Death of a boy aged less than 1 year from unknown causes. A post mortem examination identified seven fractures which predated the death. Child G had been taken out in his mother's partner's van and had been driven around for about two hours. He stopped breathing, an ambulance was called to the family home and the child was pronounced dead on arrival at hospital. Child G lived with his three older siblings and parents in a relationship of violence and temporary separations. The family had been in receipt of services from Children's Social Care, health visiting, general practice and nursery and primary school. Four months prior to the death, the father left and a new partner moved into the family home. The mother and partner were charged with neglect. Issues identified include: reluctance to name neglect by professionals involved with the family; the crucial importance of the assessment process to ensure appropriate intervention; the need to review the types of cases that are discussed in supervision. Uses a systems approach drawing significantly on the work undertaken by Professor Munro and SCIE to identify greater understanding of safeguarding practice. Recommendations include: the need to challenge agencies to demonstrate they are working in line with its strategic approach to neglect; to ensure that those families and children managed under Children in Need are the correct ones and are properly reviewed; the need to deliver safe and effective services for children within its traveller communities and to use this learning to enhance services to other minority communities.
      
 Title:  Child G: serious case review. LSCB: Hertfordshire Safeguarding Children Board Author: Ann Duncan and Sian Griffiths Date of publication: 2017  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.                           CHILD GSERIOUS CASE REVIEWIndependent Lead Reviewers:Ann DuncanSian Griffiths2ContentsThe Circumstances that led to Undertaking this Review3Family Composition4Brief Summary of the Case4How Professionals Understood the Case at the Time5-10Appraisal of Practice and Analysis10-22Recommendations23Bibliography24Appendix 1 - Acronyms and Terminology25Appendix 2 – Methodology26-28Appendix 3 – Key Dates Table29-30Appendix 4 – Actions already taken by Individual Agencies31-3331.1The Circumstances that led to Undertaking thisReview1.1.1 In the early summer of 2014 Child G, who was aged less than one yearold, died whilst in the care of his mother’s new partner.Post Mortemexaminations were unable to find the cause of death but identified sevenfractures which predated Child G’s death.1.1.2 The Hertfordshire Safeguarding Children Board’s Serious Case Review(SCR) Sub Group recommended to the Chair of the Safeguarding ChildrenBoard that the case had met the criteria for a Serious Case Review asidentified in Working Together to Safeguard Children 20131, in that therewas information that:(a) abuse or neglect of a child is known or suspected; and(b) (i) the child has died.The Chair of the Board accepted the recommendation and commissionedthe Review.1.1.3. A Police investigation was still in progress at the time of writing. Both ChildG’s mother and her partner were arrested placed on bail. The mother hasbeen charged with neglect and her partner with neglect and failure tosecure Child G in a car seat on the night of his death.1.1.4. Child G’s three siblings were taken into police protection and are currentlythe subject of an Interim Care Order pending the outcome of proceedingsin the Family Court.1.2Family Composition1.2.1 The family members relevant to this review will be referred to as follows:Family memberAnonymisationAge at Summer 2014(Date of Child G’s death)SUBJECTChild GUnder one yearMother of Child GMotherFather of Child GFatherMother’s partner attime of Child G’s deathMother’s partnerSubject’s siblingSibling G1Under 6 yearsSubject’s siblingSibling G2Aged 4 yearsSubject’s siblingSibling G3Aged 2 yearsChild G’s maternalMaternal1 Working Together: HM Govt 20134grandmothergrandmotherChild G’s maternalgreat grandmotherMaternalgreatgrandmother1.3Brief Summary of the Case1.3.1. Child G lived with his2 mother and three older siblings, Sibling G1, G2 andG3. The mother had recently formed a relationship with a new partner whowas living with the family. At the time of Child G’s death he had been in thecare of mother’s partner. Mother’s partner’s account of what happened isas follows. He had taken Child G out in his van and had been driving himaround for about two hours. Child G was lying on the front bench seat ofthe van; he was not strapped into a car seat. Child G’s head had beencovered with a blanket, to stop the glare from the streetlights. It was laterestablished that mother’s partner was out collecting scrap metal but alsovisiting a drug supplier during the evening. A blood sample taken from themother’spartneronthe1stJune2014detectedahighlevelofamphetamines ‘that could have been lethal to some people’.Whilstmother’s partner was driving back to the family home he said he noticedthat Child G had stopped breathing; he commenced Cardio PulmonaryResuscitation.1.3.2. An ambulance was called from the family home and Child G wastransported to hospital where he was later pronounced dead. Theambulance crew informed the police.A post mortem identified possibleold fractures to the both wrists, both ankles and the left knee area whichmay have occurred at different times, but all within a period of 25 -50 days(13th April-8th May 2014) before his subsequent death. There was nounderlying cause or illness to render Child G susceptible to fractures.Expert opinion is that the fractures would cause immediate and severepain, the pain would be worse on handling and dressing Child G. Theparents/carers of Child G did not seek any medical attention in respect ofthese injuries.2.Methodology2.1.This is included in Appendix 2.2 To protect children’s anonymity all the children are referred to using the male pronoun.53.How Professionals Understood the Case at theTime3.1.The following section is a summary reconstructing how professionalsunderstood the children’s experience and their situation at the time.3.2.The father and mother of Child G and his three siblings had been in arelationship for five years. They met when they were both teenagers; therelationship between the two was punctuated by violence and temporaryseparations. The family had been in receipt of a number of services fromdifferent agencies, including Health Visiting, General Practice, Children’sSocial Care and Primary and Nursery school provision. The relationshipended four months prior to Child G’s death in February 2014 when motherasked father to leave the family home following another allegation ofdomestic abuse. It is thought that shortly after this, mother’s partnermoved into the family home.3.3.The mother of Child G is from a Gypsy, Roma and Traveller heritage, it isunclear how father defines himself. Mother’s partner is from a Gypsy,Roma and Traveller heritage. For the purpose of this review the familieswill be identified as Travellers because this is how they definedthemselves.3.4.In the middle of January 2013, mother attended E&NH Hospital; she was16 weeks pregnant; she requested a home birth. The details of the fatherwere not recorded but mother stated that he was supportive. Mother kepther antenatal appointments.3.5.Father had been subject to a two-year supervision order from July 2011 fora serious assault on his brother; he co-operated with the Probation Serviceand despite the nature of his offence was found by that service to be openand compliant. Father reported that he had stopped using drugs andalcohol. The father did not live with the children’s mother, but spent timewith them and sometimes brought the children to his supervisionappointments. The Probation Officer considered that the children seemedhappy to be with their father, but also described them as ‘grubby - ratherthan dirty’. The Probation Officer considered making a referral to CSC butdecided against it, as she perceived that the risks to the children had notchanged. (A referral had been made by Probation to Children’s SocialCare (CSC) during the pre-assessment report in February 2012; CSC tookno further action).3.6.In early January 2013, mother’s partner (at this time he was not a memberof the family household) was sentenced to a 12 month Community Orderwith a Supervision Order, for a breach of Non-Molesatation Order with aprevious partner and a requirement to participate in the Integrated6Domestic Abuse Programme (IDAP)3. The Probation Service made aSafeguarding referral to Children Social Care (CSC) with regards tomother’s partner’s children from a previous relationship. Mother’s partnerfailed to attend any further appointments with his Probation Officer andstated in clear terms that his lifestyle as a Traveller was not compatiblewith supervision and he would get any help he needed from friends andfamily within his community. Due to his lack of engagement he wasreturned to court for breach of his Order in February and March, when hewas fined and the Order continued. Following continued failure to complyhe was returned to court for a further breach and received a 12 weekcustodial sentence. He was released from prison in the middle ofDecember 2013; because the sentence was for less than 12 months therewas no supervision on licence at the time of his release and there was nofurther involvement with the Probation Service.3.7.Child G was born in July 2013 at the home of his maternal greatgrandmother. In early September of 2013 his mother requested that theHealth Visitor visit them at home as she was finding it difficult to get to thechild health clinic with the four children. Child G was observed being propfed4 by his mother, who was advised about the risk of choking, MG said‘she has fed all her children in this way’ and did not accept the HV’sadvice. Child G’s weight was on the 75th centile5. The family wereassessed by the Health Visitor and allocated to the core service6.3.8.In early January 2014, mother attended a meeting at the school to discussG1’s poor attendance (65.2%). Mother told the school that G1 was beingbullied, that he did not like school and told lies and that she was worriedabout what he said at school.3.9.Early in February 2014, a referral was made to CSC by someone close tothe family. The referrer told the Social Worker that mother had ‘dumped’two of her four children with the father, who was on probation for assault,and who had no money or food. The referrer thought that the childrenwere being neglected and ‘being passed from one person to the next’. TheSocial Worker made contact with father and confirmed that he was at thefamily home with G1 and G3, but that mother had G2 and Child G with herand her partner who was a drug user and had just come out of prison. TheSocial Worker asked for confirmation that there was food and heat at thehouse and that he was coping with the children. Father wanted motherand the other children to come home. Father was advised an assessmentmight be necessary because of the number of concerns.3.10. Four days later the case was allocated by the Team Leader to a SocialWorker and Student Social Worker. The Team Leader directed the SocialWorker and Student Social Worker to:3 This is a group work programme that is run over 27 weeks for men who have abused their wives, partnersor ex-partners.4 The bottle is wedged by a pillow or blanket into the mouth of the baby, which increases the risk of choking.5 Centile chart World Health Organisation growth charts6 Universal or core service whereby families are offered developmental assessments and encouraged toaccess child health clinics for advice and support.7see the children and their bedrooms to assess how father wascopingestablish whether he has parental responsibility.find out what level of contact father had with the children beforethis incidentfind out what the plan was if mother returned; whether there weresupport needs or safeguarding concerns.The focus at this time was on father; the initial concern was about hishistory of violence and the possible risk that he posed in caring for hischildren. The following day father informed the Social Worker that he wasnow only looking after G1 and was staying at maternal grandmother’shouse.3.11.Twelve days after the initial referral the allocated Social Worker and StudentSocial Worker visited father and G1 at maternal grandmother’s house. ChildG, G2 and G3 were with their mother at the family home.The SocialWorker realised that all four children needed to be assessed. Maternalgrandmother was described as intimidating. The Social Worker and Studentthen visited mother who appeared nervous and said her mother had beentaking her benefits away from her. Mother said that her mother (maternalgrandmother) was siding with the father, as she didn’t like mother’s partnerThe name and date of birth of mother’s partner were recorded. Mother hadasked father to leave the family home after another alleged domestic abuseincident. Consent was given by mother and father for a Section177assessment to be undertaken, including the school, Children’s Centre,Health Visitor and GP.3.12.The Section 17(Child and Family) assessment identified that mother did nothave a close attachment with G1 and was willing to allow G1 to live with hisfather despite his lack of stable accommodation. The Student Social Workeridentified that mother was an isolated young mum who said she had ‘no life,no friends’ and thought people looked down on her as she was from aTraveller background.G1 was seen at school by the Social Worker andStudent Social Worker, and said that he loved his Mum and Dad but did notlike his mother’s partner because ‘he is horrible and doesn’t buy mepresents’. The next day G1 was upset at school, because he was worriedthat his father would be beaten up, by someone who appears to bemother’s partner.3.13.TheChildandFamilyAssessment8alsoidentified:outstandingimmunisations for all the children, poor home environment, the familysleeping in one room. Despite this, the conclusion was that mother hadshown some strengths and was able to protect her children; the case was7 A Child In Need is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain asatisfactory level of health or development. Social Workers carry out an assessment under Section 17 of theAct.8 Child &Family Assessment Working Together (2013)8recorded as Child In Need (CIN). Mother’s partner was not included withinthe assessment.3.14.The school had also raised three records9 of concern between the end ofJanuary and the middle of March (2014): G2’s very poor attendance atnursery; supervision of the other three children when mother dropped G1 atschool and G1 watching a horror movie The Student Social Worker visitedthe family at home, but there was no improvement in the living conditionsand all four children, who were now back with their mother, were in ‘grubbyclothes’.3.15.The day before the Child In Need (CIN) meeting the Social Workerdiscussed the case in supervision. She was concerned about neglect; thepoor home conditions and mum’s lack of motivation to make the necessarychanges. She thought that the case was ‘borderline’ and might reach thethreshold for Child Protection, but it was ultimately concluded it should beassessed as CIN10.3.16.The CIN meeting was held at the school and was attended by the SocialWorkerandStudentSocialWorker,theHealthVisitor,AttendanceImprovement Officer and a Teacher and Children Centre Worker. Motherand maternal grandmother were present. The purpose of the meeting wasto assess whether the family could be supported under Children in Need, orif it needed to progress to an Initial Case Conference to prevent the childrensuffering from risks of significant harm. Mother had refused consent toshare the Child and Family Assessment with the other professionals. Themeeting was described as being very difficult, with maternal grandmothershouting and swearing, and saying: ‘we are Travellers, we don’t need to goto school, the only person who can liaise with us is the Travelling LinkWorker.’(Access to Education Manager). Some of the professionalsreported being frightened by maternal grandmother. The recommendationwas for a Child In Need Plan to be delivered in conjunction with ThrivingFamilies.11 The plan focused on the need to improve mother’s relationshipswith all the agencies working with the family, to improve attendance atschool and nursery for G1 and G2, and to improve the home conditions andthe Health Visitor to monitor the children’s’ development.3.17.On 7th April 2014 the Police received an anonymous phone call reportingthe sound of a child screaming at the family home. The attending policeofficer saw Child G who was dressed in a nappy and made thoroughenquiries with the family who said that Child G was crying due toconstipation. The Police Officer checked the parents on the Police NationalComputer, it was noted that the mother’s partner had an Harassment Orderagainst him, but that it wasn’t against mother.3.18.The Health Visitor made a home visit on the 16th April. Child G was seensitting on mother’s partner’s knee dressed in a nappy and was eating an9 Record of concern identified by the school and sent to CSC.10 Children in need of support rather than protection11 Hertfordshire’s Thriving Families is an early intervention programme, which incorporates the government’sTroubled Families initiative.9iced bun. The Health Visitor advised mother that this was not appropriatefood for him but she just laughed.3.19.On the 9th May the Access to Education Manager visited the family home asagreed at the CIN meeting. She had worked with the extended family andsupported them to access education. The manager was unaware that thefamily had an allocated Social Worker. Mother reported that Child G was inthe van parked on the driveway; he was in the care of mother’s partner’steenage son from a previous relationship.3.20.Mother attended the second CIN meeting in the middle of May on her own,she had requested that her own mother was not invited. The decision wasthat the case would be referred to Thriving Families (TF) after the nextmeeting. The view was that TF could offer more intensive practical supportto the family.3.21.The Student Social Worker made her last visit to the family on the 21st May.She observed a man working on a van parked on the drive and was told bythe mother that he was her partner, but that he didn’t live in the house; hehelped her with the children in the mornings as he worked nights. This wascontrary to the information that mother shared during the assessment. TheStudent Social Worker saw Child G who she described ‘as a lovely boy whoresponded well to his mother but looked grubby’. G2 was described as‘skinny’ and G3 ‘needed his nappy changed’ and ‘was grubby’.3.22.The Health Visitor made a home visit on the 27th May 2014 to undertakeChild G’s developmental check. She found it difficult to gain access to thehome but persisted as she could hear children crying and noted that theywere poorly supervised. She saw the children and described Child G asoverweight; he was not yet crawling or pulling to stand12. The health visitorfelt that the delay with his gross motor development was due to his size andlimited opportunity to explore his environment; he was either being held orstrapped into his buggy. G1 returned to the house with maternal greatgrandmother who said that she could not cope with G1 who was picking onthe other children’.3.23.In the early hours of the 27th May, a Police Patrol searched a parked vanwith two males, one of whom was mother’s partner. One of the PoliceOfficers noticed a baby, sitting in a car seat at the back of the van, he wasawake and did not appear distressed but there was a strong smell ofcigarettes and the car was full of smoke. Mother’s partner said that Child Ghad trouble sleeping so he would take him out for a drive to settle him. Hewas unable to give Child G’s date of birth but the Police Officers wereaware that he was living with the mother and were satisfied with hisexplanation. The Police Officer completed an internal Common Assessment12 Normal milestones for development are that a baby sits unsupported by 7-8 months and pulls to standfrom 10 months old.10Form (CAF)13 on his return to the police station because he was worriedabout the baby being in such a smoke filled van.3.24.In early June 2014 Child G was taken to hospital by ambulance afterbecoming unresponsive whilst being driven around during the night by hismother’s partner and subsequently died.4.Appraisal of Practice and Analysis4.1.IntroductionThis section of the Review assesses the quality of multi-agency practice atthose key points which were considered to provide the most significantlearning. In doing so, it takes into account both the contemporary requiredstandards and also the information that was known, or could have beenknown at the time of the events.Where there is information about whypractice may not have met required standards these are explained. Byunderstanding why things happened in the way that they did, rather thansimply what happened, the Review is seeking to achieve a greater depthof learning about safeguarding systems within Hertfordshire and beyondthis individual case. Where learning in relation to individual agencies’practice has been identified within the agency learning summaries it is notrepeated here. The recommendations for individual agencies, which wereproduced at the outset of this Review, are included in Appendix 4.4.1.1. The cause of Child G’s death remains unexplained. The post mortemidentified that Child G had seven healing fractures to both wrists, bothankles and his left knee. Expert opinion is that the injuries occurredprobably 25 – 50 days before his death and possibly at different times.Each of these fractures was as a result of significant forces applied to thebone, typically from a blow, impact, or bending or snapping action. Child Gwould have been in considerable pain at the time of the injuries and for afew days after when being handled and his discomfort and distress wouldhave been apparent to his main carers. Neither his mother nor her partnersought medical attention for Child G. The injuries only came to light afterhis death.4.1.2. The injuries were inflicted during the period 13 April 2014 – 8 May 2014,which was a period when there were four visits by professionals to thefamily home. Child G was seen on three of these visits, twice by the HealthVisitor and once by the Student Social Worker. There were no concernsabout any possible injuries reported following these visits. When theAccess to Education Manager visited on the 9 May, Child G was reportedto be asleep in the van being supervised by mother’s partner’s son. Thereason for this home visit was to discuss school attendance for G1 and itwas in this context that the Manager accepted the explanation given bymother that Child G was asleep in the van parked on the drive way.13 Police officers complete the form on the intranet and send to a central point that makes decision aboutfurther action.114.1.3. This Review has given careful consideration as to whether any of theprofessionals concerned could reasonably have been expected to identifythat Child G had been injured. For the professionals to have identified theinjuries they would have had to see Child G within a few days of theinjuries taking place, when his distress would have been visible, or to havephysically handled Child G. At the first visit made by the Health Visitor on16 April she observed Child G sitting on mother’s partner’s knee wearing anappy and feeding himself. Her next visit was at the end of May when thefractures would most probably have been healed. The Student SocialWorker visited on 21 May and observed mother changing Child G’s nappyand dressing him. Child G was described as happy and contented andresponding to his mother’s voice. Child G did not show signs of distressand the professionals had no reason to physically handle him. The injuriesonly came to light following Child G’s death. It is now believed that theywere inflicted at around this time. Given the nature of the professionalcontacts it would not have been possible to identify them during his life.4.1.4. Child G and his siblings had been identified as Children In Need. Theinitial concern following the referral to CSC was focused on whether therewere any safeguarding issues for G1 and G3 when their mother left themin the care of their father. When G1 and G3 were returned to mother thefocus of the intervention for the family moved to a supportive one. TheChild and Family Assessment failed to explore the significance of mother’snew partner who was living in the family home. CSC was aware thatmother’s familywere unsupportive of the new relationship and wereaware that it had created tension within the extended family. Backgroundchecks on mother’s new partner were not undertaken and therefore CSCdidnotmaketheconnectionswithmother’spartner’spreviousrelationships, including a history of violent behaviour against women, andthat his children were also known to CSC.4.1.5. Although there was evidence for some concern about how Child G and hissiblings were cared for, the Review Team were clear that there was nospecific evidence that they would experience serious physical harm.Inthese circumstances, neither Child G’s death nor his injuries couldreasonably have been predicted.In the absence of clear evidence thatthere was a risk of serious physical harm, professionals, and in particularChildren’sSocialCarewouldhavehadnojustificationintakingpreventative action such as removing Child G from his mother’s care.However, there was evidence to suggest that all of the children may havebeen at risk of long-term neglect, which could have led to a differentcourse of action in the longer term.4.2.The reluctance to name neglect by professionals involved with thefamily.‘Neglect can be difficult to define because most definitions are based onpersonal perceptions of neglect. These include what constitutes ‘good12enough’ care and what a child’s needs are. Lack of clarity around this hashad serious implications for professionals in making clear and consistentdecisions about children at risk of neglect’ (NSPCC.2012).4.2.1. Before the period covered by this SCR an outline chronology ofprofessionals’ involvement with the family featured several reportedincidents of domestic abuse, children dressed inappropriately for the timeof year and or weather conditions, failure to complete the immunisationprogramme for each child and general lack of stimulation within the familyhome. Good practice would be that given these concerns and the age ofthe parents when G1 was born for agencies to have intervened early, thisdid not happen.4.2.2. The Health Visitor had worked with the family for over four years. TheHealth Visitor was used to the fact that mother disregarded advice givenby her, particularly around nutrition, diet and socialisation. The HealthVisitor recorded these observations and facts yet did not recognise thepossible cumulative significance of these events and the impact it mighthave on the overall development of the children. Mother could becomeaggressive and hostile at times, mostly when she was being challengedabout aspects of her care: and there was a level of known violence andintimidating behaviour within the extended family.4.2.3. The family had been assessed for the core health visiting service whichmeant that the onus was placed on the family to access the service.Appointments for developmental assessments and immunisations wouldbe sent. Following the CIN plan the visits by the Health Visitor althoughregular, occurring once a month, were unfocused with no clear outcomerecorded or goals set for each child. It appeared that the Health Visitorbecame ‘desensitised’ to the situation and had become used to the familyand home conditions and accepted them as the normal. The Health Visitorwas the key professional that had known the family the longest and was ina unique position to gather evidence of signs of neglect including unmetemotional needs of the children, poor diet, home environment and lack ofsupervision. The Health Visitor was also aware of the violence within thehome between the parents and that G1 and G3 were aggressive to oneanother and using inappropriate language for their age. It was thereforesurprising that despite having undertaken the Graded Care Profile (GCP)training, at no time did she consider using the GCP tool14 to assist her inunderstanding what the issues were for each of the children.4.2.4. The home conditions were frequently commented on by professionals asbeing poor. Professionals became focused on clearing up the house andoffering practical support to the mother rather than improving her parentingskills and outcomes for the children. The children were described as‘grubby’ by more than one professional, which seemed to indicate that thiswas not ideal, but acceptable and therefore did not trigger further action.4.2.5. Staff at school had raised a cause for concern report about several aspectsof the children’s care. It is clear that the professionals that worked with the14 Graded Care Profile is an assessment tool used to assist in the identification of neglect13family wanted to improve G1’s attendance at school and this was reflectedin the CIN plan. However, the level of attendance at school was notidentified explicitly as being neglectful.4.2.6. The Social Worker identified during supervision that she was concernedabout neglect, (this was the only professional that actually used the wordneglect) the poor home conditions and that the mother appeared to lackthe motivation to make the necessary changes, and failed to act onprofessional advice. However, there appeared to be a lack of professionalfollow through of these concerns. The next day at the CIN initial meetingthe plan instead focused on practical help to sort the home conditions.There appeared to have been little if any analysis done on what the impactof living in these circumstances was for the children on a daily basis, orthat mother had failed to meet her children’s basic needs; ‘the persistentfailure to meet children’s basic physical and/or psychological needs andwhich is likely to result in the serious impairment of the child’s health ordevelopment’.15 This may also have been influenced by the family ethnicityand how professionals responded; this will be covered under the sectionon the Significance of ethnicity and culture.4.2.7. It is well known that neglectful parenting is almost inevitably a sign ofcomplex and longstanding problems such as mental-ill health, domesticviolence, a poor physical environment or entrenched behaviour by aparent or parents. The children’s needs should always be assessed andaddressed fully, including the family history and context. It is apparent thatthe CIN plan became focused on sorting out the immediate practicalissues of the physical environment; such as clearing up the house andgarden and ensuring that G1 attended school; these interventions wereeasy to measure and made professionals feel that they were effectingchange and that the case was moving forward. The plan was aboutsupport for the mother, rather than assessment and response to risks andthere is little evidence of what consideration was given to the safety andwell-being of the children. Research suggests that professionals can find itdifficult to say to a parent that their children are neglected because thisimplies that the parents are to blame and given the difficulties of workingwith this family, this may have been a feature here.4.2.8. The question is what allows professionals to fail to name neglect? TheHealth Visitor was the only professional involved with the family over asignificant period of time. The Social Worker did identify that she thoughtthat the children were neglected but didn’t follow this through and becamefocused on the practical solutions for the family. The practitioners whocontributed directly to this Review were asked directly why the GradedCare Profile was not used for this family, the response was that it wouldtake too long to complete. Training for the Graded Care Profile (GCP) hasbeen implemented by Hertfordshire Safeguarding Children Board (HSCB)since April 2014 and has trained a total of 114 staff; prior to this individualagencies were responsible for training their own staff in the tool.What isapparent is that the GCP was not at the forefront of practitioners’ minds in15 Working Together 201314working with this family and did not appear to be part of any routineconsideration. The current Board strategy (advocated by CSC) is that theGraded Care Profile is a tool that can be used by professionals shouldthey wish to use it or think it appropriate to use.Ofsted commented that ‘those local authorities providing the strongestevidence of the most comprehensive action to tackle neglect were morelikely to have a neglect strategy and / or systematic improvementprogramme across policy and practice, involving the development ofspecific approaches to neglect’16Neglect is a complex safeguarding issue that requires a complexresponse. Being able to respond effectively to cases of neglect isparticularly important given the numbers of children who are the subject ofa child protection plan under the category of neglect. In February 2015,over 600 children in Hertfordshire were subject to a child protection planunder the category of neglect. The number of children on CP Plansoutweighs the number of GCP’s by a factor of 10. If the GCP was beingused successfully to identify neglect and offer help, it could be expectedthat this would be reflected in the numbers of children subject to CP Planfor neglect. Recommendation1The Board needs to challenge agencies to demonstrate that they areworking in line with its strategic approach to neglect.4.3.The importance of robust assessments and identification of risk.4.3.1. A good assessment including family history and identification of riskfactors is fundamental in ensuring that a strong and appropriate plan forthe level of intervention is put in place. In this case the assessment madeby the professionals was too superficial and focused very much on the‘here and now’. The assessments did not adequately take into account thefamily history and dynamics, including the ‘break-up’ of the relationshipbetween mother and father, and as a consequence the loss of contactfather had with his children. There was no assessment of mother’s newpartner even though it was known that her own family was unhappy aboutthe new relationship and there would have been information available bothwithin CSC’s own records and other agencies, such as the ProbationService about risks such as violence and drug use. There was a lack ofcritical review about whether interventions previously tried with the familywere effective. This may have led to the wrong thresholds being applied.4.3.2. The Health Visitor assessed the family as meeting the core service despitethe fact that the HV identified that mother had experienced domesticabuse and had a history of non-engagement, failure to keep scheduledappointments for the children’s immunisations, social isolation and lack ofstimulation for the children. It is difficult to understand the rationale behindthis decision, even acknowledging the benefit of hindsight. Although theHealth Visitor visited monthly when the children became CIN, the visitsremained unfocused and there was no clear plan of expected outcomes16 In the child’s time: professional response to neglect Ofsted.15for each child.The Health Visitor should have been more evidentlyconcerned about a number of aspects of the children’s care anddevelopment, including Child G’s gross motor development delay.4.3.3. Following the referral to CSC in February 2014 the initial focus was on thetwo children, G1 and G3 who were residing in the care of their father whohad a known history of violence. The Team Leader gave appropriatedirection to the Social Worker and Student Social Worker on the areas tobe included in the assessment. After the visit to father, it became evidentto the Social Worker that all four children needed to be included in theassessment.This was an opportunity to move to a holistic assessmentand move away from a focused narrow view.4.3.4. The Child and Family Assessment(C&FA) was completed and despite thelong list of concerns including the fractured relationship that mother hadwith her own mother, the ages and therefore vulnerability of the children,the poor home conditions and the possible risk of abuse from father, theanalysis was fairly positive and concluded that mother had shownstrengths and the ability to protect her children. Despite mother’s statedwillingnesstoco-operatewiththeagencies,theevidentlackofengagement and hostility to such is evident at the CIN meeting on the 2April 2014 but went unchallenged. There was no re-assessment ofmother's ability to prioritise or meet the needs of her children following thisincident.4.3.5. The omission of including Mother’s new partner in the assessment is ofsignificant concern and falls below good practice standards. The TeamManager said that the normal practice would be to check all adults thatwere living in the house. Background checks were not completed onmother’s partner; he was described as supportive towards mother, helpingher in the morning with the children. There was conflicting informationabout whether mother’s partner was actually residing in the family homepermanently. Agencies were aware that mother’s family did not approve ofher new relationship. Despite this no enquiry was raised on mother’spartner. No assessment of mother’s ability to protect her children withinthis new relationship was undertaken and as a result no risks considered.4.3.6. Neither was there much consideration given to father, initially the concernwas for G1 and G3 as they were in the care of their father. In factattendance at school for G1 improved whilst he was living with his father.When G1 returned to live with his mother, there was no exploration withmother about the relationship that she had with G1, given that she hadbeen willing to allow G1 to live with his father and had expressed that shedidn’t have a strong bond with G1. Following the return of G1 to the familyhome, he had no further contact with his father. Good practice would havebeen to discuss this situation with mother, father and G1.This did nothappen. There was no further contact with father from the professionalsinvolved with his family; neither did he see his children (apart from a periodof about 5-7 hours on the 17th April when Child G was taken to hospitaland the three other children were left in his care).What is apparent is thatthere was an absence of focus on both of the men within the children’s16lives, an issue which has been a feature of previous reviews withinHertfordshire.4.3.7. Risk should be assessed from the perspective of the children and shouldnot be unduly influenced by sympathy for the adults’ experience. There isa danger that when professionals from the key agencies fail to identify therisks or understand the significance of them, children are left living in riskysituations. Potential and actual risks to the children were not clearlydefined or included in the CIN plan. Research evidence from SCRs(Brandon et al17) suggests that history is an important part of assessingcurrent and future parenting capacity, and should be considered as apotential risk factor. It is apparent that ‘the past is the best predictor of thefuture’. Reder et al18 have written about a cognitive error, which results indisregarding new evidence that might challenge the current direction orconcept of the case (e.g. family support as opposed to child protection).Within this family history should have suggested a risk of continuing poorcare and neglect of the children’s needs across a variety of theirdevelopmental needs.A safe child protection system needs to dealproficiently with risk and probability and the impact; it is not enough torespond reactively after an incident of harm has been caused to a child4.3.8. The assessment of this case was that the multi-agency intervention, i.e.Child in Need procedures was not underpinned by an adequate, robustassessment of the full family circumstances and all the needs of and risksto the children. These procedures are intended to be built on good qualityassessments, by developing a plan of action, which is owned by the multi-agency group and reviewed regularly to see what progress is being madeto promote children and young people’s outcomes. Without an adequateassessment, the decision to manage the family within Child in Need wasflawed, and in practice appeared to encourage a focus on supporting themother rather than identifying or managing possible risks to the children.The review is not challenging the decision to manage the family withinChild in Need but is highlighting the need to constantly review and assessthe progress being made against the CIN plan and take the appropriateaction where there is no change or lack of engagement. Both thepractitioners and members of the Review Team considered that this casewas not untypical of practice and that staff across the agencies felt thatincreasing numbers of children in circumstances such as these were beingmanaged under Child in Need.4.3.9 CIN and CP numbers within Hertfordshire have been unstable for sometime and at times CP numbers have been considerably higher thanstatistically comparable authorities. The reasons for fluctuations in thesenumbers are not always easy to identify. There has been a concern withinHertfordshiretoreducethemandthisisanongoingfeatureofmanagement planning. What is very apparent from the experience of ChildG is that if in the future Hertfordshire’s ambition is to meet the needs ofmore children as CIN then there must be a very robust CIN assessmentprocess. This also requires a recognition by professionals of the need to17 Brandon et al: 200818 Reder et al 199317escalate or reconsider the level of intervention when the CIN process isnot working in neglect cases. This is what should have happened quicklyin this case when there was no improvement at home and the CIN meetingfailed to meet its objectives.4.3.10.What is therefore very significant learning from the experience of Child Gis the crucial importance of the assessment process in order to ensure thatthe intervention is appropriate to the needs and risks facing children.Recommendation 2The Board needs to be assured that appropriate and proportionateassessments are undertaken to ensure that those families and childrenmanaged under Children in Need are the correct ones and are properlyreviewed.4.4.Management oversight and supervision.4.4.1. It is well documented that in working with families to safeguard children,the sense that professionals make of information they receive willinevitably be vulnerable to common errors of human reasoning (Munro,1999). As Munro (2008) notes:‘Psychological research has shown that people are very bad at policingtheir own biases. Social workers need regular critical supervision to ensurethat their biases are not distorting their assessments.’4.4.2. The Health Visitor did not identify this as a case that she wanted to take tosafeguarding supervision during the timeframe of this Review. There is apotential risk to the rigour and strength of supervision if the cases underconsideration are only those with very evident high risk factors such asprevious physical abuse, excluding those with longer term but repeatedconcerns, such as those associated with neglect. This is particularly a riskfor services such as health visiting where supervision prioritises casesknown to be high risk, but is equally applicable across services. Duringdiscussion with the practitioners in this case there was some acceptancethat possibly because of the family culture and ethnicity a differentthreshold of parenting was accepted. Supervision can become even moreimportant when a family has been known to agencies for ”years” to providea critical and challenging view that allows the facts to be viewed from adifferentperspective.Italsoallowsprofessionalstobeabletocommunicate and express their anxieties about the work that they areundertaking with the family, and identify gaps and risks in the multi-agencysystem.4.4.3. From January 2014 the health visiting teams moved to a corporatecaseload. The Information System that Health Visitors use also changed inFebruary 2014 which now allows managers and the Safeguarding Team tohave an overview of families with identified concerns, including CIN andchildren in receipt of a child protection plan. The supervision policy within18HCT has been recently updated to ensure that cases such as this one arebrought to supervision.4.4.4. The Social Worker received supervision on this case the day before theinitial CIN meeting. It is interesting to note that she thought that thechildren were neglected, and that mother lacked the motivation to change.Although it had been assessed as a CIN case she was of the view that itmight reach the thresholds for child protection. The meeting took place thefollowing day and there is no evidence in the minutes of the meeting thatthe concerns raised in the supervision arena were explored. The CINmeeting had been difficult and professionals had found the experiencechallenging and intimidating. It is difficult to understand why those presentat the meeting failed to feed this back to their respective line managers orreflect on the behaviour and attitude of maternal grandmother in particularand what the consequences of this display were in relation to the CINPlan.4.4.5. Supervision varies across agencies. Within CSC there is an expectationthat Social Workers receive monthly supervision on all their caseload andif that isn’t possible the manager will help identify those cases that need tobe discussed. Only two supervision sessions were recorded in the timeframe (rather than four). There was also evidence of a possible overreliance on using email to share information in managing this case. Thereasons cited for using e-mail by the professionals working with the familyincluded unavailability or difficulty in accessing staff at the time of the visit,lack of time, and by sending the information electronically it provided anaudit trail. The danger of this is that the focus is on evidencing actionstaken, rather than good professional information sharing and that theopportunity to discuss the case and challenge one another face to face islost and the importance of new information may not be picked up.4.4.6. The Social Work Team leader gave very clear direction to the SocialWorker and Student Social Worker about what needed to be included inthe assessment. It is evident from the conversation with the team leaderthat this wasn’t one of the significant cases that they were dealing with andthat once the perceived risk of two of the children being in the care offather was removed with them returning to mother the urgency of obtaininginformation and background checks diminished.4.4.7. We know that practitioners across agencies are working with a highnumber of families with concerns that may not immediately stand out asmeeting the thresholds for intervention but nevertheless continue to causeconcern. It might be argued that it is these very cases that the practitionersshould be bringing to supervision on a regular basis. However, the focusfor many agencies when identifying cases for safeguarding supervision isoften those cases, which are already within Child Protection procedures.There is little evidence to suggest that individual agency managers wereaware of the changing circumstances of the family. Further work needs tobe done on reviewing the types of cases that are discussed in supervision;to ensure the correct cases are taken to supervision and that there is aclear plan to support the professional in working with families and children.Such a review should focus on those cases that may not immediately19present as a high risk, but may need attention for example due to being onthe edge of thresholds for long periods, or to help workers identify wherethey are becoming ‘stuck’ with a particular family. Recommendation 3.The Board needs to be assured by partner agencies that high qualitysupervision plays an integral role to improve assessments and practice inorder to further safeguard children.4.5.To what extent did the culture and ethnicity becomes the defininginfluence in shaping the agencies’ response to the family situation?4.5.1. It was identified at the outset of this Review that there was potentiallearning about the way in which agencies worked with families from theTraveller community.Information provided to the review has frequentlyhighlighted that this was a Traveller family and that some professionals feltthat they could be difficult to work with. Hertfordshire has one of the largestGypsy and Traveller populations in England accommodated on 41 sites. Asignificant number of Travellers have also been provided with permanenthousing locally. Mother and her extended family were all housed locally.Research suggests that when the decision to leave the Traveller sites ismade, families can be exposed to more direct and immediate forms ofpublic hostility focused on their ethnicity or lifestyle. This is coupled withthe fact that they may be forced to move further away from their widercommunities, culture and support systems and can lead to a cycle ofdisadvantage,oppressionandmarginalisation.19Motherexpressedfeelings of isolation, being bullied at school and ‘being looked down on’because she was a Traveller. Staff need to be equipped to understandand support those who identify with a Traveller heritage but now live infixed accommodation.4.5.2. Motherappearedtohavedifferentrelationshipswiththedifferentprofessionals involved in her care and this appeared to be shaped by therole they had within the family. The Midwives were universally accepted bymother and maternal great grandmother, and were made to feel welcomeat the home of maternal great grandmother during the birth of Child G. TheHealth Visitor was accepted (she was allowed into the home) but advicethat was given was often ignored or disregarded. Both the Social Workerand Student Social Worker had been refused access to the family homeon different occasions and had experienced verbal aggression. Mother’sinteractions with GPs were mostly around care for an acute condition foreither her or the children, which were appropriate. Mother attended E&NHHospital on at least three occasions when she went against medicaladvice and took her own discharge, twice towards the end of herpregnancy and then following an operation. Mother also walked out of theEmergency Department with Child G because she didn’t like the advicethat she had been given by the Consultant. There was a generalacceptance that this was her pattern of behaviour and there was little19 Lau and Ridge, 201120evidence found that the reasons behind mother taking this action werefully explored with her, or whether any consideration was given that if thiswas how mother looked after herself; how does she care for her fourchildren?4.5.3. There appeared to be limited insight from professionals within the acutehospital about what the needs of children living in this community mightbe. Good practice would be that staff across the Trust, in this case, theEmergency Department would complete an Information Sharing Form thatis sent to the liaison Health Visitor, who would then communicate directlywith community staff. This did not happen on this occasion; the HospitalTrust has acknowledged that this was an omission. Child G, G1 andMother were seen in the Children’s Emergency Department, the DayAssessment Unit and the Adult Emergency Department. All are located indifferent areas within the Trust and with different members of staff.Currently there is no facility for incidences such as ‘discharge againstmedical advice’ to be shared within the Trust and as a consequence theincidences were viewed in isolation. In the community a record system isused whereby community staff can view information and alerts. Both theReview Team and Independent Reviewers were also concerned that therewas no evidence shared with us that staff in the hospital, but in particularthe Emergency Department, had considered whether there were otherchildren within the family and who was caring for them. Further work hasbeen undertaken by the hospital trust for all staff to ‘Think Family’ and isreflected in Appendix 4.4.5.4. During conversations and meetings with the frontline staff the issue aboutapplying different thresholds to families from a Traveller background wasraised. A significant number of professionals involved with this family feltthat although the same threshold should apply, in practice they aredifferent, and they have become over familiar with seeing certain practicesand accepting them as normal. Examples were given that small childrenwere under stimulated and parented in a neglectful way whilst olderchildren were allowed to play in a destructive way without challenge.Professionals seemed reluctant to challenge, often because if they didthey feared it would be met with aggression and hostility (some of theprofessionals were scared when working with this family) and mightjeopardise their ongoing relationship with the family and possibly with thewider Traveller community.4.5.5. The behaviour of mother and maternal grandmother at the CIN meeting inearly April was aggressive and challenging. Maternal grandmother made itvery clear that because they were Travellers they didn’t need to send theirchildren to school and it was up to the parents as to whether they wantedtheir children immunised. Mother refused to allow the Children & FamilyAssessment to be shared with the other professionals at the meeting andcontinued to be uncooperative. There appeared to be lack of considerationor reluctance by the professionals to stop the meeting and reschedule,possibly as a consequence, the plan was task centred rather than focusedon meeting the needs of the children to support them in achieving their21maximum potential. It is clear that the meeting achieved the minimumacceptable level of intervention, one of support and practical assistance,rather than developing a plan that was child focused and addressed thedisparity of mother’s behaviour towards the agencies working with thefamily and whether she had the ability and motivation to make the requiredchanges. Given the powerful description of the meeting, it is the Review’sconclusionthatthiswassignificantly,althoughquitepossiblyunconsciously, influenced by the family’s behaviour.4.5.6. Professionals were unaware of the Access to Education Team (AET) forTravellers and Refugees and the specialist knowledge and experience thatthe team has. It became apparent during the review that staff within theteam had acclimatised themselves, or believed that they were uniquelyplaced to help Travellers without going through the legitimate safeguardingchannels. As a consequence there continues to be a risk of the Access toEducation service not referring concerns.4.5.7. Over the course of the SCR there has been much discussion about howprofessionals found it difficult to challenge and work with Travellers. Thiswas because some professionals felt scared and intimidated, whilst otherprofessionalsdidnot fully understand thecultureofthe Travellercommunity or had preconceptions, which they did not question. Theknowledge of the professionals about the culture and values of theTraveller community appeared to be at a superficial level and wasinterspersed with ‘stereotypical’ views of how Travellers behaved.4.5.8 We know that there are a number of significant attitudes and values thatare widely shared within Traveller communities, although it is absolutelycrucial that each family’s individual values and traditions need to beexplored and understood ( see Bristol City Council, Myth busting bookleton Gypsies and Travellers) Commonly family and particularly children areextremely important to Travellers and a source of great pride andaspiration for their children. The extended family tends to support and lookafter one another. Travellers have an oral culture passing their traditionsfrom one generation to the next. Men and women generally still follow themore traditional gender roles, men provide for the family and women lookafter the children and the house/trailer. Travellers live by their set of valuesand behaviour codes; they have strict rules on cleanliness, modesty andfaithfulness. The special hygiene rules (including using different washingup bowls and anything such as a bag that has been on the floor will neverbe put on the table)20 are in some ways stricter than those of the widercommunity but are not well understood outside the Traveller community.Had more of the professionals working with the family known, for example,about the importance of cleanliness, more time might have been spentunderstanding what the implications might be within this family of suchrules not being observed.20 Good practice guide Working with housed Gypsies and Travellers,2008224.5.9 If the professionals did challenge behaviour and parenting practice somewereanxiousthattheywouldbeseenasdiscriminatorytowardsTravellers. It is therefore crucial that staff need to be able to engage withthe wider Traveller community, be curious about that communities typicalnorms and value and feel confident about being able to challengebehaviour and child rearing practice when it does not conform to theexpected standards within the wider community4.5.8. Although this review was on a family with a Traveller heritage whichprovided a particular focus on how agencies work with the Travellercommunities, the issues and lessons learnt have wider implications for theagencies in Hertfordshire as more families from different ethnic groupsmove into the area. Agencies must ensure that the workforce is equippedto work with all families, to develop greater understanding of differentcultures and beliefs and how to engage constructively with differentcommunities in order to deliver a safe but sensitive service, respectingcultural differences but ensuring that the same standards and thresholdsare applied. Recommendation 4Partner agencies need to assure the Board that they are equipping theirworkforce to deliver safe and effective services for children within itstraveller communities and to use this learning to further enhance servicesto other minority communities within Hertfordshire.4.6.Concluding comments from the review.At the time the Review was commissioned the following two issues wereidentified as of particular interest:What do the findings in relation to the care provided to Child G tell theHSCB and member agencies about the strengths and vulnerabilities tosafeguard and promote the wellbeing of children?What steps should the HSCB or member agencies consider taking inorder to improve services for vulnerable children?These two overarching questions have formed the basis for this analysisand the following recommendations.5.Recommendations.This section brings together the recommendations arising out of the learning fromChild G’s experience, which the Review Team concluded provided insights intosafeguarding practice more widely and therefore will require further considerationand prioritisation by the Board.235.1.The Board needs to challenge agencies to demonstrate that they areworking in line with its strategic approach to neglect.5.2.The Board needs to be assured that appropriate and proportionateassessments are undertaken to ensure that those families and childrenmanaged under Children in Need are the correct ones and are properlyreviewed.5.3.The Board needs to be assured by partner agencies that high qualitysupervision plays an integral role to improve assessments and practice inorder to further safeguard children.5.4.Partner agencies need to assure the Board that they are equipping theirworkforce to deliver safe and effective services for children within itstraveller communities and to use this learning to further enhance servicesto other minority communities within Hertfordshire.BibliographyBrandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth,J., and Black, J., Analysing Child Deaths and Serious Injury Through Abuseand Neglect: What can we learn? – A Biennial Analysis of Serious CaseReviews 2003-2005,DSCF 2008.Framework for the Assessment of Children in Need and their Families,Department of Health, Department for Education and Employment andHome Office, 2000.Lau, A and Ridge, M., Addressing the impact of social exclusion on mentalhealth in Gypsy, Roma and Travelller Communities, 2011.Mary Sheridan’s From Birth to Five Years: Children’s DevelopmentalProgress, Fourth Edition.NSPCC, Research Briefing, ‘Neglect’, 2012.Reder, P., Duncan, S and Gray, M., Beyond Blame: Child Abuse TragediesRevisited, Routledge, 1993.24Reder, P and Duncan, S., A Follow-up Study of Fatal Child Abuse, 1999.UK – WHO Growth Charts (2013)Working Together to Safeguard Children, A guide to inter-agency working toSafeguard and promote the welfare of children, HM Government, 2013.25Appendix 1: ACRONYMS AND TERMINOLOGYAETAccess to Education for Refugees andTravellers.CAFCommon Assessment Framework.CGCase GroupCINChild in Need.CPPChild Protection PlanCSCChildren Social Care.C&FChild and Family Assessment.DADomestic Abuse.E& NHEast & North Hertfordshire NHSHospital Trust.E&NH CCGEast &North Hertfordshire ClinicalCommissioning Group.GPGeneral Practitioner / Family Doctor.GCPGraded Care Profile.HCTHertfordshire Community NHS Trust.HSCBHertfordshire Safeguarding ChildrenBoard.HVHealth VisitorIDAPIntegrated Domestic AbuseProgramme.IVTIntravenous Therapy.POProbation Officer.RTReview Team.SCRSerious Case Review.SWSocial Worker.St SWStudent Social Worker.TFThriving Families.26Appendix 2: METHODOLOGY2.1.1. Statutory guidance within Working Together requires Local SafeguardingChildrenBoardstohaveinplaceaframeworkforlearningandimprovement, which includes the completion of Serious Case Reviews.The guidance establishes the purpose as follows:Reviews are not ends in themselves. The purpose of thesereviews is to identify improvements, which are needed, and toconsolidategoodpractice.LSCBsandtheirpartnerorganisations should translate the findings from reviews intoprogrammes of action, which lead to sustainable improvements,and the prevention of death, serious injury or harm to children.(Working Together, 2013:66)2.1.2. The statutory guidance requires reviews to consider: “whathappened in a case, and why, and what action will be taken”. Inparticular, case reviews should be conducted in a way which:recognises the complex circumstances in which professionals worktogether to safeguard children;seeks to understand precisely who did what and the underlyingreasons that led individuals and organisations to act as they did;seeks to understand practice from the viewpoint of the individualsand 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 thefindings.2.1.3. In order to meet these requirements the model adopted in undertaking thisreview uses a ‘systems approach’, which draws significantly on the workundertaken by Professor Munro21 and SCIE [Social Care Institute forExcellence].A ‘systems approach’ to learning recognises the limitationsinherent in simply identifying what may have gone wrong and who mightbe ‘to blame’. Instead it is designed to identify which factors in the widerwork environment support good practice, and which create unsafeconditions in which poor safeguarding practice is more likely. The purposetherefore is to move beyond the individual case to a greater understandingof safeguarding practice more widely.2.1.4. The process was led by two Independent Reviewers working with aReview team and included:Consideration of chronologies and learning summaries produced by10 key agencies.4 meetings of the Review team.21Social Care Institute for Excellence (Fish et al,2008)271 meeting with the ‘Case Group’ – key practitioners involved in thecase.Conversations with 11 key practitioners.2.1.5. Two Independent Lead Reviewers, Ann Duncan and Sian Griffiths werecommissioned to lead the review. Ann Duncan, an independent consultantwho has experience in undertaking Serious Case Reviews, authored theReview. Sian Griffiths is an independent consultant who has significantexperienceinundertakingSeriousCaseReviews.BoththeLeadReviewers were independent of the case and of all the agencies involved.2.1.6. The Review Team was comprised of the Independent Lead Reviewers,and the following senior managers/senior professional leads who wereindependent of the case:Job Title / RoleOrganisationChild Protection & Statutory ReviewService ManagerHCCNamed Nurse for SafeguardingHCTLead Adviser, Health &WellbeingHCCDCIHertfordshire ConstabularySenior ManagerNational Probation ServiceHead of Early Help & Thriving FamiliesHCCInterim Named Nurse for SafeguardingE&NH Hospital TrustNamed GP for SafeguardingE&NH CCGActing Business ManagerHSCB2.1.7. The Case Group consisted of key front line practitioners and first linemanagers who had worked with the family in various capacities. Individualconversations took place with 11 of these practitioners in order to obtain adetailed picture of what happened in this case, with a particular focus onestablishing what the practitioners knew at the time the events unfolded inorder to avoid the bias of hindsight.The members of the Case Groupattended a Learning event at which the emerging analysis was discussedwith the Review team.2.1.8. As well as the individual agency chronologies and agency reflection andlearning summaries, the Review Team requested and had access to arange of other documentation, including Pathology reports and theminutes of the initial CIN meeting, Child and Family Assessment andsupervision records.2.1.1. The timeframe under consideration for this Review was:281st January 2013 – 2nd June 2014The period under review covers the pregnancy and birth of Child G, thebreakup of the relationship between MG and FG and the referral toChildren’s Social Care. We have also included information about MP in theyear before the relationship between MG and MP started as it provided auseful background and context. The review finishes at the time of ChildG’s death.2.1.10.In order to minimise the risk of pre-judging any learning, the Review didnot set out specific terms of reference. However the Review took intoaccount two questions posed when the review was commissioned, whichare as follows:What do the findings in relation to the care provided for Child G telltheHSCBandmemberagenciesaboutthestrengthsandvulnerabilities of wider arrangements to safeguard and promote thewellbeing of children?What steps should the HSCB or member agencies consider taking inorder to improve services for vulnerable children?2.1.11.Family involvement. The involvement of key family members in a Reviewcan provide particularly helpful insights into the experience of receiving orseeking services. Letters were sent to five family members: MG, FG,MGM, MGGM and MP, informing them about the process and invitingthem to contribute. However, due to the ongoing criminal investigation wehave been advised by the police not to meet with the family. Furtherconsideration will be given to meet with family members at the conclusionof the criminal proceedings.29Appendix 3: KEY DATES TABLE03/01/13MP sentenced to 12 month Community Order with a SupervisionOrder and a requirement to participate in the Integrated DomesticAbuse Programme (IDAP)17/01/13MG, late booking at 15 weeks +5 days and requests a home birth.15/02/13MP breaches order.06/03/13MP guilty of breach of Community Order, fined.10/07/13G born at MGGM house.04/09/13Health Visitor (HV) makes home following request from MG.11/09/13MP returned to court for further breach of the Community Order.Community Order revoked and MP re-sentenced to 2 yearCommunity Order plus supervision requirements and unpaid work.There is no IDAP requirement with new order.28/10/13Child G is seen in emergency department with nappy rash, MG leftas did not like the advice that was given.20/11/13MP receives three-month custodial sentence No supervision onlicence after this as sentence less than one year, Case terminatedby Probation Service.26/11/13MG has operation, takes own discharge.13/12/13MP released from prison.06/02/14Referral made to Children Social Care (CSC) that raises concernsabout the children.08/02/14General Practitioner receives police notification of Domestic Abuse(DA). MG told FG to leave the family home.10/02/14Directions given by Team Leader to allocated Social Worker (SW)and Student Social Worker. (St.SW)25/02/14Home visit by CSC to inform MG re the findings of Section 17enquiry MG agrees to work with HV.25/02/14SW and St SW meet with G1 at school.G1 stated he did not like MP, was happy with his Dad and MGGMbut not with his Mum, MP or MGM. G1 said his Mum was happywith MP but not with his Dad.26/02/14G1 upset at school, worried about his Dad being at home as hewas going to be beaten up by someone called (name of MP)School inform CSC.10/03/14Child & Family Assessment completed.21/03/14Home visit by HV, MP present. Child G eight month checkundertaken, Child G is not sitting un-supported.01/04/14Case work supervision, SW states home conditions poor- MGdescribed as lacking the motivation to make changes and thatwhilst case originally assessed as Child In Need (CIN) SW30considers could be CP. CIN meeting to take place on the 02/04/14at the school.02/04/14CIN meeting held at the school. MG and MGM present. MGMnoted to be forceful and shouting and swearing at times.07/04/14Police called by neighbour after reports of child screaming andvisited home. No evidence for concern.16/04/14SW makes a phone call to MG to arrange a home visit, accessdenied. HV visits and observes Child G sitting on MP’s knee.17/04/14MG advised by Paediatrician that G1 needed to be admitted intohospital for Intravenous (IV) antibiotics, MG refuses and takes G1home. MG attends with G1 daily at the day centre for 4 days of IVtherapy.09/05/14Access to Education Manager visits family at home to discussschool attendance. Child G reported to be asleep in the vanparked in the driveway. MP’s teenage son from a previousrelationship reported to be supervising him.13/05/14CIN meeting held at Children’s Centre, MGM not invited at therequest of MG. Plan to step down at the next meeting and refer toThriving Families. Next CIN meeting 20/06/14.14/05/14MP stopped by police at 05.05 hours. MP verbally aggressivetowards officers.21/05/14SW visits the family home; Child G and G3 described as grubbyand require a nappy change.27/05/14HV visits to undertake developmental assessment on Child G.Identified that Child G is delayed in his gross motor development.Home conditions poor.29/05/14MP stopped by the police at 04.40 hours. Another male in the caras well as Child G in a car seat.June 2014MP takes Child G out in the van he is not in a car seat. On thejourney back home, MP noticed that Child G wasn’t breathing, MPstarted CPR. Ambulance called to home address, the ambulancecrew informed the police. Child G taken by ambulance to hospitaland was pronounced dead in the early hours of the following day.31Appendix 4:ACTIONS ALREADY TAKEN BYINDIVIDUAL AGENCIESThe following actions were identified by individual agencies at the outset of thisReview based on their initial analysis of the practice:General Practice.The way to respond to and deal with failure to have your childrenvaccinated for reasons other than conscientious objection needs to bediscussed and agreed.Hertfordshire Community NHS Trust.1. Concerns for children must not be considered in isolation, previous care/family history should be considered.2. The risk of domestic abuse must be fully assessed. Failure to engage inassessment may leave children at risk of harm and may lead to a childprotection referral. Details of father’s and partners must be recorded onappropriate health records.3. Accurate record keeping needed to assist in the assessment of risk.4. Increasing the recognition of vulnerability and risks to children.East & North Hertfordshire NHS Trust.1. Communication and liaison both inside and outside of the organisation isessential where there may be small concerns as this can inform a biggerpicture but this can only be achieved and is dependent on the capacity orunderstanding of the health professional involved in the case at thatparticular time. There were missed opportunities for information sharingand although East & North Herts Trust have limited viewing access toSystmOne for the child health module it is possible that greaterfunctionality would have assisted in this area.2. It is likely that not enough indicators identifying the family as vulnerablewere recognised at individual health contacts, however staff need to beaware that the small concerns help inform a bigger picture and couldidentify a referral opportunity.3. Since the appointment of the Named Midwife in January 2014 the HSCBPre-Birth Protocol has been rolled out. This document has beendisseminated to all community midwives, managers and team leaders. Itis available on the Trust Intranet and is referred to in supervision andduring training.324. Safeguarding children supervision has been introduced on an individualor group basis to staff who carry a children’s caseload or who haveregular contact with children. The supervisee is expected to takeresponsibility for their supervision by bringing cases for discussion wherethere are concerns. This includes where there are CP plans, concernsregarding parental behaviour e.g. DV or drug and alcohol use. Theimpact on parenting is discussed and plans made during the episode ofcare being delivered. The supervision is offered on a four monthly basisand contract agreed outlining expectations.Hertfordshire County Council Children’s Services1. Lack of robust challenging of family members, even when drift or lack ofchange evident.2. Focus on supporting mother rather than the safety and well-being of thechildren.3. Lack of identification and assessment of risk factors. Poor assessment ofrisk. Risk factors evident but not explored nor resolved nor assessed,particularly in relation to mother’s new partner4. No risk assessment of mother as a consequence of her relationship withher new partner and her lifestyle and choices.5. SSW working with what appears to be minimal support and/or direction bysupporting SW.6. Lack of evident supervision of SSW and possibly the SW.7. Concern re management oversight and understanding of concerns.8. Management of CIN by Children’s Services.9. The effectiveness of multi agency working on this matter must be an issuefor consideration.Hertfordshire Police ConstabularyIn relation to the stop check and submission of intelligence there may bean issue regarding professional judgement and safeguarding awareness.National Probation Service1. Routine contact with both CSF and the Police Domestic Abuse Unit wouldhave enabled the Offender Manager to feel more confident that thepositive things being shared were backed up by a lack of call outs/socialwork intervention. Again this would have added weight to providing a moreinvestigative approach to support or challenge the perception created of asettled relationship and household (which may have been true at this timeof course).2. The issue of Home visits is one which would benefit from furtherconsideration by the NPS in terms of its current policy; I am satisfied thatthere were no specific incidents of concern which may have led to theOffender Manager missing an opportunity to conduct a home visit but33wonder in general terms, when there is a young family with very youngchildren and some issues of concern with regards to their support network,that there should be an expectation that a home visit is made to see thefamily interact in their environment. This will have resourcing issues andthus would suggest that this is an issue for review and consideration bythe NPS at this time.Access to Education Team for Refugees and Travellers1. Look to ways of improving information sharing across agencies andimprove joint working practices2. Early alerts from other agencies should be routine.3. Good practice models of partnership work with social workers in certaindistricts to be shared with teams in other districts.