Large number of unexplained injuries to a 3-year-old boy in April 2021. Leo was assessed to be showing signs of neglect of his physical care. Children's social care and universal services had been provided across two local authority areas. Learning themes include: assessment of injuries to young children and the need for child protection medicals; holding the child and their experience in mind; consideration of child protection processes while a child is subject of a supervision order and the role of the lead professional at step down to universal services; supporting parents who experience mental health problems; information sharing with busy GP Practices; case supervision and multi-agency management across two local authorities; maintaining significant relationships for care leavers being rehoused; the need for a wider perspective in domestic abuse work; work with care leavers as parents; and the impact of Covid-19 on service provision and identifying vulnerable families. Recommendations include: seek assurances that the role and skills of the lead professional are understood and embedded within any team around the family arrangements, especially when a case is being closed to social care and the lead professional role is not held by a dedicated early help specialist; a standard child protection data sharing form is sent to GPs for completion and that this is a form based on the template developed by the National Named GP Group; to develop best multidisciplinary practice guidance where services are provided across more than one local authority, to ensure that the needs of children and their parents who are care leavers are met; and to review the skills of frontline practitioners in supporting the emotional attachment between carers and children.
      
 Title:  Child safeguarding practice review: Leo. LSCB: Barnet Safeguarding Children Partnership Author: Malcolm Ward Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            Barnet Safeguarding Children Partnership               Child Safeguarding Practice Review  Leo        November 2022       1 Contents   1. Executive Summary                                                                                                              2  2. Reason for this Review and its Methodology                                                                4  3. Leo and his Family - Background                                                                                       5                                     4. Local Agencies’ Involvement and Services Offered to Leo and His Family   6  from October 2018 to April 2021                     5. Key Analysis and Learning         10       6. Recommendations          33  7. Appendices           34 Learning from the Rapid Response into the injuries to Leo       2 1  Executive Summary   Leo, age 3 years, was found to have a large number of unexplained injuries and to have been neglected. His mother was a Care Leaver in receipt of services in her own right.  Children’s social care and universal services had been provided for Leo across two local authority areas. Ms A and Leo were moved from Ms A’s home local authority during Family Proceedings and a Supervision Order was made on Leo to the new local authority.  Ms A continued to receive aftercare services from her original local authority.  There were concerns about domestic abuse, parenting, parental mental ill health, neglect, and injury. Leo was noted to be a vulnerable Child in Need of early help at the step down when the Supervision Order ended. There was some confusion about the role of the Lead Professional.  The Covid 19 Pandemic increased Ms A’s isolation and impacted on services’ ability to support her. Leo ceased to attend nursery because of the Pandemic.    Attempts were made to support Ms A with understanding the dynamics of domestic abuse and to help her improve her parenting and manage Leo’s behaviour, about which she expressed difficulty.  A question has been raised about the number and timing of tasks that parents can be asked to undertake to help them increase their understanding or develop skills.   Learning has been identified in relation to:   • The assessment of injuries to young mobile children and the need for and management of child protection medicals.  • Holding the child and their experience in mind.  • Use of safeguarding thresholds, including consideration of child protection processes while a child is subject of a Supervision Order and the role of the lead professional at step down to universal services.  • Supporting parents who experience mental health problems.  • Information sharing with busy GP Practices.   • Working with parents who have difficulties engaging with services because of their own childhood experiences. • Requiring reluctant parents to undertake many tasks at one time.  • Case supervision and multi-agency management across two local authorities.  • Maintaining significant relationships for Care Leavers being rehoused.  • The need for a wider perspective in domestic abuse work rather than reliance on protection from a single identified abuser.  • Recognising risk and planning when a known domestic abuser is being discharged into the community.  • Practitioner skills in supporting parenting and parent-child emotional relationships.  • Work with Care Leavers becoming parents and as parents.  • The Pandemic’s impact on service provision and identifying and supporting vulnerable children and vulnerable parents.     3 The Review has made four recommendations in relation to safeguarding practice and looked after children’s systems.   These cover:  • The need for understanding and skills by Lead Professionals in the multi-agency co-ordination of Early Help work.  • Information sharing with GP Practices.  • Cross local authority working when Care Leavers with children are placed outside the Care Leaver’s home authority  • Supporting Practitioners in understanding parent- child relationships and attachment.  A number of practice points are also included within the Review.    November 2022       4 2 Reason for the Review and Methodology  2.1 In April 2021, Leo was noted to have 37 bruises and marks to his body, some of these were assessed to be caused by non-accidental injury or neglect. He was made subject of Care Proceedings. A criminal investigation started.   2.2 The Barnet Safeguarding Children Partnership held a Rapid Review to identity early learning 1; and commissioned this Child Safeguarding Practice Review2 to explore how services had worked singly and together to support Leo and Ms A and to identify any actions which are required to improve local services to children and families. Each Agency which had offered services to Leo and Ms A undertook an internal independent review which was analysed by an Independent Review Panel. The Review covers multi-disciplinary services across the London Boroughs of Barnet and Brent.   2.3 Leo’s Mother (Ms A), Father (Mr B) and Mother’s Partner (Mr C) were invited to contribute to the Review. Ms A declined and stated that she “felt blamed for what had happened”. Mr B and Mr C did not respond.   2.4 Key practitioners and managers were able to contribute to the thinking and learning.   2.5 The period to be reviewed in detail was agreed as October 2018, when Leo (aged nearly one) was made subject of a Supervision Order (Children Act 1989) to April 2021, when the significant marks were discovered.   2.6 Leo was subject of multi-agency support from birth (late 2017), initially through a Child Protection Plan, and later through Family Court Proceedings, a Supervision Order and Child in Need Plan, Early Help and/or Universal Services.   2.7 Leo’s Mother, Ms A, was in receipt of services as a Care Leaver, as a victim of domestic abuse and as the parent of a vulnerable child.  Mr B, Leo’s Father, was also a Care Leaver. He had minimal contact with local services and was in receipt of services from criminal justice agencies. He is not responsible for the injuries to Leo. Mr C was also a Care Leaver.   2.8 A key systemic dynamic of the period under review, and for the review itself, was the Covid 19 Pandemic from March 2020.     1 Rapid Review – See Appendix 2 Child Safeguarding Practice Review (CSPR) – A CSPR is authorized under statutory guidance Working Together to Safeguard Children, 2018 (2020)  Working together to safeguard children - GOV.UK (www.gov.uk)   Their purpose is to identify improvements to be made to safeguard and promote the welfare of children, locally and nationally and to identify whether there are systemic issues, and whether and how policy and practice need to change.    5 3 Leo and his Family – Background   3.1 Leo is a mixed heritage child.  Ms A, Leo’s Mother, is White British. Mr B, Father, is of dual heritage, White British and Black Caribbean. Mr C, Ms A’s Partner from late 2020 is White British.    3.2 Ms A (19), Mr B (21) and Mr C (21) were all previously looked after by Barnet Children’s Services3.    3.3 Ms A, was involved with Barnet Children’s Social Care Services from 2011, aged 10. She was accommodated under the Children Act, aged 14 and subsequently had 12 moves of home. Ms A was also known to Child and Adolescent Mental Health Services. The breakdown in the relationship with her own mother impacted on Ms A's self-esteem, mental health, and confidence.  Ms A maintained occasional contact with her mother and sister; they occasionally had contact with or care of Leo.   3.4 Ms A first met Mr B and Mr C when she was a teenager living in a residential unit which they used to visit. Mr B and Mr C were friends, who had both been in care. Ms A became a friend to both.   Ms A and Mr B later started a relationship and Leo was born. Mr C continued as a friend.     3.5 Mr C had a child with a partner in another Local Authority. An assessment there showed no parenting concerns.     3.6 In Barnet, before Leo’s birth, Ms A experienced domestic violence from Mr B. She was supported by the Barnet Leaving Care Service, Midwifery Service and Family Nurse Partnership, a Children’s Centre, and MARAC4 / Independent Domestic Violence Advisor. Leo was subject of a Child Protection Plan to Barnet from birth (late 2017).   3.7 Mr B seriously assaulted Ms A shortly after Leo’s birth. In January 2018, Barnet Children’s Social Care initiated Care Proceedings because of concerns about Leo’s welfare. Leo and Ms A were placed in a Mother and Baby Unit for an assessment of her parenting.   In October 2018 (aged 11 months) Leo was made subject of a one-year Supervision Order to the London Borough of Brent, where he and Ms A had been re-housed.  3.8 In 2020, Ms A maintained to Barnet Leaving Care Services that she was not in a relationship with Mr C.  When the relationship became known, in 2021, the service undertook a risk assessment because of known tensions between Mr B and Mr C, and Mr B’s impending release from prison.   Leo     3.9 Leo was cared for by his mother, Ms A, throughout the period under review.  The extent of Mr C’s involvement in Leo’s life from December 2020 was not known known at the time.    3 The ages of the adults were those at the start of the review period October 2018.  4 MARAC:   Multi-Agency Risk Assessment Conference. MARAC FAQs General FINAL.pdf (safelives.org.uk) A MARAC is a multi-0agency information sharing and planning meeting for the local highest risk cases of domestic abuse.    6 3.10 Leo was seen often by professionals in the period up to the Pandemic and observed to be a healthy child.  He was said to be meeting his developmental milestones, except for speech. He was primarily cared for by his mother but sometimes by his maternal grandmother. He was said to have a good relationship with them both and was noted to be attached to his mother.  It is not clear what the quality of that attachment was and whether it was an anxious attachment.  Leo became a boisterous child and there were times when his mother found caring for him challenging. She acknowledged that she found him hard to manage and gave in to him. Ms A stated that the injuries were self-inflicted; if this was the case it is evidence of poor supervision.   3.11 Following discovery of the multiple historic injuries, in April 2021, Leo was placed in foster care pending the outcome of Family Proceedings. It was confirmed that his speech was delayed; he has since caught up. He remains an energetic child, who is seen, at times, to lack a sense of danger.  He prefers to be active and outside and loves climbing and swimming.  Initially, when he was upset or did not get his own way, he threatened to hurt himself and if he thought he had been naughty he would say that he should be punished.  It is thought that these were learned behaviours, as they are not usual for a three-to-four-year-old. He has not hurt himself or caused any new bruising, however. This self-blaming behaviour has diminished as he has grown in security and confidence, and he is seen by those around him as more confident. He loves all superheroes, but his favourite is Spiderman.   His new Nursery reports that he is progressing well.    4 Local Agencies’ Involvement and Services Offered to Leo and His Mother from October 2018 to April 2021      For the majority of the period under review Leo was living with his mother in Brent, until February 2021 when they returned to Barnet. They continued to be registered with a Brent GP and Health Visitor, until April 2021.  Ms A received services as a previously looked after child from Barnet throughout the period.    October 2018 – November 2019   Leo aged 11 months to two years.   Supervision Order / Child in Need   (Brent)  4.1 A one-year Supervision Order was managed under multi-agency Child in Need processes.  The key agencies were Brent Children’s Social Care, Health Visiting, Leo’s Nursery and Barnet Leaving Care Team.   4.2 In October 2018 Ms A was assessed following a mental health crisis and referred to her GP for treatment for depression.    4.3 Also, in October there was a significant incident of domestic abuse by Mr B, following further investigation the decision was made that a Child Protection Plan was not appropriate as Leo was already subject of a Supervision Order.     7 4.4 Multi-agency Child in Need Meetings were held throughout the year; not all the key agencies attended each one.   4.5 In November, the risk from further domestic abuse was assessed as high. Ms A was referred for counselling but was perceived not to be co-operating with professionals.    4.6 In December, Leo (aged 13 months) was scalded in the bath. The injury was assessed as accidental but neglectful.   4.7 By January 2019, there was concern about Ms A’s ability to maintain a consistently good enough standard of care, the Child in Need Plan and Supervision Order were not effective and further legal advice was required.   4.8 Mr B was remanded in custody on another matter and the domestic abuse was dealt with alongside this. He was later convicted and imprisoned. Leo and Mr B had no contact from this point.    4.9 In February, Leo started attending nursery, part-time.   4.10 In February and March the Child in Need Meetings questioned if Ms A was “disguising compliance”.  The care of Leo was said to be good. Ms A had not undertaken any of the domestic abuse training to which she had agreed.  She was to attend a 13-week Parenting Under 5’s Programme, and to meet the Independent Domestic Violence Advisor; but did not do so.  It was noted that Ms A was planning to visit Mr B in prison. She was to see her GP for her mental well-being.   4.11 Mr B told the social worker that the relationship with Ms A was over.    4.12 It was noted that a Legal Planning Meeting was still required and an up-to-date risk assessment was to be completed.    4.13 The Multi-agency Child in Need Meetings in June and July noted that Leo and Ms A were “doing well” but there was continued concern about non-engagement with the agreed domestic abuse and parenting services.   4.14 By August, Leo (aged 21 months) was “doing well”. His speech was improving. Ms A had not undertaken any work on domestic abuse, but she agreed to attend the Parenting Course to help her manage Leo’s temper tantrums.   4.15 In September, Ms A was worried about Leo’s delayed speech, and his challenging behaviour, which she could not manage. The Nursery had no concerns about his physical development, his health, or his behaviour while in the nursery.  4.16 The Supervision Order ended in October. At the final Child in Need Meeting Ms A agreed again to attend a domestic abuse course.  Leo’s attendance at nursery was low.  Ms A had not followed up seeking advice about managing Leo’s challenging behaviour. Mr B was asking to be assessed for Leo to visit him in prison.  Ms A declined further social work assistance under the Child in Need threshold. The Nursery was to take on the role of Lead Professional and was informed of this but   8 was not present at the meeting. The case was closed to Brent Children’s Social Care.     4.17 Ms A later ceased her medication and therapy.   December 2019 – March 2020   Leo aged 2 years to 2 years 4 months. Early Help Services   (Brent)  4.18 Leo was attending the Nursery, but not for his full allowance of sessions.  He was not brought on several occasions for his two-year health development check.  Ms A was struggling with her moods and reported self-harming. She resumed medication and was to self-refer to the Community Mental Health Service.    March 2020 – December 2020    Leo aged 2 years 4 months to 3 years 1 month      Early Help and National Lockdown Measures in response to Pandemic, Isolation, attempts to re-engage Ms A and Leo with services from summer, move to Northern Ireland  (Brent)  4.19 In late March, the National Pandemic Lockdown started. Only essential high priority face-to-face work could be undertaken by professionals.   Leo was offered a part-time place, at a different nursery, as his own nursery was closed for Lockdown, but Ms A did not take this up.    4.20 There was concern that Mr B was in touch with Ms A and that he may be granted home leave.   4.21 Between March and May the Barnet Leaving Care Personal Advisor attempted to keep in touch with Ms A remotely. Ms A was very anxious about the Pandemic and was reluctant to go out, even for her own medication. The Leaving Care Service provided a laptop to access online therapy.    4.22 The Personal Advisor had face-to-face contact at the front door at the end of April. Leo and Ms A were well, but Ms A was frustrated with lockdown and finding it difficult to cope with Leo on her own.  Leo did not return to the Nursery when it re-opened in June.  4.23 Ms A did not respond to further contacts from the Personal Advisor until mid-July. She had decided against on-line therapy, especially with Leo at home.   Ms A was worried about Mr B coming out of prison. Leo and Ms A’s isolation in Brent was noted.   4.24 In August, Leo was not brought to an agreed health development review. The Personal Advisor spoke with Ms A who wanted help with re-housing. She also asked for respite care for Leo.  The Personal Advisor was concerned about Ms A’s parenting and referred Leo to the Brent Early Help Service as Ms A had been struggling since November 2019 and it was thought she was unlikely to be able to meet Leo’s emotional needs.     Ms A agreed to use therapeutic services for herself.   4.25 The Brent Early Help Service assessed by phone.  Ms A said that Leo was “very testing”.  The GP had prescribed medication for Ms A’s low moods. Mr B was threatening to go to court for contact with   9 Leo.  He was due to be released in February 2021. It was agreed to allocate the case to an Early Help Keyworker.   4.26 Leo returned to nursery in September. He had not been since March.  He was not brought for all his eligible sessions.    4.27 In October, after several unsuccessful attempts the Brent Early Help Keyworker and Barnet Personal Advisor competed a joint home visit.  It was noted that Ms A had difficulty trusting and engaging with professionals.  The home was clean, with lots of toys. Ms A had been anxious and low and felt that she was taking it out on Leo. Parenting support was planned. Mr B was due to be released in early 2021.  A housing transfer was to be explored.  The Barnet Personal Advisor agreed to refer Ms A for in-person therapy.   4.28 In November Ms A and Leo moved to Northern Ireland.  The Brent Early Help Service closed the case. The Barnet Leaving Care Service referred the case to Northern Ireland Services in early December.  Just before Christmas Ms A and Leo returned to Brent. The Barnet Personal Advisor was worried about Ms A’s isolation. Leo was no longer in nursery.    January - February 2021  Leo aged 3 years 1 month to 3 years and 3 months Possible bruising to Leo, Ms A’s new relationship, risk from Mr B on discharge from prison   (Brent and move backed to Barnet in February)   4.29 The Barnet Personal Advisor arranged for Leo to return to the Nursery. Leo was not re-referred to Brent children’s services in this period. It was learned that Ms A had started a personal relationship with Mr C.        4.30 Bruising to Leo   Leo was seen by a Brent GP Out of Hours service in a video consultation and noted to have possible bruising to his upper lip. There was no stated history of trauma or injury. The Family GP and Health Visitor in Brent were informed.    4.31 Urgent move back to Barnet   In February, the Barnet Leaving Care Service, unaware of the possible bruise to Leo, reviewed the case.  There were no concerns noted about Ms A’s parenting or Leo’s well-being at that time. Risks were:  Mr B’s imminent release and Ms A’s new relationship with Mr C.  The case was escalated to Barnet Housing which immediately moved Ms A and Leo to temporary accommodation back in Barnet, thereby ending Brent’s responsibility.  Ms A was no longer able to take Leo to the Nursery after this.             March 2021 – April 2021    Leo aged 3 years 4 months to 3 years 5 months               Return to Barnet   Release of Mr B    Extensive bruising noted to Leo   (Barnet)   4.32 Injuries to Leo – new and old   In early March, Leo was seen in the Emergency Department with an injury to his arm. It was stated by Ms A that he had probably fallen from a worktop, while unsupervised. No injury to his arm was found but nurses did note a bruise on his cheek. Ms A said that Leo had hit his face on a sofa at her boyfriend’s house, a few weeks earlier. Treatment had not been sought at the time. Leo was noted to be very active. Ms A was asked to wait to see a   10 paediatrician, however, she left with Leo as it was late, and he was tired.   Emergency Department staff tried to ring her, with no response.   4.33 ED contacted Barnet Children’s Social Care Out of Hours Team and were advised of the background to the case. A child protection medical was to be done within 48 hours and a referral was made to Barnet MASH.   4.34 The Barnet MASH Team consulted further with the hospital about the need for a Child Protection Medical. The final decision was that the hospital was satisfied with Ms A’s account and that there was no need to examine Leo again. The Personal Advisor was to consider a referral to Barnet Early Help.     4.35 In April, Leo was found to have multiple bruising.  A criminal investigation and family proceedings were initiated.  Leo was placed in foster care.  He was assessed to be showing signs of neglect of his physical care.     5     Key Analysis and Learning                 Comments and learning from a Practitioners’ Reflective Learning Workshop and other discussions with the Practitioners or direct Line Managers for the work are included in this section.    Leo’s injuries – were these considered in sufficient detail?  5.1 Ms A took Leo to health services on several occasions when he was injured. A serious scald in December 2019 was rigorously followed up by health staff and deemed to be accidental but caused by Ms A’s lack of attention to the temperature of the water in the bath.    5.2 In January 2021, Ms A consulted an Out of Hours GP service about a possible bruise to Leo’s lip. Appropriate questions were asked and, from the information given the injury was assessed not to be a safeguarding issue. The GP was informed.  A practice/systems challenge in this assessment was that it was a video consultation, because of the Pandemic. This raises practice questions about the skills required to undertake such assessments by video with a child patient and parent who are not known to the practitioner making the assessment.  5.3 Online consultations became essential practice, by necessity, during the Pandemic. They were being trialled before the Pandemic with mixed success. The Royal College of GPs noted the benefits and a need for caution5.  It will be important for learning about the efficacy of such online and  5 Online consultations need careful consideration, says RCGP 2018     See also: Making and using visual and audio recordings of patients (gmc-uk.org) 2013     COVID-19 Resource Hub: RGGP - Online consultations in general practice: the questions to ask    (rcgp.org.uk)   updated May 2021   11 telephone consultation to be drawn from the experiences gained, from both practitioners and patients.  They are likely to apply wider than GP, for example in mental health,  as patients, including children, are offered a range of online services.   5.4 In early March 2021, Leo was seen at the Emergency Department with a reported injury to his arm and bruising to his cheek. The injury to the arm was said by Ms A to be from falling from a work surface, while unsupervised. Leo was asked but did not say how the injury happened only that it hurt. After assessment no injury to his arm was identified. The facial bruising was said by Ms A to have occurred when Leo hit his face on a sofa, “a few weeks earlier”. The Hospital internal independent review noted the systems context and complexity of provision of Emergency Care for children and the numbers that can pass through an Emergency Department in one day. The nurse noted the need to explore the facial bruise further, which was good practice. Leo was seen by an ED Registrar and was due to be seen by a Paediatrician for further investigation, but volume of work, prioritizing and handover between teams for the evening shift prevented this before Ms A took Leo home.  The Paediatrician phoned Ms A several times to clarify the history, but Ms A did not respond.  They then contacted Barnet Children’s Social Care, out of hours, and were advised of the background to the case. The EDT also referred the matter to MASH.     5.5 A balance had to be struck about whether it was proportionate on the seriousness of the injuries to call Leo back for further assessment. In the follow-up conversations between the hospital and the MASH Team over the next two days the hospital finally gave the view that this was not necessary. It was initially agreed that Ms A’s Personal Advisor from the Leaving Care Team, who had a good relationship with Ms A, would advise Ms A to take Leo to the child protection medical.  Later the Personal Advisor was to discuss with Ms A what had happened in order for MASH to make further decisions.  It is noted that there was some misunderstanding between the hospital and the MASH about what the Personal Advisor was being asked to do and the requirement of a child protection medical.  5.6 This raises a question about when it is or is not appropriate for partner professionals who are not medically trained or children’s specialists to ask such questions.   5.7 Action taken:  As a result of this review Barnet Agencies are reviewing the way in which multi-agency strategy meetings will be co-ordinated. This will include decision-making about the need for child protection medicals.  The Partnership is also drafting Local Multi-Agency Guidance for the assessments of bruising in mobile children, to supplement the guidance issued in 2019 on non-mobile children.     5.8 CP-IS   Child Protection - Information Sharing Project The Rapid Review raised a wider systems question, whether the CP-IS should hold wider information about children in need or on Supervision Orders.   If such a wider provision of data had been included in CP-IS, it would not have made a difference in this case. Leo was not a Child in Need or on a Supervision Order, therefore even if these additional provisions had been available in the national CP-IS scheme staff would not have been alerted automatically to Leo’s vulnerability. The ED consulted Out of Hours Children’s Social Care, which was good practice, as there were unanswered questions and consultation with Social Care was required; and it was undertaken. Professional curiosity was more important than an automated database.    12  5.9 The learning from this case suggests that there is no need for a recommendation to government to widen the scope of CP-IS. The much larger number of children who would be involved raises questions of human rights, data protection, proportionality, and manageability.  When there are questions about a child’s presentation to out of hours medical care with unexplained injuries, injuries that are inconsistent with explanation, or suggestive of neglect, or unexplained medical conditions it is practitioner curiosity which is more important over a database which will only trigger an alert indicating the need for greater curiosity and the need to speak with Partner Agencies for fuller information. That curiosity worked in this case and contact was made with social care.  Leo’s experience and holding him in mind       5.10 There is good evidence that the multi-agency Child in Need process from October 2018 sought to hold Leo in mind, mainly through the original Child in Need Plan, based on the reports to the Family Proceedings, in place at the start of this period and subsequent Child and Family Assessments, and the Child in Need Meetings process up to October 2019.   5.11 The Brent social worker was able to observe Leo and note his reactions to the domestic abuse he had witnessed and to the pain from the scald.  The social worker  assessed the home as chaotic and Ms A as not coping. Ms A lacked focus on Leo and was not able to think about his needs.  The social worker raised these concerns but they were not dealt with at the time; see the section on supervision and management below.   5.12 From February 2019, Leo had a part-time nursery place and Ms A brought him most of the allotted time, sometimes late and sometimes missing single half days. It is understood that she had a long bus journey  which may have impacted on the half days. This meant that most weeks, except when the Nursery was closed for school holidays, Leo was seen and could be monitored.   5.13 The  Nursery noted Leo to be happy. Staff observed a “warm attachment to his mother”. Leo was seen to be well cared for physically. He found routines hard to adapt to and tended to play in parallel to his peers rather than with them. He was not identified as having any special educational needs. The Nursery acknowledges that they did not have a clear picture of his life at home. Home visiting was not a practice in place.   5.14 The Nursery has acknowledged that the record keeping at the time was not as good as it should have been. However, information shows that the Nursery saw Leo as progressing well and there was said to be a good relationship between Ms A and Leo’s keyworker. Ms A was noted to welcome advice. Yet she did not like to engage with formal training programmes and did not follow up work on managing Leo’s increasingly challenging behaviour; instead giving in to him and leaving him to his own devices.  The Nursery recording systems have since been improved.   5.15 There were times when Ms A said that she found it hard to manage Leo and although she was given advice by the Nursery worker, she did not follow this and she did not attend the parenting courses   13 she agreed to. It is not clear how much the Nursery knew about Ms A’s poor mental health and whether they were able to monitor its impact on Leo.   5.16 From late March 2020 to September 2020, because of the Pandemic, no agency saw Leo. Ms A’s Personal Advisor was aware of Ms A’s acute anxiety about the Pandemic and was conscious of Leo’s needs and did on one occasion arrange to see Ms A and Leo briefly at the door rather than just support her by phone or text. He was shy and hid behind his mother.   5.17 It has been noted in several Child Safeguarding Practice Reviews that practitioners are at times making decisions without a fuller understanding of a child’s daily lived experience away from how they are observed in occasional one-off contacts by professionals or in child care settings.      5.18 In August 2020, Ms A asked for respite from Leo. Given her own history and her worry about him being taken in to care this was a significant request from her.  This and Ms A’s request for re-housing led to the Personal Advisor referring Ms A to the Brent Early Help Service for an assessment. As noted above there were delays in that assessment as Ms A did not respond, had changed her phone number, and a worker was self-isolating. It seems that Ms A’s request for respite from Leo and more importantly what that meant for her and for him, was never explored. She had been managing him alone for several months since the Pandemic had started. He finally returned to the Nursery in September, that may have provided the “respite” Ms A had said that she needed but it is not clear that that possibility was explored.   Mr B’s impending release from prison had become a more serious concern to her.    Practice note:  It is important, especially with young or vulnerable children to consider the quality of their daily life beyond the observed here-and-now contact with a professional or in a day care or a school setting. Practitioners and their line-managers need to develop skills to reflect on the child’s experience, including emotional relationships, more widely beyond the setting in which the child is being seen.   Assessments and interventions   5.19 Risks to Leo were recognised early and appropriate actions were put in place to protect and support him by supporting his mother, Ms A. He was subject of a Child Protection Plan from birth, then family proceedings which resulted in a Supervision Order, from just before his first birthday. The Supervision Order used Child in Need systems to lead multi-agency work to monitor him and support the family. During these earlier formal and statutory interventions there was close monitoring and regular multi-agency networking where practitioners shared information and thought about Leo’s needs and planned for him.   5.20 In parallel Ms A was offered regular support from her Personal Advisor(s) as a Care Leaver. They sought to link her to mental health provision, when needed, sought to advise and help her resolve housing and practical issues, and contributed well to the safeguarding arrangements for Leo.    14  5.21 The formal assessments in these earlier stages were robust and showed good reflective thinking about the risks from Mr B and at times queried whether Ms A was able, in her own right, to meet all Leo’s needs. His physical care was assessed as good but later there were examples of neglect regarding his supervision, for example, he was scalded by neglect. Ms A also found parenting him hard at times. She was encouraged and agreed to attend parenting courses but did not. Given her own traumatic history these courses may have assisted her as she became more challenged in parenting Leo as he become older.    Use of Safeguarding Thresholds     5.22 Supervision Order   A question raised by the Rapid Review was the value of a Supervision Order in protecting children. A Supervision Order is an order of the Family Proceedings Court made after thorough multi-disciplinary assessments, including independent assessments. A Supervision Order  can only be made when it is established that a child is suffering or is likely to suffer significant harm. A Supervision Order does not give the Local Authority parental responsibility but can impose conditions in relation to actions that the parent, or child, must take. However, such requirements can only be negotiated with consent. The Supervision Order confers on the relevant local authority, usually where the child is living, but not necessarily so, a duty to “advise, assist and befriend” the child.   5.23 In recent years there has been questioning of the effectiveness of Supervision Orders as they have no impact if parents do not comply and require that the case is brought back to court; and unless there are grounds for a Care Order and removal of the child into care there may be nothing to be gained. See the summary by the Nuffield Family Justice Observatory, April 20216 which examines the advantages and disadvantages of Supervision Orders.   5.24 The assessments led by Barnet up to the Family Proceedings in October 2018 were robust and established that there were no grounds to remove Leo to care but that Leo was at risk of significant harm without intervention to monitor him and support Ms A in parenting him.   5.25 Leo as a subject of a Supervision Order / Child in Need  When the Supervision Order was granted the case management transferred to  Brent Children’s Social Care. Shortly after, there was a new serious incident of physical domestic abuse of Ms A by Mr B, affecting Leo. Ms A showed that she was not co-operating with the actions needed to protect herself and Leo from domestic abuse and to improve her parenting and understanding of Leo’s needs. A Legal Planning Meeting in Brent recommended that representation should be made to Barnet to seek safer accommodation for Ms A and Leo.  Brent could also have sought to do that themselves.   5.26 The case was escalated back to child protection and a multi-agency child protection conference was convened. However, on the day it was stated that there were no grounds for a child protection  6 nfjo_supervision_orders_survey_findings_summary_final_20210408.pdf (nuffieldfjo.org.uk)   15 conference, as there was a Supervision Order in place, even though a manager had  agreed that a child protection conference should be held.  Practitioners present from other agencies, if they had understood this, could have challenged this decision and escalated it.  Being subject of both a Supervision Order and a Child Protection Plan is unusual but it is possible, and in this case, it may have acted as a useful statement to Ms A of the seriousness of the situation and the actions she needed to take, especially when later she did not follow through on agreements made about actions to be taken.  At later stages when she failed to co-operate consideration should have been given to stepping back up to child protection alongside the Supervision Order.   5.27 The case remained as Child in Need for the remainder of the Supervision Order and lacked the authority to insist that Ms A undertake the courses that may have helped her to safeguard herself and to parent Leo.   There were further suggestions of the need for legal advice but this was not followed up in a timely way, because of workload and management issues in the case, including changes of managers and supervisors.    5.28 This Review has not been able to establish what the practitioners from other services understood about the power and role of a Supervision Order as they were no longer employed locally at the time of the Review. Work undertaken in other areas by the Lead Reviewer has shown that outside Children’s Social Care other agency practitioners rarely understand the powers or functions of a Supervision Order. The Order is a statement that this child has been deemed by a court to have suffered or is likely to suffer significant harm.    5.29 A Practitioner informed this Review that when a case is Child in Need rather than Child Protection, staff from Partner Agencies may not give the case priority and attend Child in Need meetings. This is anecdotal and this Review does not have wider evidence about this. In this case it is noted that at the final Child in Need meeting, held after the Supervision Order had ended, neither the Nursery nor the Health Visiting Service was represented when the case was stepped down to Early Help. The Commissioning Agreement for the Health Visiting Service in Brent requires Health Visitors to attend all Child in Need Meetings, having conducted an up-to-date health visiting assessment of the child and family. The health visitor retains the lead health role for the healthy child programme from birth to 5 years and should have regular contact (minimum of 3 monthly) with the child and their family for on-going assessment. The Health Visitor completes all mandated contacts.     Practice Note:  It is important that practitioners from all agencies, including health, nurseries and schools, understand the role and authority of a Supervision Order so that they can challenge the thresholds and escalate concern if any protective actions required under a Supervision Order are not working. If a Supervision Order is not working it may require a parallel Child Protection Plan, where it is not appropriate to return to Court and consider other orders. Partner Agencies need to be able to challenge this with authority and escalate if required.    16  5.30 The multi-agency Child in Need work,  under social work leadership, ceased in October 2019, when the Supervision Order came to an end, as Ms A would not agree to continue with the Child in Need support led by a social worker. There were not grounds, at that time, to go back to Court for either an extension of the Supervision Order or a Care Order, or a step up to a Child Protection Plan.   5.31 Universal Services and the Role of Lead Professional The Nursery was to be the Lead Professional with the step down from Child in Need to Universal Services.  Nursery staff were not present at the final Child in Need Meeting.  They received an email clarifying that they were “Lead Professional” but it has been suggested that the staff at the time were not clear what this meant in the context of this case. As the step-down was to Universal Services and not Early Help Services, there was no requirement for the network of professionals to come together as a “Team Around the Child”.  The health visitor moved on and a new health visitor was not appointed immediately. The tighter network of professionals previously held together by regular Child in Need Meetings fell away.       5.32 Monitoring of Leo and his mother’s care of him by the agencies working with him in Brent ceased because of the Pandemic from late March 2020 until July 2020. During that period the only worker holding Leo and Ms A in mind was the Barnet Personal Advisor, Ms A’s worker.  This Review has noted the strong attempts by the Personal Advisor to support Ms A and monitor the possible impact on Leo during lockdown even though Leo was not the Leaving Care Service’s responsibility (although safeguarding is everyone’s responsibility).  His Nursery closed because of the Pandemic in late March and when it re-opened in June Leo did not return.  It is not clear what attempts were made to encourage his return but it is understood that key senior staff were shielding for personal reasons at the time and thus capacity and leadership may have been limited.  Leo returned to the Nursery in September 2020.   5.33 It was not until after the first phases of the Pandemic that services based within Brent  started to consider Leo again when his health development check was due in July and the new Brent Health Visitor sought assistance from the Barnet Personal Advisor to engage with Ms A who did not bring Leo to appointments.  By September the Personal Advisor was sufficiently concerned to re-refer the case to the Brent dedicated Early Help Service for a new Early Help assessment. Ms A’s lack of engagement and the worker needing to self-isolate delayed the assessment. An Early Help service was agreed but was soon closed when Ms A moved to Northern Ireland.   5.34 Following their return to their accommodation in Brent in late November 2020 the Barnet Leaving Care Personal Advisor took the lead to support Leo and Ms A, even though Leo was not a client of this service. The Personal Advisor arranged for Leo to return to the Nursery in mid-January 2021 but then events overtook any local coordination when the Barnet Leaving Care Service, with Barnet Practice Note   Good practice would be that where step down is being considered all relevant agencies with a continuing role should be party to that decision and the prospective Lead Professional should be consulted and agree to the role and be present at the final Child in Need meeting.    17 Housing, arranged for them to move back to Barnet because of an assessed high level of risk following Mr B’s release from prison.    5.35 Supporting Ms A with her mental health    Ms A had a history of poor mental health from adolescence.  She had an acute mental health crisis and assessment shortly after the Supervision Order was made in October 2018. In January, March and August 2020 she reported low moods and  self-harm and said that she was taking medication prescribed by her GP. Given her traumatic history these episodes of mental ill health are not surprising. They perhaps required more investigation by children’s services to see what impact they may have been having on Leo to ensure that Ms A was able to hold him in mind and meet his emotional as well as physical needs. However, it seems that there was no linking by children’s services agencies with Ms A’s GP about her mental health assessments or treatment and how it may have been impacting on her parenting, even though Child and Family Assessments were undertaken.   5.36 From March 2020, (just after the start of the Pandemic) the Leaving Care Service arranged psychotherapeutic counselling for Ms A through a separate (Barnet) provider but Ms A was reluctant to engage in online sessions (required because of the Pandemic) and she told the Personal Advisor that therapy made her feel bad about herself.     Practice note: When working with parents who have poor mental health or critical mental health episodes and who are responsible for vulnerable children, children’s services (such as social care or health visiting) should liaise with the parent’s GP or mental health services to confirm diagnoses and treatment plans, subject to consent to share information.  If consent is denied this may be a threshold to consider whether the work should be on a higher threshold of safeguarding intervention.   5.37 A gap in our analysis is how Primary Care supported Ms A with her mental health as a mother of a vulnerable young child. Feedback from the Primary Care Review in relation to GP support for Leo was that Ms A was “a single mother struggling with her mood but who was engaging with the practice on a regular basis”. There were no concerns about her parenting capacity based on the GP consultations with her for Leo.   5.38 Community Health Services have noted in their analysis that the Family Nurse Practitioner and the Health Visitor do not appear to have been aware of Ms A’s mental health crises or her self-harming behaviour at critical times. It is noted, however, that each of these services did discuss Ms A’s anger Recommendation 1    Barnet Safeguarding Children Partnership should recommend to Brent Safeguarding Children Partnership to review Brent’s Early Help protocols and seek assurances that the role of the ‘Lead Professional’  and the skills and experience required for this role are clearly defined, understood  and embedded within any Team Around the Family arrangements; especially when a case is being closed to social care and the Lead Professional role is not held by a dedicated Early Help specialist.    18 management. This raises practice questions about how these frontline health services liaise with GPs, and vice versa.   5.39 Information sharing and busy GP Practices  The Primary Care Review of Leo’s GP notes for this Review raised some systems issues for safeguarding practice and information sharing. It noted that GP Practices receive hundreds of documents each day to be assessed and coded for patient records. The Review questioned the use of complex and lengthy reports being sent to busy GP Practices, namely “minutes of multi-agency meetings are lengthy, with duplication and a format that is not clear as to the decisions made. There is often no specific comment or action for the GP highlighted”.  It was also noted that key history about domestic abuse and Ms A having been a looked after child was buried in Leo’s GP notes and was not easily accessible, especially when the content of a lengthy hospital report about domestic abuse had not been coded by the Practice and so did not act as a signpost about risk for future consultations. The Review noted that “GP practices receive a very high volume of documents and correspondence. This should be taken into account by external agencies within their forms which should have a relevant summary and section for the GP and primary care with actions”. It was noted that reports or letters to GPs at times lacked essential information, such as, which Social Care Department Leo had been referred to. The information should then be coded in the GP records for signposting possible risk in future consultations.                      5.40 It was noted that the GP Practice had a fortnightly safeguarding meeting to discuss cases of concern, which is good practice, but it is not known if Leo and Ms A were ever discussed in that meeting. At the time there were no regular liaison meetings with Health Visitors for sharing of information. These were to be re-instated.      5.41 A possible practice matter to be explored further by Brent and Barnet services is in relation to mental health support for parents, at distance by telephone or online; and possibly other forms of support which are being offered remotely. Ms A wanted mental health support at the start of the Recommendation 2    Barnet Safeguarding Children Partnership should recommend to the London Safeguarding Children Partnership to liaise with relevant London GP bodies to establish an agreed protocol on sharing information about children and families for child protection assessments and interventions to ensure that key information, decisions and actions are easily summarised, accessible and captured.  It is recommended that a standard child protection data sharing form is sent to GPs for completion, and that this is a form based on the template developed by the National Named GP Group.   Practice note: It is noted that it is particularly useful if any actions required from GPs are included on Page 1 of communications from Children's Services, or other agencies.   19 Pandemic, however, when this was arranged, she did not feel that she could use this through a remote online service, which was all that was on offer during the Lockdown. One issue was who would take care of Leo while Ms A had some time to herself online with a counsellor / therapist (the Nursery was closed) as well as how would she use an online service – even though she had been provided with a laptop to support her.   5.42 Increasingly mental health and other services are being provided this way, for a variety of reasons, and they can be effective. Some service users welcome this approach. There is a need for a greater understanding when face-to-face rather than remote counselling is more effective and whether for some patients this is contra-indicated.   Practice note: In recommending or assessing a person for a counselling or other service which is delivered through remote means, online or by telephone, practitioners should consider the person’s ability to engage effectively with the service remotely and, on grounds of equality of opportunity, if there is any concern about the ability to use such a service consider what other face-to-face alternatives are available.      5.43 Ms A’s engagement and non-engagement   It was known that Ms A had had a troubled childhood, before coming into care as an adolescent, she had behavioural difficulties as a teenager and had received services from the Child and Adolescent Mental Health Services. She found it difficult to engage with and work with professional staff such as the Family Nurse Partnership, Health Visiting and Children’s Social Care about Leo. She appeared to have more trust in her own Personal Advisors from the Barnet Leaving Care Service and was said to have a good relationship with Leo’s Nursery Keyworker. A young person who had experienced the adverse childhood experiences that Ms A had experienced was more likely to demonstrate disorganised attachment and find managing relationships, including with professional workers, harder.    5.44 There were concerns about Ms A’s willingness to engage. She promised to undertake activities, for example domestic abuse work or parenting courses, and to receive advice for managing Leo’s behaviour but then did not follow through with these agreements.    5.45 As a young person who had spent several years in the care system she may also have learned how to speak with and manage professionals. At times of acute need Ms A would briefly turn to professionals, for practical assistance, or for fear of Mr B and when she thought that Leo had been hurt but then she withdrew again.    5.46 On several occasions during the period of the Supervision Order this pattern of difficulty engaging with services with renewed promises and withdrawal was named by practitioners as “disguised compliance”. It was noted that Ms A had difficulty trusting and engaging with professionals but a clear multi-agency plan about how to help Ms A move on from this behaviour was not developed. Using a term such as “disguised compliance” lays responsibility at her door and potentially absolves agencies from looking at alternative approaches to how to engage reluctant service users. The London Child Protection Procedures Practice Guidance on work with families where there is   20 reluctance7 or the work on disguised compliance by the Northamptonshire Safeguarding Children Partnership may be helpful practice guides to support practitioners and managers in this.8 See also the article by David Wilkins on rethinking the use of the term “disguised compliance” in practice and the need to reframe the way that services work with parents who find difficulty engaging9.     5.47 Consideration was given on several occasions to stepping back up to a legal threshold, although this was not followed through in a timely way, and it was not clear that a threshold for a return to legal proceedings would have been met.  As noted above, a child protection conference / plan response could have been considered in the face of reluctance to engage.   5.48 It is important,  if resources allow, to be able to offer longer term helping relationships to parents and children so that trust can be developed through support and respectful, non-blaming challenge. In this case, changes of workers in different services over time may also have made it harder for Ms A to trust professionals. Given her own experiences she was also scared that Leo may be removed from her. Ms A reported her own depression or poor mental health on several occasions which would have exacerbated her personal ability to work on her problems; there was no coordination in the management of this.   5.49 The realism of asking parents to undertake multiple activities at the same time   This Review questions whether there was sufficient questioning of the realism or feasibility of the number of tasks that Ms A was being asked to do at one time given her own psychological capacity and emotional disorganisation.  As well as taking Leo to Nursery three days a week, with bus journeys there and back twice a day, Ms A was being asked to attend separate one-on-one meetings with different professionals and to attend domestic abuse courses and separate parenting courses, therapy and Child in Need meetings. Under pressure, she agreed to attend the courses and may have intended to do so but there is a question about whether it was realistic to ask her to take on  7   London Child Protection Procedures 7. Managing work with Families where there are obstacles and resistance (londoncp.co.uk) 8 Working with Resistant Families / Disguised Compliance - Northamptonshire Safeguarding Children Board (northamptonshirescb.org.uk) 9 We need to rethink our approach to disguised compliance - Community Care, David Wilkins, March 2017   Practice note:  When it is observed that there is difficulty in engaging a parent in effective work with professionals to safeguard a child the multi-agency network should take time to reflect on the reasons for this difficulty in engaging and what can be done to amend the professional response to enable the parent to engage and change, with support. This may include trust building, working to understand any defensive behaviour, including the parent’s history of responding to earlier support and ability to change, understanding their life experience and any psychological difficulties, and adapting the professional response accordingly.  Where there is continued lack of co-operation, including agreed actions, and no timely progress there should be escalation to a child protection or legal framework.    21 so many activities looking at her own behaviour and implying criticism of her as a parent at the same time.   It was probably easier for her to say “yes” and then not attend.   5.50 An Independent Assessment submitted to the Family Proceedings that led to the making of the Supervision Order in 2018  noted that as a single young parent, who was beginning a programme of educational study, Ms A should not be overwhelmed with too many initiatives and interventions at a time.  The practitioners managing the Child in Need plan did not seem to be aware of this specialist advice.   5.51 A Practitioner who was involved in the case told this Review.  “Lots of pressure is placed on victims of domestic abuse to engage with many services at once and they get overwhelmed and sometimes will disengage”.  This is a possible system dynamic and suggests that there may be a wider pattern in seeking to empower women who are subject to domestic abuse with good intentions but placing unmanageable demands on them by referring them to specialist services.     5.52 A question arises as to whether requiring a parent who already has difficulty engaging with professionals to go on courses with yet more professionals is likely to be successful, without a lot of support, including emotional and practical support.  Agency practice and the systems through which it is delivered must consider how traumatised parents can acquire sufficient knowledge and skills through the services with which they are already working rather than being referred on to other specialist resources.  A Domestic Abuse Specialist noted “Domestic abuse work needs to be completed by social workers (or others?) as opposed to overwhelming the young mother with a lot of professionals to work with, however the issue of high caseloads for social workers can be a hindrance to the effective delivery of this piece of work”.   5.53 Another Practitioner noted that, in hindsight, after the multiple injuries to Leo were discovered, Ms A’s emotional and psychological capacity was re-assessed, suggesting that it may have been hard for her to engage in such courses.  Earlier assessments, prior to this period, had already identified this issue but appear not to have been known to all practitioners contributing to discussions about how to support Ms A and what training to require her to do to safeguard Leo and herself.  This is a known phenomenon. As workers come new to longstanding cases, for example with transfer across agencies and/or boroughs, how do they come to fully understand the known history, including previous assessments about a parent’s personal capacity for change and development as adults?  (See Practice Note at 5.47 above)   5.54 Professional curiosity   It was questioned at the Rapid Review whether there had been sufficient professional curiosity and for example whether Ms A had been sufficiently challenged about her versions of events after Child L’s various injuries?  Were the “second questions” and appropriate enquiry evident?  Professional curiosity is an important skill in all safeguarding work, in all professions. It requires the asking of “why” questions together with an element of respectful doubt and not always taking information at face value.    5.55 Ms A’s traumatic history and her mistrust of professionals, as noted above, may have made it harder to work with her on her deeper feelings and problems. Her long experience of working with   22 professionals when she was looked after may have meant that she knew areas to avoid, such as when she was seeing Mr B or Mr C or when she was missing and staying with friends but would not say where.  5.56 There is evidence, however, that practitioners sought to get behind the immediate information to seek to understand its meaning and the reality. The Brent social worker was concerned about Ms A’s parenting of Leo soon after the Supervision Order was made and was later sceptical about Ms A’s motives for visiting Mr B in prison and sought to explore these. It has only become clear in hindsight that Ms A visited him more times that she declared. The Emergency Department Triage Nurses were curious about the bruise to Leo’s face in March 2021. Ms A was asked to wait to see a paediatrician to review and discuss these but did not do so on the grounds that it was late and Leo was tired.   5.57 An area which may have warranted greater curiosity and noted above was Ms A’s request in August 2020 for respite from Leo. It is not clear what the underlying meaning of this to her was and it is not clear that it was fully explored. The Personal Advisor noted it and combined with Ms A’s increased worry about risk from Mr B after his discharge from prison referred the case to Early Help children’s services for further assessment. Later Ms A said that she was having difficulty with her emotions at that time.  As noted, however, Ms A did not respond to the Early Help service and then the worker was isolating because of Covid 19. By the time the assessment took place Leo was back in nursery part time and the need for respite does not seem to have been followed up.  What may have benefitted from deeper exploration was her statements about finding him hard to manage and giving in to him; an attempt to explore more fully what she was finding hard and why and what was happening for him when she was not interacting with him.10  5.58 Another area where greater curiosity may have been required was in considering whether Ms A was herself a user of any drugs (beyond prescribed medicines) or excessive use of alcohol. Use of drugs by adults/parents is now very commonplace.  It is not clear to this Review whether any practitioner raised the possibility of drug use with Ms A.  An indicator in this case is that both Mr B and Mr C were known to be substance users, and so there was a greater possibility that Ms A and/ or Leo would be present while drugs were being used.  Professional curiosity can be exercised  through routine enquiry but would likely be responded to with a denial which is then hard to challenge without additional evidence such as smell or presence of paraphernalia.  Hindsight evidence shows that Ms A was using cannabis, at times, although she has denied this.  Given her own difficulties and her possible ambivalent feelings about Leo, cannabis if it was used, as seems to be the case, was likely to make her less mentally available to him and his needs.     Practice note:  It is important in parenting assessments to consider the possibility and extent of parental drug or alcohol use and its impact on parenting, particularly where parents are having difficulty or are stressed.   10 Two useful resources for supporting staff and managers thinking about Professional Curiosity are:  Resource Pack of the Swindon Safeguarding Children Partnership : Resource pack - Professional Curiosity - Swindon Safeguarding Partnership and the Tayside Practitioner’s Guidance:  https://www.angus.gov.uk/sites/default/files/2021-02/Tayside%20Professional%20curiosity%20%20guidance%20Nov%202019%20%282%29.pdf    23 This is part of professional curiosity  which means to seek to understand holistically what is happening in the family’s daily life and the child’s lived experience beyond the way in which it is presented to professionals. What are the predominant influences and pressures?  It involves the capacity to respectfully ask follow-up and why questions and reflect more widely with an open mind about what may be happening, and to question and critically evaluate and challenge, if necessary. Reflective support, supervision and attention to research will be useful to aid such thinking.  The materials of the Manchester Safeguarding Children Partnership may be useful tools. 11    5.59 Supervision and management of the case   A key process in supporting frontline practitioners with exercising professional curiosity and asking more complex and at times difficult questions is reflective case supervision from more experienced practitioners, who being further removed can sometimes see things differently to the practitioner who is caught up in the face-to-face interaction with the parent.      5.60 For the first phase of the work from October 2018 to October 2019, in Brent, while Leo was a Child in Need, the multi-agency work was led by a newly qualified social worker. The Review has noted that the worker had previous relevant experience and was competent. The worker was supported by supervisory arrangements to assist gaining immediate post qualification experience, although changes in supervisor were unhelpful in helping the worker think more reflectively about cases, including how to engage with reluctant parents.  The supervisory arrangements were disrupted for reasons not to do with the worker or the case meaning that from October 2018 to March 2019, a critical period, there were three different supervisors. This was at the time of the serious domestic abuse and when Ms A had a mental health crisis and was reluctant to engage in the required domestic abuse and parenting activities.  It is acknowledged that there was insufficient reflective management, support and oversight of the case in that period and actions were not progressed as they should have been.  This included the consideration of new legal action as Ms A was not co-operating, which was a complex task for a newly qualified worker.  The case, as a Supervision Order, had been seen as straightforward. However, Ms A’s own complex needs, emotional detachment and mistrust of professionals made this a complex case.   5.61 Leo was not technically Barnet’s responsibility after the Supervision Order was transferred to Brent until he returned to Barnet in early 2021. The Personal Advisor’s role was primarily to support Ms A as a Care Leaver but this extended by default to Ms A now being a mother. The main Personal Advisor from the Barnet Leaving Care Team supporting Ms A was an experienced reflective worker who was able to draw on training, theoretical knowledge and skills beyond their current role. They also received regular supervision and management support. At later stages when there was increasing concern about possible risk to Ms A from Mr B and that she had started a relationship with Mr C (both men being known to the Barnet Leaving Care Service) there was active management intervention to re-house and safeguard Leo.    11 https://www.manchestersafeguardingpartnership.co.uk/resource/professional-curiosity-resources-practitioners/     24 5.62 The analysis of the case by Barnet Children’s Services has noted that it may have been valuable to consider joint supervision arrangements with Brent when the case was open as a Child in Need to Brent.  This Review supports that view.      5.63 Legal advice  Using the Public Law Outline12 again or using a Child Protection Plan and or a written agreement to stress the seriousness to Ms A and the risk of a return to court may have assisted in getting her to cooperate with the work/courses that she was thought to need.  In effect the Supervision Order was not working.  The fact that Leo was attending nursery part time and appeared to be developing well there may have reduced concern about him when in fact little had changed in his parenting, except that for part of the week his mother was not looking after him when he was at nursery.  As the Supervision Order was coming to its end (Autumn  2019) and as the main source of risk, Mr B,  was in prison it was thought that there were no grounds to return to court to seek an extension of the order. In retrospect, Practitioners recognised that more attention should also have been paid to Ms A and her parenting at that time as an important source of risk.   5.64 Case responsibility across two Local Authorities   This Review has noted a systemic dynamic in the work being held across two local authorities.  Ms A grew up in Barnet and became a looked after young person in Barnet.  She continued to receive support from the Barnet Leaving Care Team  in her own right, throughout the period under review.  The Barnet Leaving Care Service was also,  separately, from time to time, offering support to Mr B and Mr C.   5.65 Barnet Children’s Social Care had concerns about Ms A’s parenting and about risk to Leo and Ms A from domestic abuse and made him subject of a Child Protection Plan from birth.  Barnet arranged the subsequent Family Proceedings and assessments of Ms A’s ability as a parent. Ms A and Leo were rehoused to Brent just before the Proceedings concluded and as a result the Supervision Order was made to Brent. It is understood that initially Brent planned to challenge the decision to be made responsible for the Supervision Order.  It could be argued that Leo was a child of Barnet, where his mother had been known and supported for several years and continued to be supported as a Care Leaver.  It is usual practice for a Supervision Order or Care Order to be made by the Court to the Local Authority where the child is living – but this is not automatic. There is an argument for the coordination of multi-agency child focused services to be coordinated by the authority where the child is currently living, as happened here, as there will be locally established multi-agency networks. Leadership from a social worker from a different local authority would be challenging. However, Barnet held Ms A’s and  Leo’s history and was continuing to work with Ms A and to hold her in mind.  When a vulnerable child is transferred outside a local authority area and a court order  12 Public Law Outline:  PRACTICE DIRECTION 12A - CARE, SUPERVISION AND OTHER PART 4 PROCEEDINGS: GUIDE TO CASE MANAGEMENT (justice.gov.uk) and DFE stat guidance template (publishing.service.gov.uk) Practice Note: When key professionals, with significantly different responsibilities, are working with (members of) the same family it will be important to consider whether there should be access to joint reflective consultancy/supervision, beyond Child in Need or child protection meetings, to ensure that there is understanding across the key network about family history and dynamics, and professional roles, responsibilities, actions and priorities.     25 is being considered planning must rely on the assessment of the best interests of this child not necessarily common practice about location.   5.66 Where a parent who is a Care Leaver is being re-housed it would be preferable for them to be given priority re-housing in their home Local Authority area where they have been looked after, as their history is owned and held there, and the services across child and adult needs and housing can be more easily coordinated.   5.67 In seeking to explore this further, this Review learned that it is not always possible to house Care Leavers within their home Local Authority area but that in Barnet such priority would be given, if possible. In a case where there is a history of domestic abuse, as here, it may also be important to rehouse the vulnerable person away from the Local Authority for their own safety. A Housing Manager noted, “Women are often advised to move to a new borough when fleeing domestic abuse – sometimes much further than the neighbouring borough. But this is not always the best solution if the victim returns frequently to the original area in order to maintain social connections / childcare etc”.   5.68 Maintaining significant relationships when housing Care Leavers   This case has also shown that it is important to assess the strength of key relationships for young people/parents as these will probably have significant influence on them and their day-to-day behaviour.  When a vulnerable Care Leaver is still receiving services from the home local authority in their own right it is important that time is taken to weigh up all the risks and benefits in deciding whether to place them outside the borough where all their supports and history are.  Even where there is concern about domestic abuse, a local placement with additional safeguarding against the domestic abuse may be better for the young person or mother and child than being placed away from supports in an unfamiliar area.   5.69 The relationship between the victim and perpetrator and its nature, including any coercive control or dependency, needs thorough assessment as well as protection. Ms A was traumatised and isolated and the evidence suggests that she was ambivalent about Mr B and about separating from him, although she feared his violence. When challenged she denied that she was still in touch with him. It was known that she visited him once in prison. This is a complex and skilled area for social care, domestic abuse and housing practitioners seeking to assess risk to a woman/mother from domestic abuse to know best where to rehouse them. A move away to another borough may not be productive if there is still ambivalence and an ongoing relationship between victim and perpetrator.   5.70 Soon after the Supervision Order, when Ms A was mentally unwell, the Brent Legal Service advised the Barnet Legal Service to refer the matter back to Court (Leo was placed temporarily with his grandmother in Barnet at the time).  Barnet Legal did not agree. After the serious assault of Ms A, in October 2018, the Brent view was that if Ms A and Leo were not safe at the Brent address, Barnet should be asked to re-house the family as she and Leo were not safe. The Barnet view was that they were responsible for housing Ms A but not Leo.     26 5.71 Practitioners commented that there was a lot of discussion about this issue and the responsibilities for re-housing between the two departments and that this may have reduced the focus on Leo. This was not something those frontline practitioners were going to be able to resolve.  It is not clear why the matter was not escalated for resolution at Directorate level between the two local authorities. It is noted that when it was known in early 2021 that Mr B had been discharged from prison and was thought to be seeking to locate Ms A and Leo, Barnet senior management acted immediately and arranged for them to be moved back to Barnet.   Practice Note:  When re-housing young people who have been looked after by a local authority consideration should be given to providing then with accommodation within the Local Authority area which has been responsible for them while they were looked after.  This will assist in maintaining professional relationships with other support networks such as health or mental health and will provide a stronger sense of emotional containment, belonging and continuity. Where it is thought that the young person may be at acute risk in the home locality assessments and decisions about moves out of area should take in to account any risks from such moves as well as the perceived safety benefits.   5.72 The work reviewed shows that after Ms A and Leo moved to Brent the Barnet After Care Service remained committed to and supportive of Ms A.  For the first year this was well-coordinated with the Child in Need work led by the Brent social worker. The Barnet Personal Advisor worked closely with Brent services and at times was called upon by the Brent services to help negotiate with Ms A when she was not responding. The new Brent Health Visitor and Early Help Worker in 2020 both sought out the Barnet Personal Advisor’s help in trying to engage with Ms A.  At times, especially during the Pandemic, the Personal Advisor was the only worker supporting Ms A, and by default Leo. It was fortunate that she had the personal and professional skills to hold him, as well as Ms A, in mind.  But that cannot be guaranteed in a system.   5.73 It would be more efficient for the multi-agency child-focused family services and the leaving care services to be coordinated in the same locality, if possible. As noted above, where that is not possible consideration should be given to joint supervision arrangements to co-ordinate the work and think about both the child and the leaving care parent’s needs.   Practice Note: It is important that when support and monitoring arrangements for a family move from one service to another that there are effective transfer arrangements in place to ensure that key knowledge, concerns, current working agreements and plans to meet the needs of the children are in place and are understood by the receiving team.  This is particularly important when a family moves from one Local Authority area to another.  See also the Practice Note on joint consultancy and supervision above at 5.63.    27   Domestic Abuse Work    5.74 The Rapid Review after Leo’s injuries were discovered asked whether Domestic Abuse was minimised.   This Review has shown that there were good attempts to work with Ms A on the risk to her and Leo from domestic abuse from Mr B.  He assaulted her seriously on at least two known occasions and one of these was traumatic for Leo as well as Ms A and led to Mr B’s being convicted for assault.  It was also reported to the police that he had threatened her on other occasions.   5.75  In the period under review there was a good attempt to support Ms A by police and domestic abuse services. She was referred to MARAC, an Independent Domestic Abuse Advisor was appointed to assist her, and she was offered training, group work and development courses on domestic abuse to help her understand the risks and take steps to protect herself and Leo.   5.76 In retrospect it can be noted that there may have been an over-emphasis on Mr B as the source of risk and that Ms A was safe from him while he remained in prison; with risk being assessed as high again as his discharge from prison approached. In that sense domestic abuse was not minimised. If anything, its recognition and the response may have served to divert attention from the parallel concerns about Ms A’s parenting and her ability to meet Leo’s needs; and possibly Ms A’s own anger management issues which had been noted by the Family Nurse Partnership Nurse and the Health Visitor.  It was known that Ms A had had difficulties in her relationship with her own family which continued into this period and involved violence on occasions, sometimes from Ms A herself.    5.77 It was known that in late 2018 Ms A had had a brief relationship with a man who she said had been violent to her. It was understood that the relationship had ended. The issue was discussed in a Child in Need Meeting in February 2019, but a formal referral was not made to police, or MARAC as Ms A would not share the identity of that person and attempts were still being made to link her with domestic abuse services and an IDVA. It was hoped that through those services she would be helped to understand and be more able to manage future intimate relationships and avoid violent partners, if possible.     Recommendation 3                             There is a joint housing protocol in place in Barnet that emphasises the need to house care leavers in the borough unless there are exceptional circumstances, such as where there is a need to rehouse out of borough due to concerns about domestic abuse.  Barnet and Brent Safeguarding Children Partnerships should work together, and with the London Safeguarding Children Partnership, to develop best multidisciplinary practice guidance where services to parents and children are provided across more than one local authority, such as joint supervision arrangements, transfer of key information, transition of new working relationships and timing to ensure that the needs of children and their parents who are care leavers are met.     28 5.78 It is not clear that possible risks to Leo and Ms A from Mr C, such as aggression, coercive control or drug use were sufficiently assessed when it became known in late 2020 and early 2021 that Ms A had started a relationship with him.  Mr C’s presence also created a greater prospective risk from Mr B on his discharge from prison as Mr B and Mr C had been friends and it was assessed that Mr B would be resentful of Mr C’s relationship with Ms A and Leo; that risk was seen and worked with.  5.79 A specialist practitioner in domestic abuse work shared the following reflective learning about supporting Ms A:             “Ms A would not engage with the Domestic Violence Support programme. In hindsight, we could have made a different plan around this, however, we appeared to have focused more on the perpetrator, who was in prison.  This focus meant that we thought the risk of DV was minimal. There was possibly, however, a need for us to focus more on Ms A’s own behaviour and her insight into domestic violence and coercive control given her involvement with other abusive men.”          5.80 Work with Abusers   It is noted that the Prison and Probation Services (at the time under the London Community Rehabilitation Company, CRC, which has since been disbanded and re-absorbed into the National Probation Service) worked initially with children’s services about the risks posed by Mr B to Ms A while he was in prison. There is, however, a question about whether the number of Ms A’s visits to prison, not known about at the time by children’s agencies, should have triggered further conversation with Children’s Social Care as she was the victim of a serious assault by Mr B and her visits suggest ambivalence about him and the possibility of a continuing relationship and the risk that may pose to Leo and Ms A.    5.81 In preparation for Mr B’s release in 2021 the Probation Officer undertook local checks back with Brent children’s services, to learn that the Leo’s case was closed, and with Mr B’s Personal Advisor in Barnet, but not Ms A’s.  A lesson noted by the Probation Service was that the case should have been formally re-referred direct to Children’s Services for Leo in addition to checks being made, to ensure that multi-agency plans were made to safeguard Leo and Ms A from any future harm.    5.82 A suite of domestic abuse Licence conditions as part of his release could also have been considered to protect Leo and Ms A, and to include an assessment of Mr B’s suitability for a requirement for him to undertake a relevant Offending Behaviour Programme, such as a Domestic Abuse Perpetrator Programme.  This was important as Mr B wished to re-establish contact with Leo. It was noted that there may have been a systems issue in that Probation Officers working in the Community Rehabilitation Companies were often less familiar with such higher risk prison work and with prison discharges.  The absorption of CRCs back into the National Prison and Probation Service means that this possible loophole is now closed. This is now under one service and so should have been resolved as an issue.    5.83 It is positive to note, however, that a Licence condition was made for Mr B not to contact Ms A or Leo in recognition of the need to safeguard them from harm.  However, it would have been useful if Ms A and her support workers had been made aware of it as Mr B was alleged to seek to find Ms A through social media and friends, which was in breach of his Licence conditions.     29  5.84 A systems issue which may have influenced this discharge planning was that Mr B’s prison sentence was not primarily for the assault on Ms A but was for another matter which was addressed fully in the discharge planning.    5.85 A further lesson is that prison discharge arrangements or community probation safeguarding arrangements of offenders do not rest solely with the Probation Service. Practitioners from children’s services should also be able to initiate conversations and joint planning with the Probation Service when they are aware that an offender may be a source of risk to a child or parent. However, children’s services workers may be less knowledgeable about this and about what criminal justice resources or conditions are available.   5.86 It has been noted positively that a Probation Officer is now based in the Barnet MASH Team, and this is a valuable resource to children’s services practitioners to navigate this area.    Supporting Parents in understanding parent child relationships and attachment  5.87 Ms A was nearly 19 years old when Leo was born. Her own childhood was difficult, she was looked after from age 14 years.  She was assessed in adolescence to have ADHD. Her relationship with her family in this period continued to be volatile.  She was assessed in 2018, to have chronic psychological difficulties, probably with impulsivity and prolonged periods of depression, and difficulty forming attachments.  Such traits would challenge her ability to hold Leo in mind and were thought to pose a risk of emotional harm to him. Therapy over a long period was recommended but it was assessed that there was a high chance that such therapy would not succeed.   The therapy was not part of the Supervision Order Plan.  The likely impact on Leo would be inconsistency  in parenting.   5.88 Attempts were made to engage her in therapeutic work but these were unsuccessful and at times relied on self-motivation and self-referrals. It is not known if GPs and Community Mental Health treating her with depression, were aware of the specialist independent mental health diagnoses which had been made. It was identified that Ms A’s psychological difficulties were likely to make parenting a challenge for her.  It was also likely to impact on her ability to form relationships , such as with Mr B and Mr C and trusting relationships with professionals. It is not clear that the Nursery or Health Visitors were aware of the difficulties she was likely to have, or how best to support her with these in parenting Leo.    5.89 Ms A’s early parenting of Leo was assessed in the Residential Assessment Unit / Mother and Baby Home prior to their move to Brent. She was seen to be able to meet his basic physical needs well and showed understanding and responsiveness to his emotional needs.  Leo was observed to respond to her affection; however, she was not always consistent and at times could be frustrated.   5.90 Ms A and Leo were offered continued support from the Barnet Family Nurse Partnership after the move to Brent but after the Supervision Order Ms A ceased working with the Family Nurse Specialist. Ms A was given a lot of help both in the residential unit and in the community to support   30 her as a parent. As Leo grew, she found him a challenge to parent.  Parenting courses / training were included in the Child in Need plan and Ms A would agree but then not attend the sessions. Later she agreed to receive advice on managing Leo and how to support his development and speech delay but did not meet with the Nursery worker to follow this up.   5.91 The relationship and attachment between Leo and his mother, observed by the Nursery, was described as “good”. We know that at times Ms A had her own problems and self-harming behaviour, but there is no clear picture of how she was responding to Leo at these times, or how she responded to any crying or attachment seeking behaviour.  The Personal Advisor noted that Ms A did not play with Leo much but left him to his own devices, and that occasionally she would “snap”. The Advisor wondered what the impact of that on Leo would be.  5.92 The Review has noted that assessing emotional attachment is seen as a skilled area at the threshold of Family Court proceedings, when it is deemed that an assessment of attachment is required to support key decision-making about significant harm and whether an Order is needed, this is usually done by a specialist practitioner, often a psychologist.              Support from the Leaving Care Service – preventative work and parenting?  5.93 Ms A was well supported by the Barnet Leaving Care Team. Through her Personal Advisors she continued to be assisted in her own right after the move to Brent.  Although Leo was not their responsibility, the Advisors and the Leaving Care Service Management held him in mind.  There was  13 Attachment and child development | NSPCC Learning  14 Overview | Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care | Guidance | NICE    Practice Note:  A question for safeguarding agencies is to what extent frontline practitioners working at lower levels of local safeguarding thresholds should be supported to have knowledge and skills to observe the quality of parent-child interaction, over time,  including reflection on a child’s emotional development; and when to seek more specialist advice or assessment.   NICE Guidance (2015) offers recommendations to frontline services on knowledge and skills and the use of measurement tools in this area.   See the NSPCC Briefing on Attachment and child development August 202113 NICE Guidance:  Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care  NICE guideline [NG26]Published: 25 November 201514 Recommendation 4 Barnet and Brent Safeguarding Children Partnerships and their member agencies should review how frontline practitioners and managers are supported in their understanding and skills in supporting emotional attachment between carers and children.    31 good co-operation with the Brent Child in Need process and the Advisor took on tasks, where possible and appropriate, to support Ms A and Leo.  It seems that Ms A trusted the Personal Advisor, in as much as she would or could trust any worker. At times the Advisors were able to act as an advocate for her or as a bridge to other services and there were useful joint visits to support children’s workers meeting with Ms A. Ms A’s trust was also based on the practical assistance that the Personal Advisors could give, including practical support with mental health, housing, finance and, at times, food.   5.94 A Personal Advisor noted that the case was unusual as Ms A was a young parent, had mental health problems and required more support than most leaving care cases. Housing and rent arrears were also problems.    5.95 Personal Advisors are not trained in parenting work, and such work is not included in the usual Pathway for care experienced young people. The Advisor’s view was that parenting work with Ms A “needed a social work lens”.   It was a positive systems coincidence that Ms A’s main Personal Advisor, who was not a social worker, had knowledge and skills from a parallel profession and was able to use these to try to support Ms A with her emotional state, where possible.  When Leo ceased attending Nursery (summer 2020) the Personal Advisor and Leaving Care Service became more worried about him and referred him for Early Help, for both support to Ms A’s and Leo’s emotional well-being.    5.96 From a wider systems and practice point of view Personal Advisors thought that they would benefit from more training and skills in working with young people about intimate relationships and the possibility and challenges of becoming parents.  This should include training on how to support and advise young people about their vulnerability and coercive and controlling relationships. Advisors will talk with young people about safer sex and issue condoms but do not currently have a structured way, within the Pathway Plan for Care Leavers, to work with young people about the possibility of becoming future parents. It was questioned whether there may be a role for group work in this area. Ms A’s Advisor noted that when there is a concern about domestic abuse the leaving care service relies on referrals to a specialist domestic abuse service.  5.97 Another Personal Advisor noted that Advisors need more time with Care Leavers to develop trust and work in more depth and Care Leavers could be very mistrustful because of their life experiences; “we also need more training on working with young people who have a history of special educational needs or cognitive or mental health issues”.  This Advisor noted that housing for Care Leavers can be very challenging, especially when relying on temporary accommodation. Many Care Leavers find this part of their independence hard to deal with.  5.98 Recent research, by OFSTED, analysing the views of Care Leavers provides useful pointers on support systems. However, it does not identify this issue of Care Leavers becoming parents15.  5.99 The Barnet Leaving Care Service informed this Review that the Early Years Parenting Hub (EYPH) has specialist and targeted parenting programmes for parents and their babies and children aged 0-5; and that a multi-family 12-week intervention is being developed for care experienced adults  15 ‘Ready or not’: care leavers’ views of preparing to leave care - GOV.UK (www.gov.uk)   32 who are parents.  This will include modules on attachment, attachment-based play, mentalization and relationships.  Parents are given the opportunity to practice the skills that they have learned and receive feedback from observations (filmed) to enhance their capacity to notice and reflect on their parenting/their child’s mental states and their attachment relationship with their child.    5.100 The Leaving Care Service has also expanded Group Supervision, bringing together the social worker and manager for the child with the leaving care workers to keep focus on prioritising the shared responsibilities in relation to safeguarding. The Service has been supporting 25 parents who were Care Leavers.    The Pandemic as a systems dynamic   5.101 This case has shown how the Pandemic, in particular the Lockdown from late March to May 2020, impacted on vulnerable families and the services seeking to support them. At the time,  Leo was in a part-time placement in a Nursery. He was offered a place at another nursery as a vulnerable child but this was not taken up by Ms A as she was anxious about the Pandemic and fearful of going outdoors. Leo ceased to be observed regularly by professionals and did not return to the Nursery when it re-opened in June. When it re-opened key staff were self-isolating for their own health reasons and it seems, therefore, that Leo’s return was not followed up. He was not of school age and statutory attendance was not required.  He returned in September when the Nursery re-opened.    5.102 The Barnet Leaving Care Services moved, like all agencies, to remote working and contact; visits were to be made only in emergencies. Ms A’s vulnerability was noted and positive attempts and funds were made to link her remotely with therapeutic services.  Barnet supplied her with a laptop to facilitate this. However, Ms A did not feel that she could use online therapy; this was compounded by a need for baby-sitting of Leo while in an online counselling session. She was given money and a food parcel on one occasion. The Personal Advisor sought to maintain telephone contact but Ms A was hard to get hold of. The Advisor also made a doorstep visit to check on both Ms A’s and Leo’s welfare a month after the Lockdown had started. Ms A was finding it hard to cope with Leo on her own.    5.103 This case is also one where a worker’s need to self-isolate impacted on the work with the family, delaying a re-assessment when it was recognised that Leo and Ms A required more child and family orientated services.   5.104 The OFSTED Reports16 about the early impact of the Pandemic give a national picture of how vulnerable children were affected. Leo was not of high enough priority to receive a service at a time when children’s services across all sectors were having to respond only to the highest level of concerns.  It is not clear what his daily life experience was and how much he may have been left to his own devices, given that Ms A had her own difficulties.    16 Ofsted: Children hardest hit by COVID-19 Pandemic are regressing in basic skills and learning - GOV.UK (www.gov.uk)   33 A lesson and practice note is that when a service such as a nursery or school must close for a period, as a result of an event such as a Pandemic, vulnerable children (Threshold Level 2) should be noted and planned for, to ensure that even remotely they are held in mind and monitored, through regular contact and referred to other services as necessary. When that service re-opens the child and family should be followed up if they do not return and an assessment be made about the current state of their vulnerability to see if additional services or a referral to a higher level of the local Safeguarding Threshold is required.      Section 6:  Recommendations   Recommendation 1   (See  5.31 - 5.34)  Universal Services and the Role of Lead Professional Barnet Safeguarding Children Partnership should recommend to Brent Safeguarding Children Partnership to review Brent’s Early Help protocols and seek assurances that the role of the ‘Lead Professional’  and the skills and experience required for this role are clearly defined, understood  and embedded within any Team Around the Family arrangements; especially when a case is being closed to social care and the Lead Professional role is not held by a dedicated Early Help specialist.    Recommendation 2   (See  5.39)  Information sharing and busy GP Practices Barnet Safeguarding Children Partnership should recommend to the London Safeguarding Children Partnership to liaise with relevant London GP bodies to establish an agreed protocol on sharing information about children and families for child protection assessments and interventions to ensure that key information, decisions and actions are easily summarised, accessible and captured.  It is recommended that a standard child protection data sharing form is sent to GPs for completion, and that this is a form based on the template developed by the National Named GP Group.   Recommendation 3     (See 5.68 – 5.73)     Maintaining significant relationships when housing Care Leavers     There is a joint housing protocol in place in Barnet that emphasises the need to house care leavers in the borough unless there are exceptional circumstances, such as where there is a need to rehouse out of borough due to concerns about domestic abuse.  Barnet and Brent Safeguarding Children Partnerships should work together, and with the London Safeguarding Children Partnership, to develop best multidisciplinary practice guidance where services to parents and children are provided across more than one local authority, such as joint supervision arrangements, transfer of key information, transition of new working relationships and timing to ensure that the needs of children and their parents who are care leavers are met.    34  Recommendation 4   (See 5.87 – 5.92)  Supporting Parents in understanding parent child relationships and attachment Barnet and Brent Safeguarding Children Partnerships and their member agencies should review how frontline practitioners and managers are supported in their understanding and skills in supporting emotional attachment between carers and children.   Section 7    Appendix          Lessons from the Rapid Review  7.1 The Rapid Review17 into the circumstances of Leo’s injuries and previous care noted the following factors: domestic abuse, adult mental health, adult previously looked after, teenage pregnancy, neglect, and non-accidental injury.    7.2 The immediate learning noted in the Rapid Review was: • When Leo was in hospital under Police Powers of Protection there was no handover between police officers, and some officers were unaware of their role in protecting Leo.  • When Brent Early Help Service learned that Leo and Ms A had moved to Northern Ireland the authorities there should have been notified; particularly in the light of Mr B’s impending release from prison.  • When the GP sent Leo and Ms A to the hospital about the bruises to Leo’s face the GP should have called ahead to the Emergency Department and made arrangements in case they did not attend. • The Probation Service had concerns about Mr C’s relationship with Ms A but did not share these with other agencies. • There was confusion by some agencies about the role of Ms A’s Leaving Care Personal Advisor, as a support to Ms A, and not as a worker for Leo.  Greater clarity was required about whether some of the tasks given to the Personal Advisor after the bruises were noted in March and April 2021, were appropriate.  • A recording issue for hospital electronic records was noted as the database set maximum character limits in data boxes which prevented a full account of the incident/injuries. The hospital has since addressed this issue.              These early lessons were referred to the Barnet Safeguarding Children Partnership Learning and Thematic Review Subgroup to follow up with relevant actions.    17 Rapid Review: Required under statutory guidance, Working Together to Safeguard Children 2018 (2020), following a child’s death or a significant safeguarding incident. Its purpose is to gather the immediately available facts of the case, take immediate actions to safeguard identified children and share early learning; and to consider the potential for identifying and making improvements to safeguard and promote the welfare of children, including whether or not to undertake a child safeguarding practice review (CSPR).            Working Together to Safeguard Children 2018 (publishing.service.gov.uk)    35 7.3 The Rapid Review recommended that the following Key Lines of Enquiry should be considered in the Child Safeguarding Practice Review:   • Professional curiosity – was Ms A sufficiently challenged about her versions of events after Child Leo’s various injuries?  Were the ‘ second questions’ and appropriate challenge evident? • Was the impact of domestic violence minimised?    • Support for families after Supervision Orders end and value of Supervision Orders in protecting children.  • Coordination between local authorities, where one is providing Care Leaver support to the parent and another is safeguarding the child.    • Cases which are not flagged on CP-IS18 but where there has been extensive local authority involvement historically – how medical professionals can be alerted.                            Malcolm Ward  Independent Lead Reviewer   November 2022    18 CP-IS:  The Child Protection – Information Sharing Project is a secure national electronic information exchange system in England for sharing key data between Local Authority Children’s Social Care Departments and NHS Health Services, where children may attend unscheduled appointments. Children who are currently subject of Child Protection Plans or who are looked after can be identified automatically by health staff and social care staff are automatically notified of the child’s unplanned attendance at a relevant health service.  It does not cover children subject of Supervision Orders or who are Children in Need; nor does it cover children who were previously subject of CP Plans or looked after. Child Protection - Information Sharing project - NHS Digital   At the time of Leo’s attendances in February and March 2021 his name would not have been accessible to CP-IS.  