks later, the social worker advised the school nurse that they visited the home address and saw the children.  The social worker noted that the children appeared unkempt but there were no concerns.  There are no further entries on the health record (and no corresponding entries from school or social care) so it would appear that the case was closed at this point. 4.33. There appears to be a further referral to social care in July 2016, although there is no record this in the social care chronology.  The health record notes that a family support worker contacted the family’s health visitor/school nurse as part of a single assessment, as Mother was finding it difficult to manage Sibling 2’s behaviour.  Two weeks later, the family support worker advised the school nurse that Mother no longer wanted a single assessment.  Given that single assessments are a voluntary agreement between professionals and families, the family support worker could not proceed without Mother’s consent.   Analysis 4.34. The analysis of offers of support from early help is difficult in the absence of appropriate records from children’s social care.  The independent reviewer is aware that record keeping is a key part of the improvement plan that is being currently being undertaken by social care, and new Family Support and Child Protection Practice Standards (introduced in February 2018) provide explicit guidance about record keeping.  4.35. Mother appeared to be struggling to support Sibling 2 and, in times of crisis and/or when Sibling 2’s behaviour was particularly challenging, she did reach out to professionals for support.  However, all offers of support were subsequently declined.  Professional curiosity about why Mother did not want to engage with the support on offer, particularly in light of the previous domestic abuse and subsequent Supervision Order, should have prompted further challenge about why Mother did not want to engage with support.  This is particularly significant when Mother previously reported that she found professional support helpful in providing positive strategies to help manage Sibling 2’s behaviour (see 4.6 above). Learning Point 9: Risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their current partner and/or father of their unborn child.  This may be indicative of an ongoing, abusive relationship.  4.36. Mother was reported to have been angry about social care involvement with the family in April 2016.  This may have been partially mitigated if the school nurse had advised Mother that they would be making a referral, explained the reasons for her concerns and sought Mother’s consent for someone from children’s social care to contact her and offer support. Learning Point 10: professionals should advise parents of any concerns regarding their children and/or gain parents’ consent for someone from children’s social care to contact and offer support (unless doing so would put the child at risk)  16  KPE 3:  Multi-agency response to high risk domestic incident 4.37. In early September 2016, Mother rang Police at 7:00am to report that Father had been drinking all night and had just left her address with their 18-month-old child (Sibling 3) in the car.  Mother reported that Father was not allowed to have unsupervised contact with the children.  Sibling 3 was subsequently returned to the property safe and well, and further investigation by Police determined that Father was not under the influence of alcohol when he left the address with Sibling 3 in the car. 4.38. When Police attended the address to gather further information about this incident, Mother disclosed that Father had assaulted her in the early hours of the morning.  Mother reported that Father had verbally abused her; woken Sibling 1 and told her that her mother was a ‘slag’ and ‘didn’t care about her’; grabbed Mother by her hair, ragged her to the floor and stamped on her head and back as she lay on the ground.  Mother also reported that Father threatened to return to the property and stab her if he were arrested. 4.39. During this account, Mother also disclosed a domestic history which she described as mostly verbal but included two assaults – one where he poured bleach on her and another where he punched her, pulled her hair and strangled her.  Mother also reported that he went to prison in 2014 for assaulting her, and, despite their separation, he continued to control who she could see and where she could go.   4.40. The Police record notes that Sibling 2 was not present during the assault, as he was staying with a grandparent.  Sibling 1 was recorded to have been present and witnessed the incident – officers noted that she was very quiet and clearly upset when they arrived.  However, as Sibling 1 got used to officers, she became chatty and was getting ready for school when they left.  Sibling 3 was described as being fit and well, seemed happy and smiling.  Officers noted that the house was in good order, with appropriate food, toys and clothing.  They did not identify any concerns about the children during the visit. 4.41. Mother reported that she was very scared and wanted as much support as possible.  She requested a panic alarm in the event he came back to the property.  Police requested an alarm for Mother and made a referral to Pennine Domestic Violence Group for support.    4.42. Father was arrested on suspicion of section 47 assault and damage.    Information sharing between partner agencies 4.43. Police records indicate that details of the assault were shared with social care and child health at 15:13 on the same day (Friday) as the incident.  However, the Police record does not show that information about Father leaving the property with Sibling 3 in the car was shared.  Health and Social Care records indicate that information about the assault was received the following Monday.  About a month after the incident, the school nurse advised the school safeguarding lead about the incident and that a social worker was undertaking a single assessment.   The School Safeguarding Lead confirmed that they would contact the social worker as needed. 4.44. There is no record in either the social care or Locala chronologies to suggest that either agency was aware that Father left the address with Sibling 3 in the car.   Analysis 4.45. When Father took Sibling 3 from his Mother’s property and set off with him in the car, Father breached an agreement with Social Care not to have any contact with his children unsupervised.    17 4.46. As this agreement was implemented prior to the review period, it has not been seen by the independent reviewer and it is not clear if the agreement was made with both parents (or only Mother) and/or had an end date.  It is also not clear if Children’s Social Care advised Police that this agreement, which was made with Mother, was in place.  However, Mother did advise Police that Father was not allowed to have unsupervised contact with the children (see 4.36 above).   It is recognised that written agreements are not legal documentsviii and Father could not have been charged with any offence over a breach.   4.47. It is considered likely that Mother only contacted the Police because Father had left the property with Sibling 3 in the car, and she was anxious about Sibling 3s safety.  As professionals in health and social care were not aware of this incident, those professionals focussed on safeguarding children made a judgement about Mother’s capacity to act protectively without being aware of what her motivations for reporting the incident may have been.  Furthermore, Sibling 1 witnessed the removal of Sibling 3 from the property, which is likely to have been distressing.   It would have been useful if this information about this incident was shared, so children’s social care could have had the opportunity to explore it as part of their risk assessment. 4.48. The Police information that was shared with health and social care included information about the home conditions and the presentation of each child, which is considered to be good practice in assisting social care with their decision making.    Mother’s subsequent withdrawal from agency support 4.49. The morning after the incident, Mother did not attend her appointment with Police to provide further evidence of the assault.  When Police contacted her to arrange a subsequent appointment, she declined to have her injuries photographed; declined to let Police see her phone; and declined to provide a Victim Personal Statement.   4.50. Police contacted Mother again a few days later and she declined any further support, reporting that she felt safe and did not need any further assistance. 4.51. Records from the Pennine Domestic Violence Group indicate that Police referred Mother to their service for support 11 days after the incident.  There is no corresponding record in the Police chronology so there is no explanation for the delay in making this referral.  A worker from PDVG contacted Mother and explained how the service could help to add extra security to her property and/or apply for court orders to prevent him from contacting her.  Mother advised that she did not feel she needed any support.  PDVG closed her case and advised Police that she declined their support.    Analysis 4.52. Mother very quickly retracted her statement to the police, and it is considered unlikely that this is due to any fault of police or other agencies offering to support her.  Victims of domestic abuse are most likely to retract their complaints within 5 days of a violent episodeix.  In this case Mother retracted her statement one day after the assault.  She may have been fearful of the consequences of her disclosure, as she had reported that Father threatened to stab her if she reported him to Police.  Retracting her statement may have been Mother’s attempt to mitigate the risk to her and her children.  While this may seem at odds with what professionals might expect Mother to do to keep her children safe, it is understandable given her report of ongoing coercive control, the fact that her relationship with Father began when she was a teenager, and the previous involvement of agencies that could not manage the risk that Father presented to her.  18 4.53. Research also suggests that a majority of victims withdraw or retract their complaints because they are still in love with the perpetratorx.  Practitioners working with domestic abuse cases should be mindful of ongoing feelings for the perpetrator and alert to indications that the relationship is continuing, or, at the very least, that the victim and perpetrator are in regular contact.  The Department for Education notes that disguised compliance is a common factor in families living with domestic abuse and a number of serious case reviews identify victims falsely telling agencies that they are no longer in touch with their perpetrator.xi Learning Point 11: Victims may retract statements or disclosures regarding domestic abuse.  The reasons for this are varied and complex, but fear of the consequence of disclosure and ongoing feelings for the perpetrator are likely to be contributory factors.  Retractions should not be seen as evidence that abuse has not occurred and may be indicative of ongoing contact between the victim, the perpetrator and their children.    Police investigation 4.54. Police attended Mother’s address promptly at 10:00am on the morning that the assault took place to obtain a witness statement.  The following day, Mother declined to provide further evidence of the assault (as per 4.49 above).   4.55. The following Monday, the Crown Prosecution Service requested that Father be bailed as there was insufficient evidence to charge Father with the assault.  The CPS requested that further evidence be gathered, including statements from anyone who may have visited the address and could confirm that the damage was not pre-existing; photographs of injuries; and a download of abusive messages on Mother’s phone.  The officer noted that only limited further evidence would be provided given that Mother was no longer supporting prosecution. 4.56. The following day, the officer contacted Mother again to obtain further evidence as requested by the CPS.  The victim declined to provide any supporting information and declined any further assistance from Police.   4.57. Given that Mother retracted her statement and Police could not complete any further enquiries, no further action could be taken.  Police contacted Mother to update her that the police investigation would be closed and recorded that she was happy with that decision.  Assessment undertaken by Children’s Social Care 4.58. Social Care records reflect the information held by Police about the assault on Mother.  There is no record in the social care chronology to indicate that Social Care were aware of Father’s removal of Sibling 3 from the property.    4.59. The Contact Record created by social care includes a summary of social care involvement provided in the closing summary of the Child in Need plan, which notes the ‘significant’ involvement of social care dating back to 2010, the high number of domestic violence logs with Father as the perpetrator and Mother as the victim, and that all children have witnessed domestic violence on various occasions.  The record recommends that the case to be progressed to referral to enable further information to be obtained. 4.60. There are chronology entries from Police and Health to indicate that a Strategy Discussion took place two days later and relevant checks were done with these agencies.   4.61. The social care assessment record also notes that a social worker visited Mother and the children as part of a s47 enquiry on the same day as the Strategy Discussion.  Mother did not  19 want children to be spoken to as she did not want them to be upset, so she sent them to their bedrooms to prevent the social worker from speaking to them.  She refused to allow the social worker to contact the children at school.   4.62. During the social worker’s discussion with Mother, the children kept coming downstairs and standing in the hallway, presumably to overhear what was being said.  The social worker encouraged them to come into the room and noted that all children thought the social worker was there to remove them from their mother’s care.   4.63. The social worker noted that the youngest child (Sibling 3, then aged 2½ years) had very limited verbal interaction and that Sibling 2, who was alleged to have ADHD and Autism, was observed to struggle with verbal interaction.  As a result, all children were spoken to together.  It is not clear if Mother was present when the children were spoken to, but this is considered likely given Mother’s earlier reticence for children to be spoken to at all.  The subsequent single assessment noted that Mother appeared to have anticipated social care attending and it was felt that the children had been prepared for the visit.  It further noted that ‘it was clear that Mother did not want social care intervention’ and had ‘programmed the children not to speak to’ the social worker. 4.64. The s47 assessment notes that the children were not at home when the assault took place; that the children confirmed that they were not at home when the incident happened; and that the police report of the incident states that the children were not present.  This is contradicted later in the assessment record, which in notes that a subsequent conversation with Police confirmed that two children were at the address at the time of the incident.   4.65. Mother advised the social worker that she had been away with friends and, on her return, her ex-partner had broken into her home, assaulted her and tried to steal her passport.  The assessment notes that Police contradicted this account, advising social care that Mother had let Father into the property.  The assessment also notes that Police advised that CPS did not have enough evidence to charge Father, and Mother had retracted her complaint and refused to provide any further information.  On this basis, the assessment concludes that Police advised that the assault did not take place.   4.66. The analysis of information gathered in the s47 assessment notes that Father would want regular contact with his children and Mother was likely to be ‘at further risk of harm’ if she did not comply.  The assessment also concluded that Mother was not truthful in her account of the incident and retracted her statement to police.  The social worker notes that ‘Police state that there is no evidence that supported that Mother had been assaulted’.  The Manager also adds that there was no evidence that Mother allowed Father into the family home or that they continued to be in a relationship. 4.67. The social worker concluded that the family could be supported via a Child in Need plan, but noted (incorrectly) that the family had been subject to a Child in Need plan that closed in July 2016 (the plan actually closed in January).  The assessment notes that Mother had only just ‘got rid of social services’ and could not identify any further support needs. 4.68. At the 10-day review, the Team Manager noted that the s47 concluded that the information that led to the referral was incorrect, and that this had been substantiated by Police. 4.69. A single assessment commenced as the s47 was being concluded.  The single assessment noted three home visits, two of which were conducted with the health visitor.  It notes that Father was still controlling and demanding of Mother, especially when things do not go his way or to plan.  However, they found no evidence that the children were at risk when having contact with Father and noted that Mother did not think Father would ever hurt the children.  The Single Assessment incorrectly notes that Sibling 3 (rather than Sibling 2) was not present during the incident.    20 4.70. Nearly a month after the incident, Mother advised the social worker that she had now put a plan in place to manage child contact via paternal grandfather, and that this arrangement was working quite well.   4.71. The single assessment concluded that it was unlikely that Mother could have anticipated that Father would attend her home and challenge her aggressively; and that two of the children were at home asleep and did not witness the altercation (although concedes that Sibling 1 indicated to Police that she heard the arguing as it woke her up).  The assessment concludes that Mother acted appropriately to safeguard herself and her children and subsequently put measures in place to supervise contact between Father and his children. 4.72. Health records indicate that the social worker advised the health visitor that the case would be closed with no further involvement from social care before the school nurse advised school that the domestic incident took place.  From this, it would appear that the children’s school was not contacted as part of the social worker’s assessment.  There is information in the single assessment about school attendance and a reference to Sibling 2 having an Educational Health Care Plan, but it is not clear where this information was obtained from.  Analysis 4.73. Given that the single assessment noted that Mother appeared to have anticipated social care attending and it appeared that Mother had ‘programmed’ the children’s responses to the social worker, there should have been more challenge to Mother about her ongoing relationship with Father and why children had been prepared for social care’s visit. Learning Point 12: Social workers should challenge parent’s ‘programming’ children’s responses to social workers questions and explore the reasons behind this with parents  Learning Point 13: Children being ‘programmed’ by their parents should warrant further exploration and social workers should speak directly to the children, without the presence of their parents, to explore their wishes and feelings.  4.74. The single assessment noted that Father was still controlling and demanding of Mother, especially when things don’t go his way or to plan; but were reassured because Mother did not think Father would ever hurt the children.  Given the impact of coercive controlling behaviour on victims, it is unlikely Mother would say anything else.  Furthermore, its places an on over reliance on mother’s capacity to assess risk and safeguard her children, particularly in light of the historic risks around domestic abuse and both parents’ struggle to prioritise the care and safety of their children.  Ofsted notes that ‘agencies place an inappropriate attribution of responsibly on the victim to safeguard children’.xii Learning Point 14: coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children.  Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children.  4.75. The social care assessment notes that Police could not confirm that an assault took place and, as such, appeared to undertake the assessment on the basis that no assault occurred.  This is despite Mother’s own account of an assault directly to the social worker, and the initial report  21 from Police describing Mother’s report of the assault, damage to the property, and the swelling to her eye. 4.76. It would be worrying if social care took the position that, if the police evidential test is not met, they should work on the basis that an assault has not taken place.  The evidential threshold in criminal proceedings is significantly higher than in family law proceedings; and child protection enquiries do not have to establish each element of an offence beyond a reasonable doubtxiii.  Furthermore, research into false allegations of domestic abuse demonstrates that false allegations are ‘extremely rare’ – a study by the CPS showed that in a period where there were 111,891 prosecutions for domestic violence, there were 35 prosecutions for making false allegations.  The report showed that these cases generally involved young, often vulnerable people and, in some cases, the person alleged to have made the false report had undoubtedly been the victim of some kind of offence, even if not the one which he or she had reported.xiv 4.77. This study pertains to prosecution and not to initial reports, so there may be some variation in the proportion of inaccurate initial reports.  However, given the overwhelming number of prosecutions for domestic offences in comparison to prosecutions for making false allegations, professionals should work on the basis that initial reports of domestic abuse are likely to be accurate and subsequent retractions or statements that the abuse did not occur are likely to be false. Learning Point 15: Social care should not use the police evidential test as a basis for determining whether or not an assault took place.   Learning Point 16: Professionals should be mindful that an initial report of domestic abuse is likely to be accurate, and subsequent retractions are likely to be false  4.78. The assessment concluded that Mother acted appropriately to safeguard herself and her children.  The assessment incorrectly noted that Mother had put measures into place to ensure contact between Father and his children would be supervised by his father (this arrangement was already in place from the closure of the Child in Need plan in January 2016).  Father is largely missing from the assessment, except a reference to Police information that Father was ‘difficult to engage’.  Ofsted notes that a lack of focus on perpetrators can lead to a short-term view of risks, where swift action is taken to secure the immediate safety of the victim and children without any focus on the perpetrator’s behaviour.  In these circumstances, professionals resolve the immediate incident, but can lose sight of the greater risks posed in future.xv Learning Point 17: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children  Domestic Incident in Leeds – August 2016 4.79. One week after the strategy discussion and visit with mother undertaken by the social worker, Police shared information regarding a low-level incident that occurred between Mother and Father the previous month in Leeds.   4.80. The information provided by Police indicates that Mother and Father were visiting the Paternal Grandmother with a view to the children staying there for the night.  There was an argument between Mother and Father over a difference of parenting styles, which spilled out into the  22 street, and resulted in Mother leaving with the children and returning home.  Father was reported to be in drink and remained in Leeds with his mother. 4.81. This incident was screened by a social worker and police officer in Leeds (as this is where the offence occurred) and emailed to Kirklees (as that is where the victim and children usually reside) nearly two weeks after the incident.  Information about this incident was also shared by local (Kirklees) Police to Kirklees social care at the same time, nearly two weeks after Father assaulted Mother and while the social care assessment being undertaken.  Analysis 4.82. The information from Leeds should have alerted social care and the police that Mother was having more contact with Father than she reported.  Given that they were visiting Paternal Grandmother together, as a family, in violation of an earlier written agreement that all Father’s contact should be supervised by a family member (rather than Mother), it would have been reasonable for agencies to assume that the relationship was ongoing.   4.83. It is not clear whether this information affected the ongoing assessment being undertaken by social care.  Given that information about the incident was shared by two different sources, it is reasonable to assume that the information was received by social care.  However, it is not reflected in their chronology or assessment record, so it is unclear how this information was acted upon.   Learning Point 18: social work assessments should respond to new and emerging information, even when new information contradicts what was previously known or believed to be true.  Managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information.    MARAC Meeting 4.84. The Police referred the case to the MARAC four days after the assault that occurred in Mother’s address in September.  By this time, Mother had retracted her statement and declined any safeguarding interventions, so despite initially consenting to the Police sharing information with partner agencies, her consent for the MARAC had been withdrawn.  As a result, the referral was made without Mother’s consent.  Police considered the incident to be sufficiently high risk so Mother’s consent could be overridden to safeguard her and the children. 4.85. The MARAC referral provided a summary of the incident and noted that Mother had swelling above her right eye.  It did not include details of Father taking Sibling 3 in the car. Police also advised the MARAC that Mother did not support a prosecution. 4.86. Information shared by agencies correctly notes that the case was open to a social worker for an assessment and that Mother had declined PDVG support.  As a result, the MARAC recommended that the social worker discuss improving security in the family home with Mother.  Social care subsequently advised the MARAC that this action had been completed.  Analysis 4.87. The MARAC provides an opportunity for professionals from different agencies to share information about high-risk domestic abuse cases and develop a safety plan to mitigate identified risks to victims and/or their children.  It also provides an opportunity for professionals to challenge an agency’s response to domestic abuse incidents and assumptions about risks to victims and/or their children.  23 4.88. It would have been helpful for agencies at the MARAC to have been aware of Father removing Sibling 3 from the property after the assault.  Learning regarding this point is identified above in 4.47. 4.89. There is no information in the social care chronology or the assessment record to suggest that the social worker discussed improving security in the family home with Mother. Learning Point 19: MARAC provides an opportunity for information regarding the assessment and management of risk to be shared.  Agencies in attendance must ensure that information shared at MARAC is appropriately acted upon.    4.90. Previous serious case reviews have identified improvements for the MARAC process in quality assuring the information that is submitted by individual agencies, and a number of improvements have been implemented since the MARAC in which this case was discussed in 2016.  However, the onus is on participating agencies to undertake the actions that have been agreed by the MARAC and provide an update as necessary.    Subsequent DV incidents Christmas Day 2016 4.91. On Christmas day in 2016, Mother made a 999 call at 11:44pm, which ended abruptly after what sounded to be a fight.  When Police were able to get Mother on the phone again, she reported that her ex-partner was at the house smashing her property up.  She was then heard to shout “get off me” before the call dropped again. 4.92. When Police attended the property at 11:50pm, Mother reported that there had been no assaults, no damage and no complaints.  She stated that when she said "get off me", the suspect has tried to grab the phone, but had not assaulted her.  A physical check was made of the house and there was no damage to any property and no signs of any disturbance.  Officers noted that there were no visible injuries to anyone.  Father was arrested to prevent a breach of the peace.  He was reported to have attended Mother’s address heavily in drink.  The DASH report states that Mother would not engage with officers therefore no witness evidence to substantiate further action.  Sibling 2 was awake when officers attended and reported to be clean and happy.  4.93. Details of the incident were shared with Health and Social Care (although social care have no corresponding record of the incident).  The Duty Health Visitor determined that no further action was required.  The reason for this decision is not documented.   December 2017 4.94. Mother reported a further domestic incident a week before Christmas in 2017.  She reported to Police that her ex-partner was at her address, intoxicated and being verbally abusive.  She requested that Police attend the address and remove him.  The Police record notes that all children were present and that, apart from the house being messy, the children appeared nourished and happy when officers saw them. They did not seem distressed.   4.95. The Police shared information about this incident with Health and Social Care.  The following day, the health visitor spoke to Mother about incident.  Mother reported that she and Father had separated, he attended the property and did not leave the property when he was asked to so Mother called the police to prevent escalation.   24 Analysis 4.96. It is not clear what action children’ social care took in response to these incidents, but it would appear that Father was not spoken to about the impact of his behaviour on his children. See:  Learning point 17: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children  4.97. When Mother rang Police in December 2016, she would have been flagged as a MARAC victim.  At that time, this incident would not have been classed as a MARAC repeat because no crime was recorded and, accordingly, did not warrant a referral back to MARAC for further discussion.  KPE 4:  Home conditions September 2016 to February 2017 4.98. Poor home conditions were frequently noted by professionals during their involvement with the family.  From November 2010 to January 2018, Health records noted 14 occasions when the home conditions were not considered to be satisfactory.  The records note that when improvements were made, they were not sustained. 4.99. Mother moved into a Kirklees Neighbourhood Housing (KNH) property in September 2015.  A number of professionals noted the poor state of garden in September 2016.  KNH had an opportunistic conversation with Mother about the poor condition of the garden during an estate visits inspection.  Also, in September 2016, following the domestic incident (discussed in more detail in KPE3), the social worker advised the health visitor that the home conditions were barely acceptable.  Following this conversation, a nursery nurse noted that the garden was ‘unkempt with plates of leftover food, empty beer cans/bottle and broken toys. 4.100. When challenged about the home conditions, Mother reported that she had been unaware of the social worker’s visit and had not had time to tidy up. 4.101. In early October 2016, health records indicate that the social worker who conducted a joint visit with the health visitor was happy with the conditions of the home environment.  The single assessment completed by the social worker reports that there was some rubbish in the garden but also notes that Mother had made arrangements for this to be cleaned up.  It is not clear from the record if the children’s bedrooms were seen as part of this visit. 4.102. At a quarterly inspection at the end of October 2016, KNH noted the poor condition of the garden.  By early November, KNH had commenced an anti-social behaviour case for the rubbish in the garden.  At this time, a Stronger Families Consultant working from KNH contacted social care requesting information about their involvement with the family and were advised that social care had closed the case.  KNH queried whether there were any arrangements in place to de-escalate the case following social care’s involvement and were advised there was no lead professional for the family in place and that school were the only service involved.  At this point, the Stronger Families Consultant made a number of attempts to liaise with school but were unable to speak to anyone about their concerns.  4.103. By mid-December 2016, a legal notice was served on Mother to address the garden condition.  Early in the New Year, an enforcement officer visited and spoke to Mother about the rubbish in her garden.  Mother explained that does not drive; that she could not afford the local tip due to the amount of waste; that she has three children aged 6, 5 and 2, and her 5 year old has ADHD and autism; and that her grandparents normally help her but had recently been ill and  25 unable to help.  The enforcement officer advised that there was a significant amount of waste, and she would need to address it or potentially face a fine.  The enforcement officer advised Mother to bag up all the rubbish, recycle more efficiently, and offered some advice around local services that may be able to assist.  By the end of February 2017, Mother had cleared the rubbish and the ASB case was closed.  Analysis 4.104. It is unclear from the record to what extent Mother prepared for professional visits to the home.  Opportunistic visits, as opposed to pre-arranged appointments, appeared to identify issues with home conditions, indicating that the ‘usual’ standard was probably below what professionals would expect.  Mother also indicated that home conditions were poor during an unannounced visit because she didn’t have time to tidy up. 4.105. It is recognised that different professionals will have different standards regarding home conditions as this is a subjective assessment.  This is apparent when, in October 2016, health and social care professionals were reported to be happy with the home conditions (including the garden), even though KNH were in the process of pursuing anti-social behaviour proceedings for the poor condition of the garden. Staff at the practitioner forum indicated that it may be useful to establish a benchmark to enable professionals to share a collective understanding of acceptable home conditions.   Learning Point 20: The use of a visual home conditions assessment tool may be useful to enable professionals to share a collective, objective understanding of what constitutes acceptable home conditions  Capping the gas supply 4.106. It would not appear that any professionals made any further home visits until September 2017, when KNH were attempting to access the property to service gas appliances.  In mid-September, Mother told the engineer she had no gas on and this was the 3rd occasion where she advised she would be ringing up to set a suitable date.  However, there was no subsequent call to property services.  By the end of October, following a lengthy process involving Gateway to Care, KNH made a final attempt to service gas appliances with attendance from Noise and Pollution Team.  The gas was capped at Mother’s request and there was no gas supply to the address from this point onwards.  4.107. As a result of this case, KNH identified some issues with spin capping and have implemented new processes to ensure professionals seek advice before spin capping properties where there are children and/or vulnerable adults; and monitor all spin capped properties on a monthly basis.  Sleeping arrangements  4.108. In November 2017, the midwifery and health visiting teams attended the home address on a number of occasions following the birth of Child A.  Unfortunately, the notes of the midwifery visits have been lost, so no information about the home conditions have been recorded.  The health visiting records note that the living room was cluttered and needed hoovering, and that there was rubbish in the garden.  However, there is nothing in the notes to indicate that the house was particularly cold or without hot water.  It is not clear if any professional saw the children’s bedrooms or sleeping arrangements during any of these visits. 4.109. A number of professionals that accessed the property after Child As death described the sleeping arrangements for all the children as inappropriate, in the case of Child A, unsafe.    26 4.110. Mother and Father confirmed that it was normal practice for Child A to sleep in between them, and that they were aware of the risks associated with co-sleeping.  The post-mortem identified the following risk factors in relation to co-sleeping: • a soft mattress and inappropriately heavy bedding. • both mother and father had been drinking alcohol; and  • Child A had been sleeping in between them.  Analysis 4.111. Previous child protection concerns (prior to the period under review) had identified issues with home conditions and lack of appropriate bedding/sleeping arrangements for children.  However, there is no evidence that anybody checked any of the children’s’ bedrooms during the review period.  This is particularly relevant in light of the s47 assessment undertaken by social care, as it would be prudent for any subsequent assessment to ensure that historic concerns had not re-emerged. Learning Point 21: Children’s Social Care assessments should consider the history of the case and ensure that any historical concerns i.e. home conditions, suitable sleeping arrangements for children etc are explored during any re-assessment process 4.112. Both the health visiting and midwifery records are clear that safe sleeping advice was provided to Mother during each pregnancy and following the arrival of each of her children.  From this, it would appear that Mother was provided with safe sleeping advice on at least eight occasions prior to the death of Child A.   4.113. The author is aware that a concurrent CPSR in Kirklees, with regards to Child E, has identified learning with regards to safe sleeping.  In this case, the safe sleeping advice, given consistently to mother, was not effective in reducing the risks to Child E.  This review points to emerging research that indicates that, whilst the safe sleeping message appears to have effectively reduced deaths in the general population, it appears to be less effective with parents with complex needs.  Learning in regard to this finding will be addressed in the CPSR regarding Child E and, accordingly, will not be duplicated here.  KPE 5:  Pregnancy with Child A – Mar 2017 to Nov 2017  4.114. Mother presented at the local hospital emergency department in March 2017 with bleeding and queried whether she might be pregnant.  The pregnancy test in the Emergency Department was positive and scan in the Early Pregnancy Unit suggested a potential pregnancy.  A rescan conducted nearly two weeks later confirmed a 6-week viable pregnancy.  Mother was encouraged to make an appointment to book her pregnancy with the midwifery department. 4.115. When Mother was approximately 15 weeks pregnant she attended her GP with symptoms of morning sickness.  GP queried hyperemesis gravidarum and noted that Mother reported having three children and feeling unable to cope.   4.116. In June 2017, Mother had her antenatal booking appointment at 24 weeks.  The booking notes that Mother was previously known to Children’s Social Care and had some mental health issues when she was a teenager.  The midwife made a routine enquiry around domestic abuse and noted that Mother declined to provide information about the father of the unborn.  Mother informed the midwife that she had a new partner, he was unlikely to be involved with the baby  27 and she had no concerns about domestic abuse.  The dating scan confirmed that Mother was due to have the baby in mid-November 2017. 4.117. There is a record in the social care chronology that Mother attended a clinic for a termination in July, but then changed her mind.  The clinic advised that this information was also shared with the GP and midwifery service, but there is no corresponding entry in either the GP or midwifery record. 4.118. Mother attended hospital a number of times in September, reporting that she had spontaneous rupture of membranes, reduced foetal movements and pelvic pain.  All scans, tests and observations returned normal and Mother was advised to return home, rest and come back to hospital if she had any further concerns.  At one appointment she requested an early delivery as she was struggling to cope without any social support. 4.119. In early October Mother attended a further appointment and again reported reduced foetal movements – she was immediately sent for monitoring and assured that the baby was well.  She was asked about mood and anxiety and signposted to Single Point of Access for support with managing her anxieties.  She divulged that she did not want to see her community midwife anymore, as she brought back memories of her previous pregnancy loss.  The information is passed to the community midwifery manager and different midwives were assigned to Mother’s care.   4.120. A referral was made to Single Point of Access on Mother’s behalf.  Mother discussed her anxieties over the phone and agreed to a referral to ‘talking therapies’.  However, she did not keep her appointment and was discharged from the service.   4.121. Child A was born at the end of October by a planned caesarean section.  Children’s Social Care have a record of a low-level domestic incident that occurred on the day of the birth.  This is believed to be incorrect, as it is not reflected in the Police or Health record, and Health representatives at the Practice Learning Event were certain that no domestic incident occurred on the day of the birth. 4.122. Mother and baby were discharged home the following day.  The midwife conducted a home visit the following day and made a further three home visits during November.  Unfortunately, the notes of these visits are not available as Mother lost her notes.  The health visitor also conducted a visit in November.  The health visitor discussed safe sleeping arrangements, discussed Mother’s social support arrangements, and talked about Mother’s anxieties during her pregnancy.  Mother reported that she was emotionally well and did not require any further support at this time.   Analysis 4.123. It is clear that Mother was asked about domestic abuse in her relationship as part of a routine enquiry.  Given her history of domestic abuse in her previous relationship, it may have been helpful for this routine enquiry to be more targeted and explore the risk posed by her ex-partner i.e. was he aware of the new pregnancy?  How did he/ how did Mother think he would react to the news? Learning Point 22:  Several agencies now employ routine enquiry in relation to domestic abuse.  If the case history and/or responses to the enquiry indicate historic domestic abuse, the current risk posed by violent partners/ex-partners should be explored.  4.124. Mother was routinely asked to identify who the Father of her baby was and if there was any risk of domestic abuse in her relationship.  She consistently declined to provide details of the  28 father and denied any domestic abuse in her relationship.  Given that Father was the father to her other three children, their relationship commenced when Mother was under 16, and her previous involvement with services due to domestic abuse, it was a reasonable assumption that he was also Father to the unborn.  The reviewer is aware of the difficulties in proceeding with any form of assessment without evidence that Mother was in an abusive relationship.  However, given the risk involved in domestic abuse cases and the impact of coercive control on victims, perhaps it would be beneficial to consider a different approach to risk assessment in these cases.  For example, professionals could consider working with multiple hypotheses – what if the former abusive partner is the father?  What if it is somebody else? See:  Learning point 9:  Risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their current partner and/or father of their unborn child.  This may be indicative of an ongoing, abusive relationship.  4.125. Mother was clearly very anxious throughout her pregnancy and it would appear that appropriate offers of support were made.  Mother also reported a number of difficulties during her pregnancy – in addition to her reported sickness, anxiety and pelvic discomfort, she was struggling to manage Sibling 2s behaviour and having financial difficulties (not having sufficient credit on her gas account and subsequent gas capping).  Mother reported on a number of occasions that she was not sure how she would cope with the new baby.  It is recognised that professionals tried to support her and signpost her to appropriate services.  It is not clear if Mother was asked what help she needed or what would make life easier for her and her children; Mother may have interpreted offers of support as a criticism of her parenting or an expectation that she needed to do more at a time when she was struggling.  This reluctance to engage with services may have also been a further indication that Mother was in an abusive relationship and/or did not otherwise want professional scrutiny of the daily experiences of her children.    Learning Point 23: How can we improve the offer of support to pregnant women who are struggling to cope but keep agencies at arm’s length?  4.126. There are some gaps in information following the birth of Child A as the maternity notes were misplaced by Mother.  Accordingly, it would appear that there is no electronic or duplicate copies of the notes, which would make it difficult for the midwifery service to share information with other professionals working with the family. Learning Point 24: MYHT may wish to explore electronic and/or duplicate copies of mothers’ maternity notes  Father subject to Probation Supervision  4.127. In August 2017, Father was arrested for failing to provide a specimen for a roadside breath test.  In September 2017, he is found guilty and sentenced to a 12-month Community Order, to be supervised by Probation CRC. 4.128. His Probation Officer contacted Children’s Social Care to check if Father had any contact with his children.  Social care records suggest that there were no concerns for the welfare of the children or to suggest their needs are unmet, and that this was shared with the referrer.  Probation records state that a social worker rang to advise that the children were no longer subject to child protection; that the case had been closed in November 2016; and that they had previously been involved due to concerns about domestic abuse and substance misuse.  There is no record of a disclosure around a contact agreement or arrangements for Father to have supervised contact with his children.  29  Analysis 4.129. The Probation Officer was proactive in seeking information about Father’s contact with his children.  If information about the necessity for supervised contact had been shared, there may have been an opportunity for Probation to explore this with Father and do some digging around his relationship with Mother.   See Learning point 4: Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals.  This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to contact arrangements.  KPE 6:  Police callout 01:00 on 01/01/18 4.130. Police were called to a disturbance between Father and his brother at Mother’s address in the early hours of 01/01/18.  Father stated that his brother had too much to drink and was getting very aggressive; Father had booked his brother several taxis but his brother would not leave so Father requested Police assistance to remove him from the property.  Father reported that his children were present and that his partner was trying to get rid of his brother as he phoned police.   Father reported that he was not in fear of violence or distressed.   4.131. Officers responded quickly and determined that there had been no verbal argument and no substantive offences were recorded.  Father reported that his brother was intoxicated and did not want to leave, even when Father reported that he had to put his children to bed.  Officers saw Sibling 1 from the doorway and she appeared safe and well.  Father did not appear to be intoxicated.  Officers removed Father’s brother from the property and dropped him at the taxi rank so he could get himself home.   4.132. Responding officers were not aware of the domestic history between Mother and Father or that any arrangement existed to ensure that Father had supervised contact with his children.  Analysis 4.133. Police responded quickly to the incident and took appropriate action to remove Father’s brother from the property.   4.134. Given Father’s earlier report that children were present and partner was trying to get rid of his brother, it may have been prudent to speak to his partner and ensure that she and the children were not harmed/distressed and/or in need of support.  It is acknowledged that one of the children was seen and appeared to be safe and well. Learning Point 25: Police should consider how to ensure responding officers check on the safety and welfare of children when they are called to an incident  4.135. This incident was not flagged as a domestic and, accordingly, would not have routinely been shared with Children’s Social Care.  As already stated, it is unlikely that Police had flagged that there was an arrangement in place to ensure that all contact between Father and his children was supervised.   4.136. Responding officers were not aware of the history of domestic abuse between Mother and Father.  Although this was not a domestic incident, it did occur at Mother’s address.  There  30 may have been an opportunity for responding officers to consider their response to the incident in light of the domestic history. Learning Point 26:  Police to explore what information/history can be shared with responding officers before they attend an incident  5. Contribution of family 5.1. Family members may be invited to contribute to this review following the conclusion of all concurrent enquiries.  Specifically, key family members may be asked to comment on the services and support provided by various agencies and whether this was appropriate to their needs.  Family members may also be asked to comment on issues associated with the publication of the full overview report.   5.2. The independent reviewer will liaise with the KSCP to contact family members when all concurrent processes have been concluded.  Contacts with family members will be handled sensitively and, where possible, via a professional already known to the family.    Contribution of siblings 5.3. Child A’s siblings have not been directly spoken to and given their age, are possibly not aware that a CPSR is being undertaken.   5.4. The independent reviewer and CPSR coordinator for the KSCP met with the social worker that is currently working with the children to determine if it would be appropriate to speak directly to the children.  We agreed that it would be disruptive and potentially distressing for the children if we spoke to them directly; and they may not share much information about their interaction with professionals prior to Child A’s death.  However, the social worker provided valuable insights into the children’s daily experiences, their relationship with their parents, and the relationship between Mother and Father.  Where possible and appropriate, these insights have been reflected in the analysis section of the report.  6. Analysis 6.1. This section of the report provides an analysis of work undertaken with the family during the review period.   6.2. The terms of reference for the CPSR set out specific key issues to be considered as part of this review, and these issues provide the headings in this analysis.  It is important to note that this report has already highlighted a number of areas of learning, and the aim of this section of the report is to consolidate and build on these learning points. 6.3. It is clear from the story of how this case unfolded that Child A was born into a household marked by domestic abuse and low-level neglect.  While there a number of factors that may have contributed to parental neglect of the children – for example, the parents experienced parental rejection and were exposed to parental domestic abuse and substance misuse as young people – this analysis will focus largely on domestic abuse as the principal presenting risk factor in this case.  This is considered to be appropriate given that Mother and Father were  31 subject to MARAC during the review period (indicative of high risk of serious injury or death to the victim); and that the children were historically subject to an Interim Supervision Order due to ongoing concerns that the relationship between Mother and Father was continuing despite concerns raised by professionals that domestic abuse posed a risk of significant harm to the children.    Impact of domestic abuse on children 6.4. Domestic abuse has been identified by the NPSCCxvi, Ofstedxvii and the Department for Educationxviii as the most common characteristic of situations where children are at risk of serious harm, and the most common reason for children to be assessed by children’s social care services. 6.5. Extensive research points to the impact of witnessing physical incidents of domestic violence on children, including direct physical harm, greater behavioural and emotional problems, neurological differencesxix, more disordered attachmentsxx and learning problemsxxi.  There is also a significant overlap between domestic and other forms of harm – the NSPCC reports that a third of children affected by domestic abuse also experience other forms of abusexxii. 6.6. Crucially, caregivers in abusive relationships are often absent when their children are most in need of buffers from distress.  Children depend on cues from caregivers to regulate distress and, if caregivers are absent, threatening or being threatened during times of acute distress, it can affect the way children regulate emotions, respond to fearful stimuli, and develop trusting relationships with othersxxiii.   6.7. More recent research highlights the effects of non-physical forms of domestic abuse on children (see Ofsted 2017, Department for Education 2016 and Katz 2016) and that a focus on physical acts of violence fails to appreciate the ongoing, cumulative impact of coercive control.  Accordingly, professionals focused on physical acts of violence may fail to understand the daily lived experience of victims and children, how it is affecting them, and the level of risk posed by perpetrators.xxiv 6.8. Current models of intervention that wait until there is extreme violence, stalking, or an injury to a child are problematic in that, by the time abuse reaches this point, coercive control is likely to have severely eroded a victim’s personhood from the inside out, “the way carpenter ants devour a house”.xxv  The impact of coercive control 6.9. Women’s Aid define coercive control as “a deliberate and calculated pattern of behaviour and psychological abuse designed to isolate, manipulate and terrorise a victim into complete fearful obedience”.  Research indicates that there are similarities between coercive control and tactics used to control hostages, POWs and concentration camp inmates.  The negative impact of psychological abuse and coercive control is reported to be more difficult to recover from than physical violence.xxvi 6.10. Katz suggested that children experience behavioural and emotional difficulties as a result of coercive control, as the children in her study expressed similar difficulties whether there was severe physical violence in the relationship or not.  These children reported feeling isolated within the home because the perpetrator monopolised the victim’s time; exhibited language and developmental delay due to lack of stimulus and opportunities for play; and broader isolation as victims were prevented from spending time with family members, having visitors to the home or attending appointments.  Her research found that children’s freedom to say  32 and do things was narrowed both by perpetrators, and by themselves as a means to avoid further abuse.xxvii 6.11. In addition to direct effects on children, the impact of coercive control on victims can affect their capacity to provide effective care for their children.  As perpetrators control everyday behaviours, victims have no freedom to meet their own needs (or those of their children) without worry or fear, diminishing their options, choices and ability to make decisions for themselves.xxviii  Abuse can also directly undermine victim’s parenting by humiliating or belittling victims in front of their children and thus undermining their authority.   6.12. Professionals should also be aware that the presence of coercive control in a relationship can be an effective indicator of the likelihood of serious violence resulting in death of victims.  Victims of domestic homicide that do not have a history of previous physical abuse are likely to have been victims of extreme forms of coercive control.xxix Learning Point 27: Children’s social care to ensure assessments of risk to children include a thorough exploration of the risk presented by perpetrators of coercive control; and the ongoing, cumulative impact of coercive control on victims and children  Increased risks associated with separation 6.13. Research has pointed to shortcomings with current interventions that focus on separation from the abusing partner as the means to protect childrenxxx. 6.14. Professionals should always be cautious about victim’s assurances that an abusive relationship has ended.  Victims may advise agencies that a relationship has ended as a means to avoid further professional attention on the family.  They may minimise risks posed by an abusive partner in response to threats and coercion, or as a means of minimising the harm their children may suffer. xxxi 6.15. Furthermore, this approach underestimates that ongoing risk of harm to children in the post-separation periodxxxii.  Research indicates that, in 50% of cases, domestic abuse continues even after parental separation, often during child contact visits. xxxiii   6.16. Separation and the post-separation period are considered to greatly increase risk for victims and children, sometimes resulting in deathxxxiv. The triennial review of serious case reviews also highlights difficulties with separation and child contact as a trigger for a fatal incident in a number of cases.xxxv  Furthermore, 75% of domestic homicides occur within 12 months of separationxxxvi.   6.17. Child contact, which occurs in this context, can become a pivotal part of continuing abuse of victim, and children may be more likely to witness more severe abuse post-separation.  Research has demonstrated that more than half of victims with post-separation child contact arrangements with an abusive ex-partner continued to have serious, ongoing problems with this contact.xxxvii Learning Point 28: Key frontline professionals should continue to assess risk, and provide support for victims and children, post-separation in recognition of the increased risk posed by perpetrators during this period   33 Sufficient focus on Father 6.18. This report has identified that Father was largely missing from assessments of risk to Mother and the children (see 4.78), despite being recognised as a perpetrator of domestic abuse that should not have had unsupervised contact with his children without further assessment.   6.19. Research has highlighted that professionals often focus almost exclusively on the quality of care children receive from their mothers and female carers.xxxviii, despite the crucial role fathers play in their children’s lives and the extensive influence they have on children in their care.   6.20. This is particularly important in domestic abuse cases.  Despite the increasing recognition of male victims and increased reporting to professionals, women still comprise the majority of victim reports to agencies and are more likely to be physically harmed, report greater levels of fear and are more likely to be murdered or seriously harmed than male victims.xxxix   6.21. Safeguarding agencies often focus on the victim’s role (and often perceived inability) to protect children from domestic abuse and ignore the responsibility of perpetrators to keep their children safe from domestic abuse. xl 6.22. It is also important that fathers can be seen as both a risk and a resource for children and try to avoid narrow and stereotypical approaches that perceive fathers as one or the other.  The reality is perpetrators of domestic abuse are often socially marginalised and have their own personal histories that contribute to their abusive behaviour.  Interventions to safeguard children should respond to that reality.xli 6.23. This review highlights the following learning points in relation to professional focus on fathers:  Learning point 14: coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children.  Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children. Learning point 17: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children  Contact Arrangements 6.24. Prior to the review period, there were two written agreements (Father’s contact agreement in 2012; Mother’s contract of expectations in 2013) stipulating that Father’s contact with the children should be supervised by a family member.  These arrangements appear to have been put in place as a direct result of the domestic abuse that Father perpetrated against Mother.  The effectiveness of these agreements is discussed in s6.30 – 6.32 below. 6.25. In January 2016, professionals attending a Child in Need meeting clearly communicated that Father was to continue to have supervised contact with his children, and agreed that, if the relationship resumed and/or there were any further incidents of domestic abuse, social care would conduct a further assessment.   6.26. However, it is unclear if subsequent assessments and professional contact with the family actively explored Father’s contact with his children.  At an appointment with the paediatrician in June 2017, the GP record indicated that Sibling 2 was spending more time with Father.  The GP may not have been aware that all contact between Father and his children was supposed to be supervised.  Accordingly, it does not appear that the nature of this contact was explored, and or that this disclosure was shared with other professionals.    34 6.27. Furthermore, when Probation proactively sought to determine if Father was allowed unsupervised contact with his children, they were advised only that there was no current social care involvement.   6.28. With the benefit of hindsight and following discussion with the children’s current social worker, it is clear that Father essentially lived in the family home with Mother and the children.  This report has identified learning for children’s social care in communicating their expectations around child contact, captured in the learning point below: Learning Point 4 Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals.  This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to contact arrangements.  Written agreements 6.29. This report has identified that there were two written agreements, signed in 2012 and 2013 respectively, that were presumably still in force during the review period. 6.30. At the CiN closure meeting, social care was clear that concerns would be raised if Mother resumed a relationship with Father, and that any incidences of domestic violence would trigger another assessment.  There is no reference to the contract of expectations that Mother signed in 2013 to confirm that Father was not allowed to be at the home address; or to the Contact Agreement that Father signed in 2012.   6.31. Ofstedxlii is critical of the effectiveness of written agreements, given that they are often made with the victim and not the perpetrator who is the source of the abuse and therefore the risk.  Furthermore, written agreements have no legal status and consequently will have limited meaning or value to professionals in other agencies; and are unlikely to be monitored after social care have ceased their involvement with a family.  Learning Point 29:  written agreements are not effective tools for managing risk and their use should be avoided.  Where considered necessary, written agreements should, at a minimum, be clear about the duration that they are in force; the ways in which agreement will be monitored; and the consequence of breaking the agreement.  Any written agreement should be shared with all parties with parental responsibility and shared with universal services that are likely to remain in contact with the family after children’s social care withdrawn their intervention  To what extent were agencies aware of the history of neglect of the children and domestic abuse within this family? 6.32. It would appear from the chronology that all agencies involved with the family during the review period were aware of the history of neglect and domestic abuse within the family.  When the review period commenced in 2016, the family were still subject to a Child in Need plan due to historic issues of domestic abuse and neglect.  Children’s social care, Locala and the children’s school were represented at the final Child in Need meeting.  Kirklees Neighbourhood Housing were aware of the plan as they wished to attend the meeting, but it is not clear if information regarding domestic abuse and neglect had been shared with them.  WY Police had records of domestic incidents and of Mother’s assault on Sibling 1 in 2013.  MYHT, who provided maternity care for all of Mother’s pregnancies, were also aware of the previous supervision order and concerns regarding domestic abuse and neglect.  Probation CRC were  35 advised that social care had previously been involved due to issues with domestic abuse and substance misuse. 6.33. It would appear that most professionals had access to this information in their ongoing work with the family.  The Probation Officer was not aware that Father’s contact with the children was to be supervised by a relative.  Similarly, the Police that responded to the incident between Father and his brother on 01/01/18 were not aware of the history of the domestic abuse or that Father was not supposed to have unsupervised contact with his children.  This has been addressed in: Learning Point 4 Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals.  This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to contact arrangements.  Evidence of ongoing neglect or domestic abuse within the family 6.34. This review has highlighted a number of indicators of ongoing neglect and domestic abuse. It is recognised that a number of these indicators, taken individually, may not be indicative of significant risk.  However, with the opportunity to consider these indicators collectively, and with the benefit of hindsight, there are valuable lessons to support our understanding of risk in similar cases. • Neglect –  o referral to social care due to children appearing unkempt and hungry; and o poor home conditions. • Domestic abuse –  o Mother’s report of assault and coercive controlling behaviour.  o Mother declined to provide information about identity of father to Child A; and o Mother reluctant to engage with services.  Neglect 6.35. The NSPCC provides indicators of neglect under the following broad headings: • Poor appearance and hygiene (smelly/dirty, unwashed clothes, inadequate clothing, hungry, attending school without breakfast); • Health and development problems (untreated injuries, recurring illnesses, missed appointments, rashes, thin, anaemic, tired, faltering weight/growth, poor communication skills); and • Housing and family issues (unsuitable home conditions i.e. mess or no heating, left alone for a long time, taking on role of carer) 6.36. In April 2016, the School Nurse appropriately recognised Sibling 2’s presentation at school without breakfast and appearing unkempt as indicators of neglect.  Various professionals  36 noted concerns with home conditions, including dangerous levels of rubbish in the home and garden.  The need for a shared visual description of neglect was identified in: Learning point 20: The use of a visual home conditions assessment tool may be useful to enable professionals to share a collective, objective understanding of what constitutes acceptable home conditions  6.37. It is important to note that all children were believed to have a very good school attendance record (as per the s47/single assessment carried out by social care in September 2016); and all social care assessments concluded that there were no concerns about the children, which indicates that neglect was of a low level and Mother was assessed as being able to provide adequate care for the children.    Domestic Abuse Mother’s report of assault and coercive controlling behaviour 6.38. During the review period, there were three occasions where Police were called to Mother’s address for domestic incidents in which Mother was the victim.  This is not a significant number of domestic incidents, but indicative of ongoing abuse (as it is likely that not all incidents were reported). 6.39. Significantly, in September 2016, Mother contacted Police and reported that Father assaulted her and that she was a victim of coercive controlling behaviour.  The assault triggered a social care assessment, a number of offers of support for Mother, and a multi-agency risk assessment.  This review has already highlighted learning for professionals responding to domestic abuse victims in sections 6.4 to 6.17 above.  However, it is worth reiterating that professional focus on a seemingly isolated assault ignored a potential daily lived experience and cumulative impact of ongoing domestic abuse on both Mother and her children. 6.40. Mother’s own report of a domestic assault and being the victim of coercive control were the strongest evidence of domestic abuse during the review period.  Declining to provide information to professionals 6.41. Throughout her pregnancy, Mother declined to provide details of the father of her child to health professionals.  This report has already identified difficulties in proceeding with any form of assessment without evidence that Father was having regular, unsupervised contact with the family.  However, given the risk involved in domestic abuse cases and the impact of coercive control on victims, perhaps it would be beneficial to consider a different approach to risk assessment in these cases.   6.42. This is highlighted in: Learning point 9:  Risk assessment undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their partner/father of the unborn child.  This may be indicative of an ongoing, abusive relationship.  Reluctance to engage with services 6.43. During review period, Mother indicated that she was struggling to cope and wanted support, particularly with managing Sibling 2’s behaviour.  However, all subsequent offers of support were declined or appointments were not kept.    37 6.44. Mother had twice requested support from agencies in managing Sibling 2’s behaviour, and subsequently declined to engage with the family support worker to complete a single assessment.  The Single Assessment Guidance Notes stipulate that “Where consent is withheld it is the role of the practitioner to explain the assessment process in a way that enables the family to understand the benefits of sharing information and working in partnership with other agencies they should also explain what not sharing information will mean for them. In some cases refusal may be judged to indicate “deliberate avoidance” and this in itself may raise safeguarding concerns. There needs to be careful analysis and monitoring of refusals to engage so that an informed assessment of the level of risk can be made.”  Given the limited information available to the independent reviewer about these assessments, no analysis about whether this guidance was followed can be provided. 6.45. Sibling 2 was referred to the Children’s Emotional Wellbeing Service, but no appointments were ever made.  Mother also reported domestic abuse to Police, then declined to provide any evidence to support a prosecution and declined any support around domestic abuse.  She requested support with managing her anxieties in her pregnancy, then failed to attend her appointment.   6.46. It is recognised that these records are held by different agencies so this multi-agency pattern of non-engagement may not have been apparent to frontline professionals trying to support the family.  However, during the review period there were two opportunities for professionals to collate multi-agency information to conduct a risk assessment – the assessment undertaken by social care; and the MARAC, both of which were held in September 2016.  These processes should have identified Mother’s reluctance to engage with services.  6.47. These points are addressed in: Learning point 9:  Risk assessment undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their partner/father of the unborn child.  This may be indicative of an ongoing, abusive relationship.  Learning point 18:  social work assessments should respond to new and emerging information, even when new information contradicts what was previously known or believed to be true.  Managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information.    Learning point 19: MARAC provides an opportunity for information regarding the assessment and management of risk to be shared.  Agencies in attendance must ensure that information shared at MARAC is appropriately acted upon.    Rejecting professional advice 6.48. Mother was provided with advice around behaviour management for Sibling 2, and also advised that he did not have an underlying medical cause for his behaviour.  However, Mother was eager to secure a medical diagnosis for his difficulties rather than implement the advice offered by professionals.  It would appear that she was seeking an easier alternative to good, consistent parenting; and may have been attempting to distract professionals from other issues in the family home.   6.49. This is addressed in: Learning Point 5:  some parents may be intent on securing a medical diagnosis for a child’s behavioural problems and consequently ignore advice from health and other professionals about behaviour management.  A consistent, multi-agency response should be given to  38 parents in these cases to ensure that children receive an appropriate, authoritative parenting approach.  Implications for professional practice 6.50. The indicators of neglect and ongoing domestic abuse highlighted in this section of the report highlight the need for greater professional curiosity in cases where low level concerns are identified and families are reluctant to engage with services. 6.51. Greater professional persistence and challenge are needed to support families to engage with services.  In this case, Mother had previously reported that professionals had helped her to establish a more positive relationship with her child and she felt better within herself.  It is not clear from the record that there was any challenge to Mother about accepting support, particularly for Sibling 2, when she had previously found it so helpful.  With the benefit of hindsight, it would appear that Mother deliberately kept professionals at arm’s length because of her ongoing relationship with Father.  Her reluctance to engage with agencies, in the context of her historical abusive relationship, should have piqued professional curiosity about the daily lived experience for Mother and her children.  Was family history given appropriate consideration during decision-making? 6.52. Given that the history of neglect and domestic abuse was known to agencies working with the family, and there were indications of ongoing safeguarding concerns, this section of the report considers whether family history was given appropriate consideration during decision making.   6.53. Specifically, this will focus on: • routine checking of the bedrooms; and • The use of routine enquiry when exploring issues of domestic abuse.  Routine checking of the bedrooms 6.54. Previous child protection concerns (prior to the period under review) had identified issues with home conditions and lack of appropriate bedding/sleeping arrangements for children.  Learning in regard to how this history may inform social care assessments of families has already been identified in the following learning point:   Learning point 21:  Children’s Social Care assessments should consider the history of the case and ensure that any historical concerns i.e. home conditions, suitable sleeping arrangements for children etc are explored during any re-assessment process  6.55. There were at least 12 visits to the home address by professionals from a number of agencies, but it is not clear from agency records if any professional viewed the children’s sleeping arrangements during the review period.  This may be particularly relevant in light of historic concerns regarding the children’s sleeping arrangements, and also given how professionals found these arrangements following the death of Child A. 6.56. The author is aware that the relevant hospital trust is developing guidance for midwifery staff to consider inspecting the sleeping arrangements during post-natal home visits.  It may be prudent for other agencies to consider their role in supporting parents to provide appropriate sleeping arrangements for their children.    39 Learning point 30:  in light of historic concerns regarding suitable sleeping arrangements for children, all agencies should consider how they can support families to ensure that children have appropriate sleeping arrangements in place.  Routine enquiry in historic domestic abuse cases  6.57. Mother was asked about domestic abuse in her relationship as part of a routine enquiry.  Given her history of domestic abuse in her (previous) relationship, it may have been helpful for this routine enquiry to be more targeted and explore the risk posed by her ex-partner i.e. was he aware of the new pregnancy?  How did he/ how did Mother think he would react to the news?   6.58. This is addressed through the following learning point: Learning point 21:  Several agencies now employ routine enquiry in relation to domestic abuse.  If the case history and/or responses to the enquiry indicate historic domestic abuse, the current risk posed by violent partners/ex-partners should be explored.  Quality of assessments and decision-making during the specified period – specifically relating to family engagement? 6.59. During the review period, there were three assessments initiated by children’s social care: 1. In April 2016, a health professional referred the family to social care when concerns about neglect of Sibling 2 were identified in a routine screening undertaken by a school nurse.  It would appear that a social worker conducted a home visit and identified no concerns so no further action was taken. 2. In July 2016, there appears to be a referral to social care but it is not clear who made the referral (there is no record in the social care chronology).  A family support worker advised the school nurse that they were conducting a single assessment as Mother was finding it difficult to manage Sibling 2’s behaviour.  Two weeks later, the family support worker advised the school nurse that she had been unable to see Mother to complete a single assessment, and that Mother had subsequently advised that she no longer wanted it.   3. In September 2016, Mother reported her child missing.  When Police attended the address to investigate, she disclosed that Father had assaulted her.  This assault was significant enough to trigger a s47 assessment by Children’s Social Care. 6.60. This section will focus on the quality of the assessment in September 2016 triggered by the assault.  This is largely because it was the only assessment that was successfully completed, but also because the social work records of the other assessments have not been made available to the independent reviewer. 6.61. There are a number of shortcomings in the assessment.  There is a lack of appropriate focus on the voice of the children; does not adequately assess risk to the children;  lacks sufficient challenge to Mother’s assertions about the care of her children; and places an inappropriate responsibility on Mother to be solely responsible for safeguarding the children.  These points are addressed in more detail below.  Voice of the Children 6.62. The children were seen as part of a s47 assessment in September 2016.  However, they were not seen alone and incorrectly advised the social worker that they were not at home at the  40 time of the assault.  The subsequent Single Assessment noted that the children ‘appeared to have been coached’ in their responses.  However, there was no subsequent visit with the children to explore these discrepancies, invite them to comment on the conclusions reached in the assessment or ask them if they agreed with the outcome.   6.63. Kirklees Council Children’s Services procedures stipulate that:  The child must always be seen and communicated with alone in the course of a Section 47 Enquiry by the Lead Social Worker, unless it is contrary to his or her interests to do so.xliii 6.64. In the s47 assessment record, the social worker states that the children were spoken to together because of ‘age and cognitive abilities’.  It is not clear, but considered likely, that the children were spoken to in the presence of their mother.  At the time of the assessment, Sibling 3 was only 2½, and the social worker noted that Sibling 2 was ‘alleged to have ADHD and autism’ and was ‘observed to struggle with verbal interaction’.  There is no suggestion of additional support for Sibling 2 to enable him to contribute to the assessment process.  Working Together 2018 provides for professionals to ensure that children’s voices are heard and provide appropriate support to enable this to happen where a child has special communication needs.xliv   6.65. The assessment notes that Sibling 1 was six years old and spoke to the social worker.  The assessment notes that the children were anxious that the social worker was there to take them into care, and ‘confirmed they were not at home’ during the assault. 6.66. In the Single Assessment record (which was completed after the s47) noted that the children appeared to have been ‘coached’ in their responses to questions.  There is no reference in the Single Assessment to Sibling 1’s incorrect assertion that they were not at home when the assault occurred. 6.67. The Single Assessment notes that three home visits were completed as part of the assessment but there is no indication that the children were spoken to more than once.  It is disappointing that the Manager’s Decisions concludes that Mother declined social care intervention “which is there [sic] prerogative”, but there does not appear to have been any discussion with the children about what they might want. 6.68. The social worker could have tapped into existing professional networks around the children (i.e. school and health staff) to facilitate a direct conversation with the children without the presence of their mother.  Work with children using any of the recognised tools for information gathering (i.e. ‘three houses’) could have elicited more useful information about their daily lived experience than was obtained through an informal, apparently circular and contradictory, conversation with the children in front of their mother. 6.69. This is addressed in the following learning points: Learning point 12:  Social workers should challenge parent’s ‘programming’ children’s responses to social workers questions and explore the reasons behind this with parents Learning point 13:  Children being ‘programmed’ by their parents should warrant further exploration and social workers should speak directly to the children, without the presence of their parents, to explore their wishes and feelings.  6.70. This analysis has yielded a further learning point: Learning point 30:  Children’s Social Care ensure that children subject to social work assessments:  are spoken to alone;  are given the opportunity to comment on the assessment  41 completed by social workers;  and are asked if they agree with the outcome of the assessment.  Information gathering 6.71. The assessment had already commenced when information was provided by Leeds social care to indicate that Mother was having more contact with Father than she reported.  It would appear that this information did not affect the ongoing assessment being undertaken by social care.  Given that information about the incident was shared by two different sources, it is reasonable to assume that the information was received by social care.  However, it is not reflected in their chronology or assessment record, so it is unclear how this information was acted upon.   6.72. This is addressed in the following learning point: Learning point 18:  social work assessments should respond to new and emerging information, even when new information contradicts what was previously known or believed to be true.  Managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information.    6.73. Similarly, the information shared at MARAC would have highlighted that Mother was not supporting police action or engaging with agencies for support.  Furthermore, there is no information in the social care chronology or the assessment record to suggest that the social worker discussed improving security in the family home with Mother, which was an action agreed by the MARAC. 6.74. This is addressed in the following learning point: Learning point 19: MARAC provides an opportunity for information regarding the assessment and management of risk to be shared.  Agencies in attendance must ensure that information shared at MARAC is appropriately acted upon.    Lack of appropriate challenge  6.75. Mother made a number of assertions about her children, and her care of them, that were not challenged during the assessment process.  The s47 assessment includes an observation that Mother’s parenting style with Sibling 2 was between authoritarian and authoritative, and different to her approach to other children.  Mother reported that this was the strategy she had been given to manage his diagnosis within the Autistic spectrum.  It is recognised that the social worker may have been giving Mother the benefit of the doubt regarding his diagnosis, but even if he did have autism and/or ADHD, authoritarian parenting is not an appropriate approach to managing his behaviour. 6.76. This is addressed in: Learning Point 6:  An authoritarian parenting style is likely to exacerbate behavioural problems in children    6.77. In October 2016, Mother advised social care that she had put a new arrangement in place for Father’s contact with children to be supervised by a family member and that this appeared to be working well.  This was reported to be in response to the domestic incident in September 2016.  However, this arrangement for contact to be supervised by a family member (and not Mother) was put in place during the Child in Need plan, which closed in January 2016.  As  42 such, it was not a new arrangement and, in either case, would not (and did not) prevent Father from presenting at her address.  Mother could have applied for a legal order to prevent him from attending her address (and previously had one) but did not engage with agencies that could assist her to get such an order in place.  Assessment of risk 6.78. The s47 and subsequent single assessment conclude that: • Father is still controlling of Mother. • It was likely that Father would want regular contact with his children and if Mother does not comply then this will put her at further risk. • Mother was not truthful in her account of the incident; and  • The children were ‘programmed’ in their responses to social worker’s questions. 6.79. Given the presence of these risk factors, and that Mother had declined to support police action or accept support for managing risk associated with domestic abuse, the case warranted further exploration and monitoring from social care.    Inappropriate responsibility on Mother to safeguard 6.80. As part of the assessment process, Mother was asked if she thought that Father would ever hurt the children, and she replied that she did not think that he would.  This is discussed in section 4.69, and resulted in the following learning point: Learning point 14: coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children.  Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children.  6.81. It is also important to note that the Department for Education has highlighted that, while victims may be correct in believing that their partner would not physically harm their children, this does not acknowledge the severe emotional harm suffered by the children from living in a household where controlling behaviour is the norm, or the potential risks where a controlling partner does not get their own way.xlv 6.82. This is addressed in the following learning point: Learning point 27: Children’s social care to ensure assessments of risk to children include a thorough exploration of the risk presented by perpetrators of coercive control; and the ongoing, cumulative impact of coercive control on victims and children  Contingency Planning 6.83. Kirklees Children’s Services procedures stipulate that Contingency Planning is essential particularly when working with potential crisis situations and as part of Transfer and Closing Summaries, as professionals and families need to be aware when certain situations will lead to major concerns.  43 6.84. This is considered to be particularly relevant in domestic abuse cases.  The Department for Education notes that professionals need to acknowledge how difficult it is to achieve change in these contexts, and that ongoing monitoring and support will be needed.xlvi   6.85. This is addressed in: Learning point 7:  Consideration should be given to de-escalating to a Team Around the Family plan if low level concerns still need to be addressed when a decision is made to close a Child in Need plan  Management oversight 6.86. The decision to offer the family support via child in need appeared to have been reached following the initial assessment home visit, and on the basis that Mother acted appropriately by calling the Police, and that the children were not present.  Further information yielded during the assessment process did not appear to affect this early conclusion. 6.87. It is disappointing that management oversight did not highlight where the assessment would have benefited from clarity.  Specifically: • there was some discrepancy about whether Mother let Father into the house or he forced his way in. • on the balance of probability, we can conclude that the assault did take place. • Sibling 1 witnessed and was drawn into the abuse of her mother; and • Sibling 2 did not struggle with verbal interaction, as he was observed speaking to his siblings. 6.88. Analytical supervision may also have teased out some of the issues identified above relating to the voice of the child, lack of appropriate challenge, assessment of risk, inappropriate responsibility on Mother to safeguard and contingency planning.  6.89. Crucially, the social worker should have been supported to include Father in the assessment process.  Furthermore, persistent attempts to engage Mother in support should have been made.  Rather than accept Mother’s assertion that “what else can you offer that I have not already done”, she could have been supported to obtain relevant legal orders to keep Father away from the property; attended a Liberty Programme; attended parenting programmes to assist with managing home conditions and children’s behaviour; and Children’s Emotional Wellbeing Service could have provided some support for Sibling 2. 6.90. The Independent Reviewer is aware that, since the period under review, the Kirklees Children’s 10 Point Improvement Plan refresh: Creating the conditions for success has agreed an action to: • Strengthen appraisal, supervision and management oversight embedding the 3 obsessions of assessment, planning and recording. Observation of supervisions and feedback conversations will ensure opportunities for development and training are identified 6.91. As part of this action, a new supervision policy has been launched and is supported by briefings for managers and new templates have been developed and rolled out across the service.  These changes were implemented in 2018 so the effects may not yet be evident in practice, but the service will continue to monitor the implementation through the improvement plan.  44  Was consideration given to whether or not a pre-birth assessment was indicated prior to Child As birth? 6.92. Professionals that attended the practitioner event were clear that, if they had any evidence that Father was father to the unborn, they would have referred the case to children’s social care for an assessment. 6.93. However, despite being routinely asked to identify who the Father of her baby was and if there was any risk of domestic abuse in her relationship, Mother consistently declined to provide details of the father and denied any domestic abuse in her relationship.  The reviewer is aware of the difficulties in proceeding with any form of assessment without evidence that Mother had resumed her abusive relationship.  However, given the risk involved in domestic abuse cases and the impact of coercive control on victims, perhaps it may be beneficial to consider a different approach to risk assessment in these cases. 6.94. This is addressed in: Learning point 9:  Risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their current partner and/or father of their unborn child.  This may be indicative of an ongoing, abusive relationship.  7. Concluding remarks 7.1. The independent reviewer is conscious that any review of any case, regardless of the outcome, will reveal areas where professional practice can be improved.  It is considered unlikely that that the events described in this report directly caused Child A’s death, or that the improvements identified in this report may have prevented Child A's death.  However, child practice safeguarding reviews do provide us with an opportunity to analyse professional practice and use the lessons to improve our response to children.   7.2. In preparing this report, the author has had the luxury of access to records held by a number of agencies, and the opportunity to spend a lot of time discussing this case with professionals that were directly involved with the family, their managers, and members of the KSCP.  The level of analysis provided in this report, and the opportunity to reflect on professional practice in line with current research and best practice, is not possible in day to day decision making in the context of competing priorities, pressing deadlines and heavy caseloads.  It is important to note that the conclusions drawn in this report are provided with the benefit of hindsight, time to reflect, and with an objective distance from the family and those professionals that were working directly with them. 7.3. The value of this exercise, in reflecting on how one case can highlight important learning across services, is indicative of the value of reflective activities that are built into professional development but not always prioritised amidst increasing volume and demanding caseloads – reflective supervision, training and peer support networks.  The independent reviewer found the opportunity to discuss this case with professionals in other agencies invaluable and would hope that future assessments will demonstrate greater multi-agency input to decision making. 7.4. The author of this report also has the luxury of experience focussing exclusively on domestic abuse cases, and a good grasp of coercive control and its impact on victims.  Training in this area is increasingly available, but it may also be beneficial to have named, designated officers within agencies who can provide oversight and support in domestic abuse cases.  45 8. References   i Nishi Tripathi, 2015 ii Peter Sidebottom et al, 2016 iii Lindsey Hutchinson et al, 2016 iv CAADA, 2014 v Karen Evans, 2018 vi A Jenney, 2012 vii A Jenney, 2012 viii Kirklees Council procedures:  written agreements ix Katy Barrow-Grint, 2016 x Katy Barrow-Grint, 2016 xi NSPCC xii Ofsted, 2017 xiii Ananda Hall, 2007 xiv Crown Prosecution Service xv Ofsted, 2017 xvi Ravi K Thiara and Aisha K Gill, 2012 xvii Ofsted, 2017 xviii Triennial SCRs xix CAADA, 2014 xx A Jenney, 2012 xxi Karen Evans, 2018 xxii NSPCC xxiii A Jenney, 2012 xxiv Katz 2016 xxv Peter Sidebottom et al, 2016 xxvi Women’s Aid, 2016 xxvii Katz 2016 xxviii Katz 2016 xxix Women’s Aid, 2016 xxx Rachel Robbins, 2017 xxxi Peter Sidebottom et al, 2016ysis xxxii Cathy Humphreys, Caroline Bradbury-Jones, 2015 xxxiii CAADA, 2014 xxxiv Ravi K Thiara and Aisha K Gill, 2012 xxxv Peter Sidebottom et al, 2016 xxxvi Carolyn Rebecca Block, 2003 xxxvii Ravi K Thiara and Aisha K Gill, 2012 xxxviii NSPCC, 2018  46  xxxix Heather Coady, 2012 xl CAADA, 2014 xli Scourfield, 2006 xlii Ofsted, 2017 xliii Kirklees Children’s Services Procedures:  Section 47 enquiries  xliv Working Together 2018 xlv Peter Sidebottom et al, 2016 xlvi Peter Sidebottom et al, 2016   9. 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Department for Education, May 2016.  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf   Rachel Robbins, Kate Cook; ‘Don’t Even Get Us Started on Social Workers’: Domestic Violence, Social Work and Trust—An Anecdote from Research, The British Journal of Social Work, , bcx125, https://doi.org/10.1093/bjsw/bcx125.  Accessed from https://academic.oup.com/bjsw/advance-article/doi/10.1093/bjsw/bcx125/4616221   Ravi K. Thiara and Aisha K. Gill.  (2012) Domestic violence, child contact, post-separation violence:  Issues for South Asian and African-Caribbean women and children.  NSPCC.  Accessed from : https://www.nspcc.org.uk/services-and-resources/research-and-resources/pre-2013/domestic-violence-child-contact-post-separation-violence/  Scourfield, J. (2006) The challenge of engaging fathers in the child protection process. Critical Social Policy, special issue on gender and child welfare, 26, 2: 440-449. Accessed from: https://orca.cf.ac.uk/44771/2/Engaging%20fathers%20for%20CSP%20Scourfield.pdf  Women’s Aid – Federation Norther Ireland.  Coercive Control Consultation Brief. Accessed from:  https://www.womensaidni.org/assets/uploads/2016/07/Coercive-control-consultation-brief-FINAL-15-March-2016.pdf    2 Appendix One:  Full Terms of Reference A panel representing partner agencies of the Kirklees Safeguarding Children Board identified these terms of reference for a Local Child Safeguarding Practice Review concerning child A (DOB 31/10/2017–Date of death: 01/01/2018).    The terms of reference were developed in line with Working Together to Safeguard Children (2015 and 2018), and West Yorkshire Safeguarding Children Procedures, Chapter 10.1 (8.20).  Any amendments to these terms of reference as a result of new and emerging information will be agreed by the KSCP Chair.  Decision to conduct Local Child Safeguarding Practice Review This case is concerning the death of an almost 9-week-old baby, Child A, who was found lifeless by her father in the parents’ bed. Although at the present time it is suspect that the death was due to overlay the outcome of the post mortem has not yet received.  The family are well known to local services and were subject to a Child in Need Plan the previous year.  Local Child Safeguarding Practice Learning Event Key issues are to be explored during a full day Practice Learning Event. Senior Managers will be asked to nominate relevant managers and practitioners, to attend. Agencies required to provide representation are as follows:  • Children’s Social Care • West Yorkshire Police • North Kirklees Clinical Commissioning Group • Mid Yorkshire Hospital Trust • Locala • South West Yorkshire Partnership Foundation Trust • Community Rehabilitation Company  • Kirklees Neighbourhood Housing • School -Orchard Primary Academy   In this case, the Practice Learning Event will be made up of the following:   • Reviewer • Facilitator / The Local Child Safeguarding Practice Review Coordinator for the KSCP • Practitioners/Managers who worked with the family from the above agencies  Aim of Local Child Safeguarding Practice Review This Local Child Safeguarding Practice Review will enable individuals and agencies to learn lessons about the way in which they work both individually and collectively to safeguard and promote the welfare of children.  As far as possible, this review will be conducted in such a way that the process is a learning exercise for everyone that has been involved in the case.  3  Determining the scope and terms  The review will consider the following people, although others may be included in information gathering if this is considered appropriate:   Individual / Relationship Year of birth Mother 1993 Father 1991 Sibling 1 2010 Sibling 2 2011 Sibling 3 2014  The Local Child Safeguarding Practice Review should be conducted in a way that: • 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  • Considers how and what contribution may be sought from family members in respect of service delivery.  • Specifically considers ethnicity, religion, diversity or equalities issues that may be required; and • Is able to develop a multi-agency action plan in light of the findings.  Specific Issues to be considered The key themes for learning have been identified under six broad headings as follows:   • The quality of assessments and decision-making during your involvement with the family during the specified period – specifically relating to family engagement? • Was the family history given appropriate consideration during decision-making? • Is your service responsible for assessing home conditions and does this include routine checking of the bedrooms? • To what extent was your agency aware of the history of neglect of the children and domestic abuse within this family? • Was there any evidence of ongoing neglect or domestic abuse within the family e.g. children not being taken to school and/or appointments? • Was consideration given to whether or not a pre-birth assessment was indicated prior to Child A’s  birth?   4 Some of these issues may be revisited by the Child Safeguarding Practice Workstream as the review progresses and new information emerges.    Timescale to be considered for the Review The timeframe identified for the purposes of collating detailed information covers the period from 01.01.16 to 01.01.18 (changed from 01.01.17 to 01.01.16)  Agencies are expected to provide a chronology and analysis of significant events between these dates. They will also be required to review records and provide a summary of significant interventions prior to 01.01.16.    Family Involvement Family members will be given the opportunity to contribute to the Local Child Safeguarding Practice Review process by considering the services and support provided by various agencies and whether this was appropriate to their needs. Family members may also be asked to comment on issues associated with the publication of the full overview report.    It is recognised that contacts with family members should be handled sensitively and, where possible, via a professional already known to the family.    Review Process  The review is to be carried out using a systems methodology process, which involves frontline practitioners who worked with the family. Each of the agencies known to have had involvement with the family will be required to identify both practitioner and manager representatives to attend and participate in a full day Practice Learning Event.  Agencies to Contribute Agencies have confirmed knowledge of key personnel and have provided information via a combination of the following:  • A summary of historical interventions.  • A chronology of significant events occurring within the identified timeframe; and • An analysis of key decisions made.    The following agencies have provided information, but are not at this stage considered as likely to be able to add anything further to the learning from this Local Child Safeguarding Practice Review:  Pennine Domestic Violence Group  The Child Safeguarding Practice Review Workstream may require information from other sources as its work progresses.    Timescale for Completing the Local Child Safeguarding Practice Review  It is the aim of the Child Safeguarding Practice Review Workstream to undertake the review over a three-month period from the date of the appointment of a Reviewer. The author/reviewer will provide progress reports to the Child Safeguarding Practice Review Workstream; and the KSCP business unit will update the Department for Education, Ofsted and the National Panel of Independent Experts as appropriate.   Staff Affected by the Review The Child Safeguarding Practice Review Workstream acknowledges the potential for the process to cause distress for some practitioners. Guidance will be provided to those involved explaining the process and its purpose, and the SCR Coordinator will liaise with any agency where difficulties arise.   5 Role of the Reviewer  The Reviewer is to be an individual with relevant experience and expertise that is independent of all local agencies and professionals involved in the Local Child Safeguarding Practice Review, the Child Safeguarding Practice Review Workstream and the Kirklees Safeguarding Children Board.    Outside Experts The Child Safeguarding Practice Review Workstream will consider if any aspect of the review requires expert advice to assist with understanding crucial aspects of the case and commission independent professionals as required.  Parallel Investigations, Other Reviews, Coroner’s Inquiry and Criminal Investigations The review will ensure that findings from other relevant processes are incorporated into the Local Child Safeguarding Practice Review report.  The panel will consider the impact of such processes on timescales for completing the review.  Should the case give rise to other parallel investigations of practice, the Child Safeguarding Practice Review Workstream will liaise with the appropriate agencies to develop a coordinated review process to ensure the timely sharing of information.  The Child Safeguarding Practice Review Workstream will liaise with relevant agencies to consider these terms of reference in light of other similar types of review, including internal agency reviews, to enable timely sharing of information.  The Child Safeguarding Practice Review Workstream will liaise with relevant officers undertaking any criminal investigations to ensure that relevant information can be shared without compromising any aspect of a criminal or coronial process and/or incurring significant delay in the review process.  Relevant Research The Local Child Safeguarding Practice Review will consider relevant research, including lessons from Local Child Safeguarding Practice Review’s previously undertaken in the area, and the implications for this Local Child Safeguarding Practice Review.  Publication of Reports and Media Interest The completed reports will be submitted to the Kirklees Safeguarding Children Board for their oversight and agreement. Following this, and in accordance with Working Together 2018, the Local Child Safeguarding Practice Review and Action Plan will be provided to the National Panel of Independent Experts 7 working days in advance of publication.   The presumption in Working Together 2018 is that all reports will be published. It states that Local Child Safeguarding Practice Review reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case; however, it also states that LSCBs should have regard to the advice of the National Panel when considering publication.  Reports will be published on the KSCP website. Names and other identifying elements will be removed in the interests of maintaining anonymity.   Kirklees Safeguarding Children Board legal advisers, acting as advisors to the Child Safeguarding Practice Review Workstream, will undertake scrutiny of the Review and Action Plan prior to publication to ensure no contravention of Human Rights legislation or relevant Court Orders pertaining to the case   The Child Safeguarding Practice Review Workstream will consult with media contacts in relevant agencies to develop an appropriate media strategy for this Local Child Safeguarding Practice Review if it becomes necessary.  6 Appendix Three:  List of Learning Points The Kirklees Safeguarding Children Board will be responsible for ensuring that the learning points identified in this report are translated into tangible improvements in services for children.  A list of all learning points identified in this report are provided below to assist this work.  Learning Point 1: If children have recently moved schools, the previous school should be invited to multi-agency discussions around safeguarding children. Learning Point 2: Relevant housing providers should be routinely invited to multi-agency discussions around safeguarding children. Learning Point 3: Consideration should be given to de-escalating to a Team Around the Family plan if low level concerns still need to be addressed when a decision is made to close a Child in Need plan Learning Point 4: Children’s social care should explore how their expectations around child contact should be communicated to parents and professionals.  This should include clear consequences for failure to adhere to agreed contact arrangements, recommendations for professionals in other agencies to record/flag the arrangements for supervised contact; and a clear process for reporting breaches to agreed contact arrangements. Learning Point 5: Some parents may be intent on securing a medical diagnosis for a child’s behavioural problems and consequently ignore advice from professionals about behaviour management.  A consistent, multi-agency response should be given to parents in these cases to ensure that children receive an appropriate, authoritative parenting approach. Learning Point 6: An authoritarian parenting style is likely to exacerbate behavioural problems in children   Learning Point 7: Exposure to domestic abuse may cause behavioural and emotional problems in children.  Professionals should clear about the research that supports this and evidence the work done with parents to increase their understanding of the impact of  Learning Point 8:  ‘ASK CAMHS’, the initial point of contact for those who have concerns about a child or young person’s emotional or mental health, should assist professionals in in providing clear, consistent advice to parents about obtaining appropriate support for children Learning Point 9: Risk assessments undertaken in the context of historic domestic abuse should consider the potential significance of refusal to engage with services and refusal to name their current partner and/or father of their unborn child.  This may be indicative of an ongoing, abusive relationship. Learning Point 10:  Professionals should advise parents of any concerns regarding their children and/or gain parents’ consent for someone from children’s social care to contact and offer support (unless doing so would put the child at risk) Learning Point 11: Victims may retract statements or disclosures regarding domestic abuse.  The reasons for this are varied and complex, but fear of the consequence of disclosure and ongoing feelings for the perpetrator are likely to be contributory factors.  Retractions should not be seen as evidence that abuse has not occurred  7 and may be indicative of ongoing contact between the victim, the perpetrator and their children.   Learning Point 12: Social workers should challenge parent’s ‘programming’ children’s responses to social workers questions and explore the reasons behind this with parents Learning Point 13: Children being ‘programmed’ by their parents should warrant further exploration and social workers should speak directly to the children, without the presence of their parents, to explore their wishes and feelings. Learning Point 14:  Coercive control has a detrimental impact on victims and may affect their capacity to assess risk and appropriately safeguard their children.  Victims should not be expected to take sole responsibility for keeping their children safe from perpetrators, particularly when perpetrators have parental responsibility for their children. Learning Point 15: Social care should not use the police evidential test as a basis for determining whether or not an assault took place.  Learning Point 16: Professionals should be mindful that an initial report of domestic abuse is likely to be accurate, and subsequent retractions are likely to be false Learning Point 17: Perpetrators of domestic abuse, particularly those with parental responsibility for their children, should be directly spoken to about the impact of their abusive behaviour children and included in the assessment process/safety plan for children Learning Point 18:  Social work assessments should respond to new and emerging information, even when new information contradicts what was previously known or believed to be true.  Managers should provide supportive challenge to ensure that social workers respond appropriately to conflicting information.   Learning Point 19: MARAC provides an opportunity for information regarding the assessment and management of risk to be shared.  Agencies in attendance must ensure that information shared at MARAC is appropriately acted upon.   Learning Point 20: The use of a visual home conditions assessment tool may be useful to enable professionals to share a collective, objective understanding of what constitutes acceptable home conditions Learning Point 21: Children’s Social Care assessments should consider the history of the case and ensure that any historical concerns i.e. home conditions, suitable sleeping arrangements for children etc are explored during any re-assessment process Learning Point 22:  Several agencies now employ routine enquiry in relation to domestic abuse.  If the case history and/or responses to the enquiry indicate historic domestic abuse, the current risk posed by violent partners/ex-partners should be explored. Learning Point 23: How can we improve the offer of support to pregnant women who are struggling to cope but keep agencies at arm’s length? Learning Point 24: MYHT may wish to explore electronic and/or duplicate copies of mothers’ maternity notes Learning Point 25: Police should consider how to ensure responding officers check on the safety and welfare of children when they are called to an incident  8 Learning Point 26:  Police to explore what information/history can be shared with responding officers before they attend an incident Learning Point 27: Children’s social care to ensure assessments of risk to children include a thorough exploration of the risk presented by perpetrators of coercive control; and the ongoing, cumulative impact of coercive control on victims and children Learning Point 28: Key frontline professionals should continue to assess risk, and provide support for victims and children, post-separation in recognition of the increased risk posed by perpetrators during this period Learning Point 29:   Written agreements are not effective tools for managing risk and their use should be avoided.  Where considered necessary, written agreements should, at a minimum, be clear about the duration that they are in force; the ways in which agreement will be monitored; and the consequence of breaking the agreement.  Any written agreement should be shared with all parties with parental responsibility and shared with universal services that are likely to remain in contact with the family after children’s social care withdrawn their intervention Learning Point 30:   in light of historic concerns regarding suitable sleeping arrangements for children, all agencies should consider how they can support families to ensure that children have appropriate sleeping arrangements in place. Learning Point 31:   Children’s Social Care ensure that children subject to social work assessments:  are spoken to alone; are given the opportunity to comment on the assessment completed by social workers; and are asked if they agree with the outcome of the assessment..  