Serious non-accidental injuries to a baby boy, identified by GP in March 2010. Child E was subject to a pre-birth child protection plan and subsequently became the subject of a care order; he was living in foster care during the period over which his injuries were sustained. Foster mother was arrested and charged with wilful neglect. Issues identified include: pattern of non-reporting by foster parents, concerning minor injuries to children in their care; impact of foster father's ill health on family's capacity to care for Child E; and insufficient integration between child health and social care services and adult health and fostering services. Identifies learning, including: need for the active participation of health care professionals in assessment, review and care planning for looked after children; the association between shortage of affordable fostering resources and increased risks to children. Makes recommendations for Reading Local Safeguarding Children Board.
      
 Title:  Serious case review: overview report: a baby known as Child E. LSCB: Reading Local Safeguarding Children Board Author: [Reading Local Safeguarding Children Board] Date of publication: [2012]  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1  Reading Local Safeguarding Children Board   Serious Case Review Overview Report   Subject:  A Baby known as Child E   Strictly Confidential  Independent Consultant February 2011     2 1. Introduction  There can be no meaningful review of current inter-agency practice without serious acknowledgement of the pressures facing individuals, organizations and service users as they engage directly with the multiple consequences of financial constraint and public sector reform driven by the current government. It is in this context that the following review should be read.   Child E, the child of M-CE and F-CE, was born in hospital on ||| |||||| ||||. The baby boy was the subject of a pre-birth child protection plan; |||| || ||| ||||| ||||||| |||| |||| |||||| || ||| |||| || ||| ||||||| |||| |||| |||||| |||| ||||| |||||||| An Interim Care Order was granted on the |||| |||||| |||| and Child E was discharged from hospital to foster care.  At the direction of the Court, a residential parenting assessment involving Child E and his mother was initiated in |||| 2009, but was unsuccessful. Child E returned to foster care in July, 2009 whilst plans for his future were developed. A Care Order and Placement Order were granted on ||| November, 2009 although the final written judgment was delayed until March, 2010.  During this period, Child E remained in foster care whilst preliminary introductions to adopters were arranged. On |||| March, 2010, following a visit to the GP, it was discovered that Child E had suffered 5 fractures of varying ages. A Child Protection investigation was conducted by the police. Subsequently, Child E’s foster mother was arrested and charged with willful neglect. Child E’s potential adopters withdrew their application and Child E, who recovered well from his injuries, was placed with alternative carers. Active family finding efforts continue on his behalf.  |||| ||||| ||||||| |||||||| || ||||| ||| ||| ||||||| |||| |||| ||||||| ||| ||||| |||| |||| |||| ||||||||| |||| ||| |||||| |||||  1.2 Reasons for conducting a Serious Case Review Working Together to Safeguard Children (2010) s.8.1 makes it clear that the prime purpose of a Serious Case Review (SCR) is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children. In order for this purpose to be fulfilled, • lessons learned must be acted on quickly and disseminated effectively • recommendations should be implemented in a timely manner • children’s daily life experiences, wishes and feelings must be at the centre of an SCR  3Sections.8.11 and 8.12 (2010) provide guidance regarding the circumstances in which Local Safeguarding Children Boards (LSCBs) should consider whether a SCR should be conducted. In the case reviewed below, the following criteria are pertinent: • A child was seriously harmed following a violent assault perpetrated by another child or an adult. (s.8.11) • A child was abused or neglected while being looked after by the local authority. (s.8.12) The Reading LSCB Serious Case Overview Group met initially on 26th April, 2010 and decided to recommend that a Serious Case Review be undertaken. All relevant records had been secured at this time.  Although it was noted that there were no known concerns about the way in which local professionals worked together, the nature of E’s injuries, and his status as a Looked After Child clearly warranted the scrutiny of a SCR (Working Together to Safeguard Children, 2010, s.8.11 and 8.12). The Overview Group agreed, on the advice of the Police, to defer commencement of the SCR until it was clear that its conduct would not interfere with the active criminal investigation. This decision was reviewed at the Overview Panel meeting on 19th August, 2010 and on 2nd September, 2010 the Police advised that their investigations would no longer be impeded by the conduct of an SCR. The Chair of the LSCB endorsed the recommendation to proceed. Relevant Chief Executives were informed immediately; GOSE and Ofsted were appropriately notified on 10th September, 2010.  1.3 Serious Case Review Panel A Serious Case Review Panel was established on 19th, August, 2010, chaired by Stephen Barber, the Independent Chair of Reading LSCB. Mr. Barber also acts as independent chair of West Berkshire and Wokingham LSCBs. He is a former Director of Social Services and a former inspector. He has served on the conduct committee of the General Social Care Council and as trustee or adviser of several charities. His independence is thus clearly established.   The SCR Panel is comprised as follows: Agency Panel Member Service Reading Borough Council Head of Children’s Social Care Social Care NHS Berkshire West (PCT) Designated Nurse Child Protection PCT Commissioning Thames Valley Police Berkshire West Chief Inspector and Detective Chief Inspecter Police NHS Berkshire West Community Health (PCT) Deputy Manager Community Health PCT Provider Services  4Reading Borough Council Service Manager, Safeguarding Adults Adult Social Care NHS Berkshire East (PCT) Designated Doctor Advisor Royal Borough Windsor and Maidenhead Service Manager, Berkshire Adoption Advisory Service (BAAS) Advisor Royal Berkshire NHS Foundation Trust Deputy Director, Corporate Affairs  Hospital Trust  Because of the professional context and the nature of the practice issues arising in the case, two advisors were invited to join the SCR Panel. |||||| |||||||| a specialist in fostering and adoption, has actively contributed through Panel meetings, correspondence and commentary on the Social Care IMR and on Overview draft reports. ||| |||||| ||||||| Designated Doctor Child Protection Berkshire East, was invited to act as advisor to the Health Overview author, in part, compensating for the continuing lack of a Designated Doctor Child Protection in West Berkshire1. She is a Consultant Pediatrician who has had no involvement with the people associated with the SCR.  ||| ||||||| has not contributed directly to the work of the SCR Panel.  The SCR Panel is supported by |||| |||||, LSCB Business Manager, and |||||| |||||||,  LSCB Business Support Coordinator. It has met on the following dates to progress its work: 23rd September 2010 25th January 2011  18th  October 2010 17th February 2011 14th December 2010 24th February 2011 1.4 Terms of Reference It is widely recognized that the processes involved in determining the scope of a SCR are complex and iterative; demanding several amendments if crucial areas of inter-agency                                                             1 The post of Designated Doctor in Berkshire West has been vacant since the retirement of the last post holder in the summer of 2010. The matter is currently the subject of active correspondence initiated by Stephen Barber in his role as Independent Chair of three affected LSCBs (Reading, Wokingham and West Berkshire).       5learning are to be accurately identified.2 Consequently, the earliest Terms of Reference developed by the SCR Panel have been reviewed regularly and modified as information emerged through the work of Individual Management Review (IMR) authors and the SCR Panel. The work has benefitted from the consequently increased clarity of expectation and focus. The 12th and Final Terms of Reference, circulated on 24th February, 2011 specified the issues and questions to be addressed by the review: • To establish a factual comprehensive chronology of the action taken by each agency and/or professional(s) in contact with the child, his carers and family over the period of time set   • To consider any issues arising from the Child’s identity and ethnicity  • To analyse the professional practice of those involved, the decisions made, and the actions taken or not taken in order to inform future developments both in terms of best practice and the need for change.   • To consider the quality of medical & health examinations of the child to ascertain whether the child injuries could and or should have been identified earlier.   • To analyse inter-agency working and service provision for this child   • To assess whether decisions and action taken in the case comply with the policy and procedures of each organisation and the Reading Safeguarding Children Board   • To consider whether there were organisational difficulties being experienced within or between agencies. If so, to consider whether they are relevant for this review and if so  to identify their impact  • To establish whether national, interagency and single agency policies adequately support the management of this case.  And, furthermore, in complying with guidance (Working Together to Safeguard Children, 2010) the Terms of Reference emphasised that it is important   • To record lessons learnt and to recommend appropriate inter-agency action in light of the findings  • To highlight good practice, as well as ways in which practice can be improved.  • To consider seeking contributions from the birth parents and carers if appropriate  • To develop a clear multi agency action plan from the overview report.                                                             2 The recently reported pilot of the SCIE “systems” model for SCRs conducted in the North West of England found that “not starting with a detailed Terms of Reference but going in with an open mind” was one of the features of SCRs that best supported effective learning. (SCIE At a glance 34, November, 2010 p.3)   6 • To publish the overview report and executive summary following Government guidance on redaction and consider issues relating to any criminal court proceedings that may be relevant at the time of completion of the SCR  • To keep under consideration the need for other agencies to carry out Individual Management Reviews should new information emerge.   • To keep under consideration the need to revisit the terms of reference as the review progresses and any new information emerges and seek the Panel and Chairs approval for such changes.   1.5 Timescale The timescale for the SCR is complex. The primary focus is the period of time from |||| March 2009 (Interim Care Order following the birth of Child E) to |||| March, 2010 (multiple injuries diagnosed whilst Child E was in foster care). Additionally, the Health IMRs were asked to cover the period up to the time the hospital provided statements to the Police.   Health and  Social Care IMR authors were asked to review the fostering history of Child E’s carers3, from the time of their approval by the Local Authority |||||| to the time of the incident. 1.6 Independent Overview Author The SCR Panel commissioned an Independent Overview Author on 14th September, 2010. She is a professionally qualified social worker. After working in children’s services and as a social work lecturer, she developed an independent consultancy in 1990 with a particular focus on inter-agency work in child protection, a field in which she has published widely. She has acted as the Independent Chair of an ACPC, chaired its Serious Case Review Group for several years and has experience as an independent author for several LSCBs with whom she also works developmentally.  She has no personal or professional connection with Reading LSCB and can therefore be deemed appropriately independent.  1.7 Methodology The Overview Report is based on Individual Management Reviews completed by the following agencies, all of whom had contact with Child E, his family and carers during the specified timescale for review. The Health Overview Report was particularly helpful, the author having ensured that all relevant information across the health system was brought together and systematically evaluated. Supplemental information gathered is also noted below.                                                               3 This direction applies to the foster carers referred to as MFC3 and PF, the F family, who looked after Child E f|||| |||| ||||| |||| ||| |||||||| || ||||||| |||||   7Name of Agency Nominated IMR Writer IMR Sign Off Reading Borough Council; Children’s Social Care |||||||| |||||||||| Independent Author ||||| ||||||| Head of Social Care NHS Berkshire West Community Health Services (BWCHS) |||||||| |||||||| Named Nurse Child Protection ||||| |||||||||||| Interim Managing Director Berkshire West  Community Health Services NHS Berkshire West PCT (GP) ||| |||||| |||||| Named Doctor Child Protection ||| ||||| ||||||| Medical Director NHS Berkshire West Royal Berkshire NHS Foundation Trust ||||||| |||||| Matron for Children & Young People, Lead for Child Protection ||| |||||||| ||||||| Medical Director, Royal Berkshire NHS Foundation Trust Health Overview Report |||||||| || ||||| |||||| Designated Nurse Child Protection NHS Berkshire West PCT ||| |||||| Director of Partnerships and Joint Commissioning  Supplemental Information • Thames Valley Police: Brief report outlining the nature of the criminal investigation.  • Minutes of Child Protection Conferences held in relation to Child E ( ||||||08, ||||||09, |||||09)  • Minutes of the hospital Discharge Meeting (|||||.09) in relation to Child E.  • Independent Reviewing Officer’s Reports of Looked After Children Reviews ( |||||.09, ||||||09, |||||.09, |||||.09, |||||.10) • The Reserved Judgment |||||||10) giving reasons for care and placement orders in respect of Child E.  • Annual Foster Carer Review (updated May, 2009) in relation to Foster Carers F.  • Protocol regarding delayed judgments for the South Eastern Circuit (08.02.10) • |||||||| |||||| || ||||||| || ||||| ||| ||| |||||||||||||| ||||| ||||||  8The Overview Author has attended all SCR Panel Meetings in order to facilitate the identification of key issues arising from the work. A meeting to explore the role of the Court in the case was held with the Designated Family Judge for Berkshire on 18th January, 2011.4  Current child protection procedures were consulted and additional material has been used to develop a fuller understanding of the practice context.  Care has been taken to follow the guidance provided by Working Together to Safeguard Children (2010) The Department for Education, and Reading LSCB in the conduct of the SCR  and the preparation Overview Report. Its method and approach reflect the learning arising from LSCBs who have adopted a systems approach to SCRs.  1.8 Involving the Children and Parents.  Child E is too young to be directly involved. The Serious Case Review Panel carefully and sensitively considered the potential contribution of Child E’s birth parents to the review. The Panel agreed that, alongside formal notification, the independent IMR author from Social Care would ensure that M-CE and F-CE understood the purpose of the Serious Case Review and would invite them to participate through interview. Both parents accepted the invitation and were seen separately.  ||||| ||||| || ||| ||||||||| || | |||||| |||||| ||||||||||| An especially adapted template was used to frame the meeting (see Appendix 2) and an account of the birth parents’ views forms an important part of the Social Care IMR.   1.9 Genograms The following genograms represent 1) Child E’s birth family, and  2) the foster family who were caring for him at the time of his injuries and with whom he spent the majority of time as a Looked After Child ||||| |||| | |||||| |||||.                                                            4 The Court is not subject to the statutory obligations laid on other organisations to provide an Individual  Management Review when an SCR is commissioned by the LSCB. Given the central role in decision making that the Court played in this case, the SCR Panel was determined to ensure that the judicial perspective was sought and accurately represented. The Chair of the SCR Panel, with the help of the Borough’s Joint Legal Team, arranged a helpful meeting among himself, the Overview Author and the Designated Family Judge for Berkshire to discuss practice matters arising from the SCR.   9 2. Narrative Summary to Support Integrated Chronology (Appendix 1):    2.1 Child E’s first months M-CE, a ||||| |||||| ||||||| |||| || ||||| ||| ||||| ||| |||| ||||| || | ||||||| |||| Child E, by ||||||| |||||||| ||.3.09).  Child E was her ||| ||||| ||| |||| ||| |||||| |||| ||||| | ||||| ||||||| |||| ||||| ||||||  M-CE |||| ||||||||||| |||||| |||||| |||||| |||||||| ||||| ||| |||||||||||| |||| || ||| |||| || ||||| ||| ||||| ||| |||| ||||| || | |||||||||| ||||||||  M-CE and F-CE, |||| |||| || ||||| |||| | |||||||| ||||||||||| |||| ||| |||||| |||||||||| |||||||||| | ||||||| Child E is of mixed race and dual heritage. ||| |||||| |||| || |||||| |||||||| |||||| || ||| ||| || |||| |||| ||||||| ||||||| ||| |||||||||| |||| ||||||||||| ||| ||| |||||||| || |||| |||||||| ||| |||||| ||||||| || ||||||| ||| |||| || ||||||| | |||||| |||| || |||| |||| ||| ||||| |||||||| |||||| || |||| |||||||| ||| || | ||||||||| |||||| |||| |||||| ||| ||| || ||| ||||||| ||| || |||| |||||||| ||||| || ||| |||||||| || ||||| ||||| ||| ||||||| |||||||| ||||| ||| |||| ||||| |||| ||| ||| ||| |||| ||||||| |||| ||| ||||||| ||| ||||| |||||| ||| |||| ||| |||||| |||| ||||||| |||| |||| || ||||||||||||||| ||||||||||||| ||||| || ||| ||||||||| || ||| |||| ||||||||||| |||| ||||||| ||| |||||| || |||||| ||| ||||| || ||||||||| ||| ||| || |||||||||| ||||||||||| || ||| ||||| ||||| ||||||||||  M-CE’s |||| ||||| |||| || | ||||||||||| || ||||||||||||| ||||||| |||||| || ||| |||||| |||| |||| |||||||||| ||||||| |||| ||||| |||||||||| |||||||| Given this history, a pre-birth assessment was appropriately undertaken and at the time of his birth, Child E was the subject of a Child Protection Plan which included plans for his adoption, a course of action which both parents contested. Following E’s birth, the Local Authority made application to the Court.   An Initial Court Hearing held on |||| March, 2009 was adjourned in order to allow a Children’s Guardian to join the proceedings. On the |||| March, an Interim Care Order (s.38 Children Act 1989) was granted and Child E was discharged from hospital to Foster Carers FFC2. Contact with his mother was arranged three times per week, and once a week with his father. The chronology notes communication problems both within Health services and between Health and Social Care during the period immediately following Child E’s discharge from hospital; an issue that recurs throughout the review period and is fully discussed by the Health Overview author. A new birth visit was completed by HV2 on |||| March, 2009 and following a further visit on |||| March, all appropriate advice, screening and paperwork was completed, including the establishment Child E’s Personal Health Record, commonly referred to as “the Red Book”.    10Unfortunately, two weeks following placement, Child E moved temporarily (||||09 – |||||09)  to Foster Carers FFC3 whilst the FFC2 Family were on holiday – a first indication in this case of the pressure on fostering services and of Child E’s difficult journey towards permanence.   2.2 Residential Parenting Assessment The Court directed the Local Authority to make provision for M-CE’s parenting capacity to be assessed in a residential setting at a hearing on ||| April, 2009. A specialist placement was quickly secured in a neighbouring authority and preparations for admission in late May were initiated.  During the remainder of April and May, 2009 health records show that in spite of the early disruption caused by the short term change in care, Child E was making good progress and was being closely monitored by health services5. In anticipation of residential placement with his  mother, E was having daily contact with her. His first Looked After Child (LAC) Review was held on ||| April, 2009 but no health professional was invited or involved, nor were reports requested. As the Health Overview Author points out, “it is a statutory requirement that a looked after child receives an initial health assessment undertaken by a suitably qualified medical practitioner within 28 days of a child becoming looked after”. 6 Unfortunately, this critical omission became the norm for LAC reviews in this case. The review did address |||||| ||||||| || ||| |||||||||| || ||||| ||| |||| ||||| |||||| |||||| ||||||||||| ||||||||| |||||||||| ||||| |||||||||||| ||| ||||||| |||| |||||||||||| |||||||| |||| |||||| ||| ||||||||| ||||| || ||| ||| || |||||| ||||||| a matter that does not seem to have been given adequate attention in terms of its consequences for Child E’s immediate care.  The Social Care author (4.2.4) highlights the financial pressure on workers to use in-house foster placements when she discusses the earlier decision to use Foster Carers FFC2 when it was known that E would have to be cared for by others within a fortnight of placement. Similar pressures may well account for the fact that FFC2 was not secured as part of a contingency plan for Child E. However, given 1) |||||| ||||||, 2) ||| ||| || ||| |||||| |||| 3) ||| |||| |||||| ||||||||| |||||| ||| ||||| |||| ||| |||||| ||| |||| ||| ||||| || |||||| |||| ||||| || ||| |||| |||||||| ||| | |||||| |||||||| to have been consulted and a case made to fund the retention of Foster Carers FFC2 whilst M-CE’s parenting capacity was assessed.  The fact that it did not happen is a stark example of the direct consequences for children of the current financial pressures on local authorities.                                                               5 Visit to GP for 6 week check‐up (|||.04.09) HV2 visits foster home (|||.04.09) Foster carer brings E to clinic where he is seen by HV2 (|||.05.09)  First immunizations ( |||.05.09) Community Nursery Nurse visits Child E in foster home (||||||09).  During these visits it was noted that E had dry skin and, latterly, a rash on his face. 6 Health Overview Report p.10  11Foster Carer FFC2  helped M-CE to prepare to assume his care, and on |||| May, 2009 M-CE and Child E were admitted to ||||||| |||||||7. It is important to note that at the time of admission Child E, who was 2.5 months old, “looked well”, was gaining weight, on the 75th centile, and was described as a “happy baby”.  Shortly after admission, a Review Child Protection Conference was held and, as is common practice, decided that it was no longer necessary that Child E be subject to a Child Protection Plan8. Again, there was no health representation at the meeting.  In spite of the failed connection between Health and Social Care professionals, Child E’s medical records had been transferred to the NHS Trust in which ||||||| ||||||| was situated, and his health and development continued to be monitored appropriately; M-CE took him to clinic regularly, |||| ||| |||| |||| ||| ||||||||||||| ||||| |||||||||||| |||||| ||| |||| || ||| |||||  2.3 Return to Foster Care Early concerns about M-CE’s care of E were recorded at his second LAC Review9, held on |||| July, 2009 and were elaborated at a mid-way placement meeting held at ||||||| ||||||| on |||| July. It had become clear that Child E could no longer be safely cared for by M-CE. |||| |||||| ||||||| | ||||||| || |||||||| ||||| ||| |||||| || |||||||| ||| |||||| ||| |||||| || |||||| |||||||||| ||| ||| ||||||||| |||| ||| |||||||||| ||| |||| || |||||||||| || ||||||||||| ||||||| The placement was terminated immediately; Child E, aged 4 months, moved to Foster Carers MFC3 and PF, |||||| ||||| |||||||| || |||||||||| ||||| The fostering history of Family F as detailed by the Social Care author is outlined below in section 3; a contemporaneous account of the family is described throughout the text as follows: Child E was placed with experienced foster carers MFC3 ||||| ||), and PF ||||| ||| ||| |||| ||||| ||||| ||||| ||||||||| ||||||||| |||| ||||||||||||| ||||| ||||||||| also                                                             7 The most recent Ofsted inspection (2008) judged the overall quality of service as “good” and describes |||||||| ||||||| as “a privately owned residential family centre operated by ||||||||||| || ||||| The facility has been operating since ||||||| |||||  The centre provides assessment of behaviour and personality problems as they affect parenting. The prime focus is the assessment of long‐term risks to dependent children arising from aspects of behaviour and personality in the carer(s). Single parents, couples and extended families may be assessed, with or without their children. It is expected that families would be resident for a minimum of six weeks whilst an assessment is undertaken. The majority of assessments are completed within three months. The majority of referrals are made through the court system.” M‐CE was expected to be at |||||||| ||||||| for 12 weeks. http://www.ofsted.gov.uk/oxcare_reports/download/(id)/223494/(as)/SC045018_SC.pdf    8 Working Together to Safeguard Children (2010) s. 5.144‐5.148 gives specific guidance on this matter.  9 No Health invitation, representation or report noted.   12lived in the household. Child E joined a || |||||| old girl awaiting permanent placement and a || |||||| baby girl who was offered day care by the F family10.  In late May, 2009 ||| |||| |||||||| ||||| ||||||| ||||||||| |||| |||| |||||||||||| ||| |||||||| ||||||| || ||||| ||||| ||||||| |||||| ||||| |||||| |||||||||||| || |||||||| |||||||| |||| ||||||||||| ||| |||| ||||| ||||||| ||||| ||||||||| ||||||||| || ||| |||||||| |||| ||| |||| |||| || |||| |||||||| || ||| |||||||||| ||||||||||| ||| |||| ||||| | ||||| |||||||| ||||| ||| ||||||||||     On the same day, the F’s supervising social worker (SSW2) was, herself, supervised. The pressure on the F family was acknowledged and, although SSW2 felt that ||||| |||| ||||||| ||||| |||| | |||||| ||||||| |||| | ||| |||| ||||| it was agreed that regular monitoring should include unannounced visits whilst all 3 children were in placement.   During the week prior to placement with the F’s, a Core Assessment, focused on the potential || |||| || ||||||| |||| |||| ||| ||||| | |||| ||||| ||||||||| || ||| |||||| ||||||||||| |||||| ||||| |||| |||| |||||||||||| ||| ||||| || |||| ||||| |||||||| ||||||||| |||| || |||||| ||| ||||||| ||||| |||||||| |||||||| |||||||| |||||||| |||||||| ||||||||||| || ||| |||||||||| ||||||| || ||| |||||||| |||||||| ||||||| ||||| |||||| ||| || ||||||| |||| ||||||||| ||| |||||||| ||||||||||| |||||| |||| ||| ||||||| |||||| || ||||||| |||||||| |||||| |||||. At a Court Hearing on |||| July, 2009, the Local Authority’s plan for Child E’s adoption was not challenged by ||||| |||||||| |||| ||||||||| |||||| |||||||||| || ||| ||||||||| |||||||| || | |||||||||| ||||||. Additionally, both parents advocated members of their families to be considered as family carers.  The Court directed the Local Authority to proceed with adoption plans whilst simultaneously ensuring that the viability of family care was explored. A final hearing was booked for early November, 2009.  Child E’s third LAC review was held a few days later, 2 weeks after placement with the Fs and a critical time in the parallel planning process. The review was characterized by very limited attendance. There was no health representation and, although Child E had received a routine physical and development assessment by a GP when he was 6 weeks old, the Initial Health Assessment was still outstanding. There is no note of this omission in the IROs report of the meeting. Apologies were received from M-CE |||| ||| |||||| |||||| ||||||| ||| |  ||||||| Supervising Social Worker, and the Children’s Guardian. The focus of the review can be summarized as follows: Birth parents: |||||||||| |||||||| ||||| ||| |||||||| || ||||||||||| || ||||| ||||||||| ||||||||| |||||||| |||||| |||||| |||||||||| ||||||||| |||| | |||| |||||                                                             10 This required an exception to their approval status which was given because the day care arrangement was due to end. The Social Care IMR author notes that “the alternative at this time would have been an external placement. Social Care IMR 2.86  13|||||||||| || ||| |||||||| || ||| |||||| || |||| |||||||||||| ||||||||||||| ||| ||| ||||| || ||| |||||||||| ||||| |||| ||| |||||||||| ||||||||| |||||| ||| ||||| |||||||| ||| ||| ||||||| ||||| |||| || |||||| ||||| || |||| |||| ||||| |||||||| || ||||||| ||| ||||||| || | |||||||||| ||||||||| || |||||| |||| |||| || |||| |||| |||| |||||| ||| |||||| || |||| | |||||||||| |||||||||||| ||||||||||| |||||| |||||||| ||||| |||| ||||| |||||||||| || |||||||| |||||| ||||| |||| ||||| |||||| ||||||||| ||||||| |||| ||||| || |||||| ||||||| |||| |||||||||| |||| | |||||| The social work plan for parents contact to be reduced to once a month, signaled the strength of adoption as the preferred outcome for Child E.  The route towards adoption: Application had been made for an adoption medical and the Local Authority was scheduled to present Child E to the Adoption Panel on the ||| September for what is called a “best interests decision”. A referral for Family Finding had been made.  Child E, who was present at the meeting with his foster mother MFC3, was described as a “contented baby who eats and sleeps well”; he was reported to be gaining weight. There was no discussion of the current circumstances of the F Family, or indeed, any potential difficulties associated with their continued care of E. The placement was described as a “bridging placement”, noted in the IRO’s Report as the preferred placement option, satisfactory and deemed to be meeting his needs whilst plans for adoption were pursued.  2.4 Adoption Planning proceeds: Child E is 6-8 months old.  During the next few weeks a number of important administrative steps were taken to prepare for adoption: || August 2009 Pre-permanence Medical examination successfully completed. 11 | September 2009 Adoption Panel: Best Interests Meeting confirmed that adoption was in E’s best interests.  | October 2009 Initial Family Finding Meeting, worker allocated  Links with Community Health services remained poor. There was no documented handover of Child E from any agency to a Health Visitor when he was discharged from ||||||| ||||||| and joined the F family. The chronology shows however, problems arising during this period that would have benefitted from an HV’s advice. What had, until the pre-permanence                                                             11 The Health Overview Author has concluded that “the pre‐adoption medical appears to have constituted the statutory initial health assessment.” It was the first recorded health assessment for Child E. Health Overview Report p.12  14medical, been described as “dry skin”, or a “rash” on Child E’s face, was now diagnosed as eczema12. || |||| |||||| ||||||| ||||| | ||||| ||||||||  |||| |||| ||||||| ||| |||| | |||| ||||| ||| |||| |||| |||| ||||||| ||| ||| |||| || ||| |||||| |||||| ||||| ||||||| |||||||| || |||||| ||||  On ||| September, 2009 HV3 telephoned MFC3, presumably in relation to other children placed with the family. HV3 learned that E had been placed with them since mid- July. HV3 noted that MFC3 was “happy with care” and there is no evidence of subsequent follow-up HV contact with the F Family.  On |||| September, 2009 a Cultural Advisor (|||| ||||||| Team) visited the foster home and after discussing the care of E’s skin and hair, suggested that MFC3 take him to the GP. She did so on the |||| October, 2009 and, helpfully, the Cultural Advisor telephoned MFC3 later to confirm that this had been done, and to offer further advice.  Other contacts with the GP during this period were focused on PF’s increasingly poor health. ||| |||| |||||||| || ||||||| ||| ||||||| || ||| |||||||| |||| | |||||| ||||| |||||| |||||| |||||||||| ||||| ||| |||| |||||||||| |||| | ||||||| |||||||| |||| || |||| || ||||| |||||||| | |||||| || ||||| ||| ||| ||||||||| || ||| || |||||| ||| |||||| ||||| ||||| ||| | |||||| ||||||| ||||||||||| ||| ||| |||||||| |||| |||||||||||| |||| |||||| ||||| |||| ||||| || ||||| |||||| ||||| ||| |||| | ||||||| ||| |||| |||| |||||| || | |||||| | ||||||| |||||||||||  |||||| ||| |||||||||| || |||||| || |||| |||||| |||| ||| ||| |||||||| || ||||||||| ||||||| |||||||||| |||||| ||| |||||||| |||| ||| ||| ||||   ||||| || ||| |||||||| |||| |||| |||| ||||| |||| ||| ||| |||| |||||||| |||| | ||||| ||| ||||| |||| |||||| |||| ||| | |||||||  |||| |||||||| ||||| ||| |||| |||||| ||| ||||| ||| | ||||||| In early November, 2009 significant progress had been made to secure E’s future; Family Finding had identified 7 possible “matches”, and further searches were underway. At the final                                                             12 Many children in the western world suffer from infantile eczema or atopic dermatitis, a form of eczema (skin inflammation) that won’t stop itching. It's characterised by periods without symptoms, followed by further outbreaks of differing severity. Children who suffer from infantile eczema tend to have dry skin and a high sensitivity to itching. Babies with infantile eczema develop an itchy red rash, often on their cheeks. This spreads over the face, down the neck to the nappy region. But it may also appear on the arms and legs. Because of the itching, the child may seem upset or irritable – particularly at night. It needs constant treatment with moisturisers (with or without steroid ointment) – even when there are no symptoms. But with consistent skincare, a number of the more serious complications can be avoided. Treatment of infantile eczema should always take place under your doctor's close supervision.  http://www.netdoctor.co.uk/diseases/facts/infantileeczema.htm. Accessed 03.02.11  15Court Hearing on ||| November, 2009, a Care Order and Placement Order13 were made in respect of E. However, the Judge reserved his judgment; it was to be written up and circulated at a future date. As both parents were considering appeal, placement could not be made until the judgment was received and the appeal period expired. The policy context in which these events unfolded is shaped by the Public Law Outline (PLO) which came into force on 1 April 2008. The PLO formed part of a series of changes designed to bring about a cultural change in Care and other children’s proceedings. Of relevance to children like E, is the fact that the PLO assumes that proceedings may take place over a six month timescale rather than the previous nine. It also stresses that the timescale of a case needs to accommodate those of the child (author’s emphasis). Once an application is brought, the Court is required to set a timetable which is to be appropriate for the particular child and may take account of social, educational and health events - presumably, like adoption.  Initially, there was no reason to believe that the reserved judgment would directly cause delay in E’s placement, but it extended the period of uncertainty about the likelihood of M-CE and F-CE appealing against the orders, and course, compounded the uncertainty about the length of time that E would remain in the F’s care, thus making the already complex case management even more challenging.  These were the prevailing conditions when, triggered by the Care Order, case responsibility for Child E was transferred to the ||||||| |||| Team  and a new social worker was introduced to the case (SW8).  ||| |||| |||||||| || ||||||| ||||| |||| || ||| |||| ||||||||| ||| ||||||||| |||| |||||| || ||| ||||||||||| || ||| |||||||  || ||||||| |||| || |||||| ||| |||| || ||||||| || |||||||||| |||||| || ||| |||||||| ||||||||| |||| ||||||||||||| ||| ||||||||| ||||| || ||| |||||||| |||| ||| |||| ||| ||||||||||||  It was during this period that a request for a medical reference was sent to the F’s GP by Social Care. ||| |||||| || | |||| |||||| |||| ||| ||||||| |||||| || ||| |||||||| were included in the reference, but no other concerns were noted. As the Health Overview author states, “ It would have been entirely appropriate for the GP to have a conversation with relevant social care colleagues to discuss the potential impact of the male carer’s illness on the family’s capacity to adequately care for children placed with them.” 14                                                              13 This is an order authorising a local authority to place a child for adoption where there is no parental consent, or where consent should be dispensed with.   14 Health Overview p.7  162.5 E’s progress and 4th LAC Review (||.11.09) At the time the Care Order was granted Child E was 8 months old and had been in placement with the F family for just under 4 months. On |||| November, the chronology indicates that a Health Visitor made a home visit, having been asked by MFC3 to review Child E’s weight in advance of his LAC Review. He had not been seen by a HV since placement with the F’s, so this was a first HV contact with the child. His weight was recorded on the 25th centile. Although the HV record describes this as a “slight” drop, it is, in fact, dramatic15 given that reports were of steady weight gain until placement with the F’s. At the pre-adoption medical exam ||| |||08.09 Child E was at the 75th centile. There is no documentation arising from this visit regarding other aspects of his development or the management/control of his eczema. Of further concern at this time, highlighted by the Social Care IMR author, was MFC3’s failure to take Child E to the GP as requested when, |||||| ||||||| |||| ||| ||||||| ||| |||| |||||||||| | |||||| |||| ||||| || ||| |||||| || ||| |||||  The foster home was visited by the SSW2 and separately by SW8 on the |||| November in preparation for the 4th LAC Review. After meeting E for the first time, SW8 described him as a ||||||| ||||| ||| |||| ||| ||| ||||||| || ||||| |||||| ||| ||||| ||| ||||| || ||||||||| ||| ||||||| ||| ||| |||| |||| |||||||||| but SW8 understood it was being treated by MFC3. |||| ||||| |||| ||||| |||| ||||| |||| | |||| |||||| ||||| |||||||||| |||||| |||| |||| |||||| ||| ||| ||| ||||||| ||||||| ||||||| ||| ||||| |||| |||||| || ||||||| ||||| |||||| ||||| | |||||||| |||||||  The LAC Review was attended by these two professionals only, and was chaired by a new Independent Reviewing Officer. There was no health representation, nor was M-CE or F-CE present. Had they been so, or had their views been well represented, they may well have directly raised concerns about Child E’s care. In her interview with the Social Care author |||||| ||| |||||||||| || ||| |||| ||||| |||| ||||  ||||||| |||| ||||| |||| |||| ||||| |||| |||||| ||| ||||||||||||||| |||| |||| |||| ||||||| ||| ||| ||||| |||||| ||| |||| |||||| ||| ||| |||| |||| ||| |||| ||| ||| |||||| |||| ||||||||||||| |||| ||| |||| ||||| || ||| ||||| || |||||| ||||| ||||| ||| || ||| |||| ||| |||| ||||| |||||| |||||| ||||||||| |||| |||| |||||| |||| |||| ||||||| ||||||||||  Notes from IMR author interview with MFCE ||12.2010 In describing the LAC review, the Social Care IMR author went on to note that it would have been good practice to include the Family Finder at this stage of case development; indeed this is so. But the most critical omission was the health perspective – to contribute to a                                                             15 Referred to by the Health Overview Author as indicative of  “significant faltering growth”. Health Overview Report p.12  17discussion about Child E, and most particularly to discuss the impact of PF’s health on the F’s fostering capacity. According to the minutes of the Review, the matter was not discussed. It is possible that the new IRO knew nothing of the issue, but both SSW2 and SW8 should have raised it.  The concerns that might have been brought to the review at this stage are as follows: • Child E’s weight and the change from 75th to 25th centile in a 3 month period.  • Child E’s reported behavior since the last review, || ||||||||| |||||||||| |||||| ||| ||||| |||||||| |||||  • The consequences for Child E of the |||||| ||| ||||||||| |llness of the foster father.  • The response of the family || ||| |||| || |||||| ||||| ||| ||||||| ||||| |||||| |||||||| || |||| |||||| ||| |||||||  • Risks of associated with the continued uncertain timing of an adoptive placement.  2.6 Managing in a climate of continuing uncertainty During SSW’s supervision session on |||| December, it was noted that MFC3 was “coping but showing the strain”; she was receiving more help |||| ||| |||||||| |||| ||||||||||||| with fostering tasks, ||| ||| |||||||| |||||||| ||||||| ||||| ||| ||||||||| || ||| ||||| ||| || |||||||| The Social Care IMR author draws attention to Child E’s worrying behaviour, reported in the Foster Carers monthly summary ||||12.09), and to the bruising to his face that was reported to SW8, but not investigated.   A Family Finding meeting during the same week reported that there were 16 families identified as having potential to meet E’s needs, in particular a couple, T & C were highlighted.  ||| ||||||| |||| |||||| ||||| ||||||||| |||| |||| |||||||| || ||||||| ||| |||| ||||||| ||| ||||||| | |||||||||| |||| |||||||| || | |||||| |||||||||| ||| |||| ||||| |||||||| |||| |||| ||||||| |||| |||||||||| |||||||||| |||||| ||| ||||||||| |||| || |||| ||| ||||| |||||  SSW2 responded quickly to the increasingly difficult situation in the foster home and, prior to |||| ||||||||| || |||||||| she checked with MFC3 whether she needed additional support. She was told not. This was followed by a discussion between SSW2 and SW8; both agreed that the least disruptive alternative for Child E was for day care/ and possible night care with Foster Carer JW (| ||||||| || ||| ||| |||| |||| ||| |||||||| ||||| ||||||| JWs support was confirmed during SSW2’s visit to the foster home in January. ||||| |||| |||| ||| |||| |||| ||||| ||||| |||| |||||| ||| |||| ||| |||| |||||||||| ||||| ||| |||| |||||||||| ||||| ||| |||||||| || ||||| |||| ||| ||||||  Against these concerns, there was hopeful news regarding adoption. A family had been identified, visited and in an e-mail from the Family Finder to the Adoption Team Manager on  18|||h January, the Family Finder said “we were really impressed with their ability to meet all racial & heritage needs.” Next steps were taken to ensure that Child E’s case was booked for the Adoption Panel on |||| February, 2010.   The perfect tension was established; there was clear acknowledgement of the pressure on the foster home, and there was a likely placement on the horizon –with the consequent and understandable desire not to disrupt Child E by further placement before permanence could be established.  Given this tension, the still pending judgment, now almost 3 months overdue, added a further dimension to planning complexities. There had been no “developments” reported since an e-mail exchange between F-CE’s solicitor and the County Court during December which did not specify a date when the judgment could be expected.   On the ||| February, 2010, the Family Division Liaison Judges of the South Eastern Circuit wrote to all family –ticketed Judges within the Circuit highlighting policy on delayed judgments in family matters. It requested notification of any judgment delayed above 1 month in order that steps could be taken to avoid judgments “slipping over the 2 month mark” – a delay which required report to the President of the Family Division. Consequently, Social Care suggested that the Joint Legal Team contact both the Court, and the High Court Family Division Liaison Judge for the area. They did so on ||||| and |||| February, 2010, stressing the importance of receiving the overdue judgment in E’s case in order to expedite presentation to the Adoption Panel (now set for |||| March). Reassurances were given and, ultimately the judgment was received on |||| March 2010.  Efforts to secure the judgment ran in parallel with those of SW8, the Family Finder and Cultural Advisor to progress the adoptive placement. Child E was taken to a pre-adoption medical on ||| February by SW8 and a social work student. Unfortunately, the paediatrician was delayed and SW8 left for another appointment. It was noted that whilst good practice demanded that SW8 and/or the foster carer should have been present in order to provide an up to date history, the paediatrician decided to proceed, possibly given the pressing adoption timetable. She did so, however, without knowledge of the current fostering context, and in particular, the ill health of the foster father; an omission which, in the view of the Health Overview author, was significantly limiting in terms of holistic assessment. A full report of the examination is outlined in the chronology.  Of note was the eczema on E’s face, the treatment of which needed review. |||| |||||||||||| |||| ||||| ||||| |||||| |||||| ||||||| || ||| | ||||||||||| || ||| |||||| |||| |||| ||||||||||| |||||| || |||| ||||||||||||| |||| ||||| | ||||||| |||||||| |||||||||||| || ||||||| ||| ||||| |||||| ||||| |||| ||||||| |||||| ||||||| || | ||||||||||||||  The chronology during February outlines further detailed administrative steps taken to prepare for the Adoption Panel and the continuing efforts of the Joint Legal Team to secure the judgment. Any Adoption Panel would be reluctant to approve a match if there could be an appeal from parents pending.  19||| |||| |||| || ||| ||||||||| |||||| |||||| ||| |||| |||||||| |||| |||| |||| |||| ||| |||||| ||||||| ||||||||| |||||||||||| || |||| ||| |||||| || ||| |||||| ||||| ||| ||||||| |||||||| ||||||| ||||||   On the |||| March, 2010 a LAC Health Assessment was undertaken by HV3 and a LAC Nurse- an opportunity for a Health Visitor to see Child E in his foster home environment. However, as the Health Overview points out, the opportunity was not exploited and the resulting documentation focuses exclusively on core health matters: • ||| |||| ||| |||| ||||| || ||| |||| |||| || ||||||| • ||||||| ||||| |||||| ||||| || |||||||| ||||| |||||||| • |||||| ||| ||||| |||| || |||||||| • ||||||| ||| ||| |||| ||||||  • |||||||| || |||||||| ||||||||| |||| | ||||| |||||  |||| |||||| ||||| |||||||| ||||| |||||||| ||||| ||| ||||||||||||| ||| |||||  || |||||| |||||| |||| |||| || ||||| |||||| | |||||||||| |||| || ||| ||||| ||||| ||| ||| |||| || |||||| | |||| |||| |||| |||||| ||| |||| ||||| ||||| |||||||||| ||| |||||||||| || |||||||| ||||||| |||| days later, the Family Finder visited the foster home to prepare a DVD of Child E for prospective adopters. |||| |||||| |||| || ||||| |||| |||| |||||| ||| ||||||||| ||||| ||| |||||||||| || |||||||| ||| ||||| |||| |||||| ||||| |||| ||| ||||||||| ||| ||||| |||| ||| ||| |||||| During SSW2s own supervision session on the |||| ||arch, the consequences of PF’s ill health were discussed and it was decided that the F’s should be encouraged to look at their own support needs. It was also noted that the Annual Foster Care Review was overdue16; SSW2 was to start work on it within the next fortnight.  Two days later, on the |||| March, | |||| ||||| ||||| ||| ||| ||||| |||| |||||||| |||| |||||||| and on the |||| March, MFC3 took Child E to the GP who, following examination, referred him directly to the Accident and Emergency Department of the local hospital . He was found to have several fractures of differing ages, for which no explanation could be given. Each of the fractures was the result of significant and excessive forces applied to the bones. E was admitted to a Paediatric Ward and a Strategy Meeting was held at the hospital the following day where a decision was taken to initiate a single agency (Police) child protection investigation. Child E remained in hospital whilst further tests were undertaken. He was discharged on |||| March, 2010 and placed with Foster Carers S.                                                              16 It was scheduled for completion in December, 2009.  203.Summary of F Family’s Fostering History  The Family Placement Teams in Reading Borough are currently being re-structured, and their establishment strengthened17. The fostering and adoption functions which have been separate since 2006, remain specialist areas of practice. The Social Workers in each Team are supervised by an Assistant Team Manager (ATM) whilst overall responsibility for each specialism rests with a Team Manager. The Adoption Team also embraces a small Family and Friends team with a special focus on permanence.  The issues raised in this review include both the Adoption and Fostering Teams; however, in this section reference is made exclusively to the Fostering Team.  The Social Care IMR author has been painstaking in constructing a thorough account of the F’s history as foster carers, detailed in the chronology and fully discussed in the text of the IMR (pp 12-24). The salient points are as follows: The F’s, referred to as MFC3 (female carer) and PF (male carer) are |||| ||||| |||| ||||||| ||||| || |||| || ||||||||||| ||||| |||| |||||| | ||||| |||||| ||||| |||| |||| |||| |||||||||| ||||| ||| ||||| || |||| |||| |||||| || ||||| ||||| ||| |||| ||||| ||||||| ||| |||| ||||||| || ||||| |||| |||| |||||||||| ||||||| ||| ||| |||||||||||| || ||| |||| ||| |||||||| ||||||||| ||| ||||| |||| ||| ||||||| |||| ||||| |||||||| ||||||||| |||| |||| ||| |||| |||| ||||| |||||| || |||||||| || |||| ||||| ||| ||| ||||| |||||||| ||||||| ||| ||| || |||||| PF was in full time employment at the beginning of the review period. MFC3 is not employed outside the home. The F’s history as foster carers can be divided into two distinct chapters. Chapter 1 began in |||| when they were approved in Reading. They fostered for that authority for some years and then, in 1998, “moved” with their Link Worker to foster for ||||||||||| ||||| ||||| |||||||||||| || | ||||||||||| || |||||||||| |||||| ||||| |||| |||||| |||||||||||| |||| |||||||| ||||| ||||| || ||||||||| || ||||| ||||||||||||||||  Chapter 2 began in late 2003 when the F’s again applied to foster for Reading. After an assessment that the Social Care IMR author finds illustrative of good practice in its comprehensiveness, the F’s were approved in |||||||||| 2004 to provide emergency, short term and relief care for 2 children of either gender between the ages of 0-5. At the point of approval, the Fostering Panel noted a number of issues that required the attention of the Supervising Social Worker (SSW).  || |||| |||||| |||||||| || |||| ||||||||||||| |||| |||||| ||| ||||| |||||||| ||||| ||| |||||||                                                              17 An Assistant Team Manager is being redeployed to the Fostering Service from elsewhere in the Family Placement Service.    21||||||||| |||||||||||| ||| ||||| | ||||||| || |||||| ||| ||| ||| || |||||||| || |||| ||||||||||||| |||| |||| |||||| |||||||| ||||||| ||| |||| |||||| |||||||| |||| |||||||||| |||||||| ||| ||| |||||||  ||| |||| ||||||||||||| |||| ||| ||| |||||| ||| |||||||| ||| |||||||||||| ||||||||| ||||| ||| ||||||||| ||||| ||||||||||| |||||| ||| |||||| ||||||||  The worker who had assessed the F’s went on to become their SSW; a relationship that continued until July, 2007 when, following promotion, she became the supervisor of a new SSW. This relationship continued throughout the review period; an example of remarkable continuity in the current professional climate.  During the first year following approval, the F’s fostered 7 different children, across the specified age range for approval. Having examined the record in detail, the Social Care author identifies a number of issues that arose during that year which can be said to characterize the F’s continuing “story” as foster carers.  a. Children suffer relatively minor injuries in placement which are neither reported (as required) or, followed up with the GP by the Fs.   b. Agreements made in relation to placement policy with the F’s are not implemented.  c. SSW is inconsistent in following up requests made to the foster carers.  An Annual Foster Home Review was undertaken in ||||||||| 2005 which addressed these concerns, but the pattern continued into the following year. During 2006, the F’s fostered 3 more children, including a 2 year old boy who became the focus of a child protection investigation because of multiple bruises to his face and head. Before the investigation was concluded, ||| |||||||| | |||||| and both children in placement were removed. It was, appropriately, agreed that no further placements would be made until an Annual Foster Parent Review was presented to the Fostering Panel.  In the following |||||| 2007, the Fostering Panel recommended a change in approval to 1 short term, and 1 relief/emergency placement, again for children between the ages of 0-5. The F’s non-compliant behaviour continued; indeed, the Social Care author comments  “it becomes clear when tracking the injuries that throughout the last four years and thirteen recorded injuries, it was only on one occasion  that MFC3 reported an injury to any professional.” Appendix 2 to the Social Care IMR provides full details of the injuries children sustained in placement.   This pattern of unreported injuries appeared to be impervious to change; the question is what does that behaviour mean? Why would a foster carer continue to ignore requests and instruction? And why is it tolerated in a foster home responsible for the safe care of some of the community’s most vulnerable children? The Social Care IMR author did not directly address this perplexing question, but she carefully interviewed all practitioners involved which highlight a number of factors that may be contributive:  22a. Paradoxically, the depth of knowledge of the F family and their fostering style that was built up through the extraordinary continuity of contact between the foster carers and their SSWs may have hindered rather than helped an objective assessment of the strengths and weaknesses of the foster home.  b. The relationship between foster carers and social workers that is widely advocated is one of trust18. Whilst it was acknowledged that the F’s experienced difficulties with some children, and were placed under extra strain when PF became ill (both in 2006 and latterly), the F’s were trusted to make judgments about the degree of support they needed to maintain acceptable standards of care.  c. The authority of recommendations made at Annual Foster Parent Reviews and Fostering Panels may be compromised by the growing pressure on foster placements, and, under those circumstances, recommendations to limit the children placed with foster carers may be mediated by the reported good experience of some children cared for by them.  These issues are explored more fully below in 4.2                                                              18 See for example the letter from Tim Loughton,MP, Parliamentary Under Secretary of State for Children & Families sent to local authority colleagues on 27 August 2010 about “excessive restrictions that can sometimes be placed on the decisions of foster carers…”   234. Learning from Experience    The story of Child E is particularly difficult to hear; not only were his parents unable to provide him with a safe and nurturing family environment, but neither, as we have seen, was foster care. The task of this SCR is to learn from his story, and following the close examination of case detail undertaken by IMR authors, to identify issues arising from his experience that may be generalized to other similar circumstances. Nationally this work is currently the subject of much discussion, review and development as LSCBs recognize that “blaming individuals for errors and mistakes has been unhelpful and unproductive, producing inadequate learning and, in some cases, creating new obstacles to improving performance.” (Munro, 2011, 5.38) A systems approach to SCRs is now widely advocated, emphasising that “typically incidents arise from a chain of events and the interaction of a number of factors.” (Munro,2011, 5.41)   No one knows who was directly responsible for Child E’s injuries. In the discussion that follows effort has been made to illuminate the multiple factors that may have contributed to a situation in which neglect and injury was possible. To do so involves hindsight, a powerful tool which needs to be used cautiously.  It can, however, assist the understanding of complex practice if it helps us to “get into the moment”, to see the world as workers may have seen it, and to make the sense that they may have made at the time.    4.1 Working within a complex system Berkshire is divided into two geographical areas covered by two separate NHS Primary Care Trusts; Berkshire East and Berkshire West. During the first year of his life, Child E lived for periods in both PCT areas, and, during a residential parenting assessment, he lived a third.  He was, at the time of his birth, the subject of a Child Protection Plan, and, following an Interim Care Order granted on |||| March, 2009, he became a Looked After Child for whom there were early plans for adoption. These geographical and administrative distinctions have consequences for the smooth development of intra and inter-agency work and for case management.  As the narrative summary (s.2) describes, Child E was at the centre of a highly complex web of professional relationships. Such complexity requires workers to hold, simultaneously, a whole system perspective whilst focusing on their own area of specialist knowledge and responsibility. The difficulties associated with this testing work (particularly when organizations are undergoing change or experiencing capacity problems), are well known and have been widely discussed in the literature on interprofessional work since Hallett’s seminal research during the 1990’s19.                                                              19 Hallett,C (1995) Interagency Coordination in Child Protection, Studies in Child Protection, HMSO, London.   24Working in a Complex Practice System  Figure 1 Given such complexity, a number of what might be called “interprofessional practice events” have been designed into the child welfare system in England which potentially facilitate whole system intersection. When working effectively, these events enable an appropriately multi-professional discussion of an individual child’s circumstances, leading to informed judgments about the course of action that optimally supports his/her best interests. In Child E’s case, in addition to judicial hearings, these included child protection conferences, LAC Reviews and Adoption Panel Meetings. There were also a number of intra-professional practice events in his case where, similarly, his circumstances were considered in the context of the wider system that supported him; in children’s social care, professional supervision sessions, for example, addressed this function.     25In the case of Child E, there is evidence that a whole system approach to his welfare began well; good connections between adult mental health services, children’s social care, and maternity services ensured that M-CE’s pregnancy was referred at an early stage and a clear and appropriate child protection plan was developed. Similarly, cooperation between health and social care proceeded smoothly in preparing for adoption, as did work with independent home finding and cultural advisory services. In each instance, there is evidence that Child E’s needs, including his ethnicity, were appropriately recognized and responded to. Both the Health Overview author and the Social Care IMR author draw attention to the fact that there was insufficient attention to the correct recording of Child E’s racial background and cultural heritage in both agencies –however, in practice, his distinctive needs were recognized.   Following Child E’s birth, however, the narrative has also highlighted two areas of practice where insufficient inter-agency connection was made, and a whole system perspective was  lost; 1) lack of integration between health and social care professionals working with looked after children and 2) insufficient connection between adult health and fostering services. This lack of connection had consequences for the accurate assessment of the pressure on foster home F. These issues are considered more fully below. 4.2 Management & Supervision of Foster Homes The management and supervision of foster homes in the public and independent sector is specifically regulated by the National Minimum Standards for Fostering Services 20 ; it is primarily executed through the relationship built between foster carers and their Supervising Social Worker located in the Fostering Team; in this case, a relationship of remarkable continuity . The quality of the work undertaken by an SSW is overseen by the SSWs own supervisor, and should be more formally reviewed and recorded at least annually.  “A (foster carer) review shall take place not more than a year after approval, and thereafter, whenever the fostering service provider considers it necessary, (author’s emphasis) but at intervals of not more than a year. When undertaking a review, the fostering service provider shall (a) make such enquiries and obtain such information as it considers necessary in order to review whether the foster parent(s) continue to be suitable to act…”  Fostering Services (Amendment) Regulations 2009 Part IV (29.2,3)  As stated earlier, the F family were approved as foster carers in |||||||||| 2004 and the Social Care IMR author has closely evaluated the quality of supervision provided to the foster home from that time onward (s.4.2.10-4.2.22 ), carefully balancing the many instances of good practice, with those that were insufficiently challenging. There was no equivalent                                                             20 A statement of national minimum standards published by the Secretary of State for Health under s. 23(1) of the Care Standards Act 2002, and supplemented by the Fostering Services (Amendment) Regulations 2009.   26discussion of Annual Foster Home Reviews; no review was undertaken during the period covered by this SCR21.  Although the F’s changing circumstances were regularly discussed in SSWs supervision, there were two points at which a wider discussion, specifically including health colleagues, might have been helpfully triggered.  b. During the autumn 2009, |||||||| ||| ||||||| || | || |||||| ||| |||||| ||||| || |||||| |||||||| || ||| |||||| ||| ||||||| |||||| ||||||||, and when PFs health ||| ||||||||||| |||||||||||| A (possibly informal) review had been agreed, but there is no evidence that it was undertaken. c. To coincide with and contribute to E’s 4th LAC Review in November, 2009 the point at which severe signs of strain were evident in the foster home.   These opportunities were not taken, and the monitoring of the F’s changing circumstances was managed exclusively within SSW2’s supervisory sessions. This may be common practice in Children’s Social Care; ie, that Foster Carer Annual Reviews are bureaucratically, rather than professionally, driven.  4.3 Reviews for Looked After Children LAC Reviews provide a catalyst for connecting health and social care (and other professional perspectives when relevant). Chaired by Independent Reviewing Officers (IROs) who, because of their independence, have an increased capacity to look broadly at children’s circumstances, the LAC Review should be characterized by whole system thinking. In building an LAC Review:  “The IRO should ensure that the views of the following are considered at the review,    whether or not they attend a meeting: • birth parents and any other adults with parental responsibility; • other significant adults in the child life, for example extended family members; • those caring for the child, such as foster carers; and relevant professionals(authors emphasis).” IRO Handbook (2004) As we have seen, health professionals did not participate in LAC Reviews. The Health Overview author is rightly concerned about that deficit, about the GP’s lack of proactivity  and about PF’s District Nurse’s failure to act when she saw Child E |||| | ||||||| |||| a clear failure to follow LSCB guidance.  Given that neither contacted social care colleagues, the Overview Author concludes that there was an apparent “lack of a coordinated pathway for the contribution of health information to inform the local authority care plan for Child E.” One post designed to facilitate such a pathway is the Designated Nurse for Looked After Children. Evidence gathered by the SCR suggests that, at 0.5 FTE, this post may be under-                                                            21  Because the F’s were approved in December, their annual reviews were triggered each year at that time. They were the subject of a review dated ||||||||| |||||||| |||| |||| – two months prior to Child E’s placement with the family. No further review was undertaken during the time covered by the SCR although, as the guidance suggests, it would have been possible to do so…”whenever a fostering services provider considers it necessary.”   27resourced. This matter is currently part of a wider review being conducted in |||||||| ||||| Community Health Services. 22   The Munro Review of Child Protection has been asked to consider the potential value of having a national means of providing a “quick and reliable way of identifying whether a child or young person is, or has been, the subject of a child protection plan or whether they are, or have been looked after.” It is impossible to predict whether such a system would have helped to connect health and social care in this case – but the intention to support hard pressed practitioners in all agencies with data that will help them to focus their attention on areas of greatest need is clear.23   And so, there was no “push” from Health to encourage the fostering team, and others responsible for Child E (his allocated social worker, the IRO responsible for reviewing his progress and care plan) to consider the impact of PFs health on the F’s fostering capacity – and there was no “pull” from social care to draw relevant health colleagues into discussion.  To return to the questions posed earlier; how might this be explained? A number of factors seem relevant: 4.3.1. Two social workers (SSW2 and her supervisor) had known the F family for 7 and 3 years respectively. During that time, as the Social Care IMR outlines, they had supported the Fs through a number of crises which the family met with some resilience; including a previous episode of PF’s ill health ||||| || |||||. The picture held by the social workers was therefore, quite naturally, one of tough, determined and resourceful people; the F’s kept SSW2 informed of changes in PFs health and they said that they were managing. Hence, there was little felt need to consult with health colleagues.  4.3.2. Few children are abused in foster care. Although limited and inconclusive, evidence from two UK studies suggest that confirmed maltreatment may be found in relation to less than 1% of foster carers per annum. Numerous studies mention “many incidents of maltreatment concern poor standards of care rather than abuse”.  Foster care therefore is not generally seen a “risky” place for children; quite the opposite, it is a place of refuge and nurture.  Given SSW2 and her supervisor’s knowledge and experience of the F family, maintaining Child E in placement seemed the sensible thing to do. In their judgment, the further disruption caused by a move at this stage in Child E’s care plan was the least desirable alternative.  4.3.3. Should they have been more suspicious of the number of minor, accidental injuries to children in placement with the F family?  Firstly, until constructed by the IMR author, the fostering team will not have seen such a graphic inventory of injuries. Furthermore, as the                                                             22 Health Overview Report, p.26 “Other considerations.”  23 Munro Review of Child Protection, Interim Report (s.5.5 Signposting)   28chronology shows, the problem that SSWs were occupied with was one of individual episodes of non-compliance in reporting injury. It appears that this was understood to be a problem to be solved through education, encouragement and by successive reminders.  “MFC3 and PF are always very co-operative if any issue has to be raised with them and will take on board any advice given by a Social Worker… The issue of reporting accidents has been raised several times, but MFC3 has acted on advice. She needs regular support to maintain this.”24 It was not considered a problem of attitude or trust, although given the intractability of the MFC3’s behaviour, it should have raised questions in the SSWs minds about the meaning behind the behaviour. Had a better connection with health colleagues existed, this view may also have been challenged – challenge, after all, is one of the strengths of interprofessional work when handled with skill.   4.3.4. The Fostering Network estimates that there is a shortage of just over 10,000 foster families in the UK. This shortage means local authorities in England, Scotland and Wales and health and social care trusts in Northern Ireland are often forced to place children where there is a vacancy rather than where best meets children’s needs. There were four instances in Child E’s relatively short story where pressure on fostering resources was clear: a) In April, 2009, Child E (1 month old) was moved from his initial placement to respite foster carers due to holiday arrangements which must have been known at the time of initial placement from hospital.  b) In May, 2009, Child E (2.5 months old) moved to residential parenting assessment with M-CE where there was a high risk of failure without his initial foster parents being retained as contingency.  c) In July, 2009, Child E was placed with the F family whilst they were fostering another child and offering daily care to a second. Officially this did not exceed their approval quota, however it did represent a considerable, possibly excessive, caring responsibility at a time when PF was known to be unwell. d) In October, 2009, given the distress caused to the family when one of the children placed with them moved, it was agreed to review the F’s circumstances. This was not done and a newborn baby was placed the following week.   This is the real context in which Child E’s placement with the F’s was managed, and it will, at some level, have played a part in SSW2 and her supervisors confidence that they could continue to manage the care of two children under age 1 whilst PF’s health deteriorated. Again, the lack of robust challenge from health during this period needs to be noted.  4.4 Judicial delay and parallel planning.                                                               24 Foster Carer Review |||.1.09 updated May, 2009.   29“2 months of delay in making decisions in the best interests of a child or young person equates to 1% of childhood that cannot be restored”25 One of the central concerns of current Family Justice Review is delay. It is understood  that the Review, due to publish an Interim Report in March, 2011, will focus on children’s experience of the court process and how related aspects of local authority procedures, such as permanency and adoption planning, can be improved. Improvements will be contingent upon the actions of local authorities, children’s social care and, of course, the judiciary.  In the case of Child E, it has been acknowledged that the delay in the reserved judgment |||| November, 2009 – ||| March, 2010) was unacceptable and far exceeded PLO guidance. The LSCB has been reassured that the causes of the delay have been fully explored by the judiciary, and a protocol introduced locally (see earlier discussion in s.2.6) should prevent delays in the future. Additionally, it is understood that from April, 2011 there will be a modest increase in sitting time in the South Eastern Circuit, thus relieving some workload pressure thought to be contributive to delay.   The delay in this case highlighted the very great difficulties for social workers who, in terms of case management, must coordinate progress across a number of different parts of a complex system in order to ensure a good outcome for children. A snapshot of the task of SW8 in January, 2010 is illustrative: Monitor Child E’s safety, welfare and development in his foster home Coordinate with SSW in the Fostering Team regarding placement appropriateness  Liase with Home Finder and Cultural Advisor re: introduction of adopters to Child E Liaison with Legal Services re: delay in reserved judgment and likely appeal.  Liaise with parents regarding changing contact schedule  Administrative preparation for Adoption Panel.  Prepare for and receive case supervision This multifaceted task can be likened to a spider web; changes in one part may not be wholly determining, but will predictably have an impact on all others. As the discussion thus far has shown, there were a number of difficult issues being managed in January, 2010  including stress in the foster home .The delayed judgment  played a part in lengthening the time that Child E was cared for by the Fs. As we have seen, this put him at increased risk of significant harm.                                                              25 District Judge Crichton (1 July 2010) Family Drugs and Alcohol Court, Wells St. London, quoted in Munro (2011) 5.57, p.91  305. Conclusion  This SCR has told the story, in some detail, of the complex work required to achieve permanency. Child E was conceived in difficult circumstances which were well recognized and responded to by health, adult mental health and children’s social care services during the months preceding his birth. Child E became looked after following his birth in ||||||, 2009 and it is this period, until the discovery of multiple fractures when he was just one year old, that has been the focus of this SCR. The Social Care IMR and the Health Overview Report have thoroughly reviewed practice across relevant services, paying careful attention to the Terms of Reference. A number of practice strengths were recognized and well evidenced, within and across the organizations, as were areas that require development. Their recommendations reflect that analysis.  No one could have predicted that Child E would have been neglected or injured in foster care. However, in order for Child E’s daily experience to be better understood and responded to, the difficulties associated with the complex professional environment in which his future care was negotiated, required a stronger foundation of interprofessional work than was evident.  One of the major areas of learning arising from this SCR is that the crucial link between health and social care, both of whom have clear responsibilities in relation to looked after children, requires improvement; specifically the active participation of health in assessment, review and care planning for children. We have also learned that there is a connection between the shortage of affordable fostering resources and increased risks to children, particularly when the processes involved in securing permanency on their behalf become protracted. This connection, now recognized, requires the attention of management; the different circumstances now prevailing require different professional and organisational solutions. The Social Care IMR author has made specific recommendations to improve social work practice in this area, but a wider review is indicated.   316. Recommendations Arising from the discussion above, it is recommended that: 5.1 The Reading LSCB (Performance Scrutiny Sub-Group) receives reports from the partner agencies who have contributed to this Serious Case Review and ensures that Individual Management Review Action Plans are implemented and evidenced within specified timescales.  5.2 That the Reading LSCB commissions work to explore the current connection between relevant health and social care professionals working with looked after children and makes recommendations.  5.3 That the LSCB ask the Family Court Business Committee to receive regular monitoring reports from Family Division Liaison Judges regarding any delayed judgments in care proceedings.  5.4 Given the anticipated continued pressure on fostering resources, that Health and Children’s Social Care review, using local, regional and/or national resources, the most effective means  of helping staff to recognize, assess and respond to stress arising in foster homes as a consequence of ill health or other factors.   5.5 The Reading LSCB employs suitable processes through which the lessons learned from this Serious Case Review may be effectively disseminated and positively inform practice.  7. References  Biehal,N and Parry, E (2010) Maltreatment and Allegations of Maltreatment in Foster Care: A Review of the Evidence. Working Paper No. WP 2437, Social Policy Research Unit, University of York in partnership with The Fostering Network.  Department for children, schools and families (2010) Working Together to Safeguard Children, A guide to inter-agency working to safeguard and promote the welfare of children. DCSF-00305-2010. Department of Health (2002) Fostering Services, National Minimum Standards, Fostering Services Regulations. The Stationary Office. London dfes (2004) IRO Handbook, statutory guidance for independent reviewing officers and local authorities on their functions in relation to case management and review for looked after children.  Dfes (2009) The Fostering Services (Amendment) Regulations. Statutory Instruments No.394 Downs, M, Ager, R and Smith, A. Public Law Outline: A Summary. http://www.1cor.com/1155/records/1143/PLO%20Summary.pdf  32 Hallett, C (1996) Interagency Coordination in Child Protection, Studies in Child Protection, HMSO. London Munro,E (2011) The Munro Review of Child Protection, The Interim Report: The Child’s Journey.   INSERT APPENDICES APPENDIX 1: Integrated Chronology APPENDIX 2: Template for Involving Parents in the SCR     