Serious and potentially life-threatening incident to a 4-year-old boy in July 2019. Child O was taken to hospital after accidentally swallowing Gamma-ButryoLactone (GBL) he found in his mother's handbag. Child O lived with extended family under a Special Guardianship Order (SGO). Child O was alone with Mother when the incident happened, contrary to the SGO agreement. Concerns raised about neglect due to parents' misuse of drugs. A Child Protection Plan was made for Child O but was unsuccessful in reducing risks. Father was convicted of child neglect in 2015 when he was found in-charge of Child O under the influence of drugs. Child O was accommodated under section 20 of the Children Act 1989 and placed with his grandmother. A police investigation was underway but not concluded. Care proceedings were initiated for Child O and sibling which concluded in 2020. Ethnicity and nationality not stated. Learning looks at: the support offered to the family under the SGO and the quality of the support plan; robustness of the communication between local authorities (LAs) including how safeguarding referrals were raised; adult mental health; domestic abuse and MARAC involvement; issues arising from management oversight and supervision information. Recommendations include: review training programs about the legislations, governing and meaning of different types of placements such as SGOs, Children Looked After (CLA) and adoptive placements that are open to LAs when considering the future of children who are unable to live with their birth parents; oversee a multi-agency review of current arrangements for Children in Need that are also subject to SGOs.
      
 Title:  Child O – local child safeguarding practice review. LSCB: Bexley SHIELD Author: Jane Doherty Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1   Child O – Local Child Safeguarding Practice Review (Bexley S.H.I.E.L.D.)  Reviewer – Jane Doherty – Independent Social Work Consultant  March 2021  1 Introduction 1.1 This review was commissioned by Bexley SHIELD (Safeguarding Partnership for Children and Young People in Bexley) after a serious and potentially life threatening incident to a four year old boy (referred to in the report as Child O).   1.2 In July 2019, Child O was taken to hospital after accidentally ingesting the drug Gamma-ButyroLactone (GBL)1 he found in his mother’s handbag whilst his mother was visiting him. Child O lived with his extended family on a Special Guardianship Order (SGO)2 and contact with his mother was arranged between the family members. When the incident happened Child O was alone with his mother which was contrary to the agreement under the SGO where it was agreed that contact should be supervised.   1.3 After the incident, a Rapid Review meeting took place and it was agreed that a Child Safeguarding Practice Review (CSPR) should be undertaken to examine the circumstances in which the incident occurred. Child O has made a complete recovery but the Partnership considered that there were lessons to be learnt, as early in the enquiries there were indications that Child O’s living arrangements were subject of concern.  The placing Local Authority, which was Lambeth, were invited to join the process to enable them to review their own practice.   1.4 At the time of writing the review a police investigation was underway but not yet concluded. Care proceedings were initiated in respect of Child O and his sibling which concluded in 2020.                                                       1 GBL is a Class C drug, sold as a colourless oily liquid that has a euphoric effect. It converts to GHB in the body and is highly addictive.  2 A Special Guardianship Order (SGO) is a court order made by a judge in the family court about where a child should live and who has parental responsibility for them.  2  2 Terms of Reference  2.1 The Terms of Reference are attached at Appendix 1.  Agencies involved with the family were asked to analyse their involvement via a brief written submission. The timeframe for the review is from July 2018 to August 2019.  NB This time period was extended for Lambeth Children’s Social Care (CSC) and CAFCASS so that they could provide the relevant background information, prior to Child O being placed in Bexley.   2.2 The Terms of Reference were agreed with the Panel overseeing the review. The broad areas that the Panel agreed were the most important to look at were;    The quality of the Special Guardianship Assessment including the capacity of the potential carers to look after two small children, their health needs (mental as well as physical) and their ability to place the children’s needs first   The support offered to the family under the SGO and the quality of the support plan  The robustness of the communication between Lambeth Children’s Services and Bexley Children Services when the children were being placed in Bexley under a SGO  Were safeguarding referrals raised appropriately and directed to the correct agency/local authority? If not what were the barriers to these?  Were issues of mental health in the adults known about, understood and assessed appropriately?   Were issues of domestic abuse known about, understood and dealt with appropriately?   How effective was management supervision and oversight in this case?  How has this case demonstrated good practice?   How was the voice of the child represented by agencies  3 Review Process  3.1 The report is based on the agencies’ submissions (referenced above) and a practitioner event with key staff that had worked with the family and knew them well. The report author had access to other documents relating specifically to the family such as assessments and minutes of relevant meetings held with the family.  3.2 In order to provide context to the working practices at the time of the review, the author also read a number of contemporary policies and procedures.  In addition early responses to some of the issues raised by the case were made available. These are referenced in relevant sections.  3  4 Agencies involved in the review      Bexley Children’s Social Care  Bromley Healthcare    2 local nursery provisions (Bexley)  CAFCASS CAMHS Dartford and Gravesham NHS Trust Lambeth Children's Social Care Lambeth Probation Services Metropolitan Police Service  Oxleas NHS Foundation Trust SOLACE  Lewisham and Greenwich NHS Trust  5 Summary of professional contact with the family  Family Members Age at the time of the incident  Child O 4 years  Sibling (known as Child P) 3 years  Mother 31 years  Father to Child O 33 years  Maternal Grandmother (SGO Carer) 54 years Maternal Aunt (SGO Carer) 34 years  Maternal relative  19 years  Cousin  5 years  Cousin  2 years  Half sibling (same father) to Child O (living in Bexley) 2 years  Half sibling (same father) to Child O (Living in Bexley) 1 year   4  5.1 Agency submissions to the review have been co-ordinated into a combined chronology, summarised here. Key events leading up to the period under review have been added here for context. Further factual information is provided in subsequent sections to add perspective where relevant.                               Background information from Lambeth Children’s Services (2015/16) 5.2 Lambeth CSC became involved with Child O in 2015 (when Child O was 3 months old) after concerns were raised about neglect due to his parents’ misuse of drugs.  A Child Protection Plan (CPP) was made in respect of Child O but was unsuccessful in reducing the risks. In June 2015 Father was convicted of Child Neglect, when he was found in charge of Child O, under the influence of illicit substances.  5.3  Child O was accommodated under s20 (Children Act 1989)3 and placed with his Maternal Grandmother (MGM) in Bexley. Mother revealed at this time that she was expecting another child (Child P) and had had no antenatal care. Planning for this child was joined to Child O, which had entered the Public Law Outline (PLO)4 as a precursor to issuing care proceedings. When Child P was born in the spring of 2016, he was placed in a Mother and Baby foster placement with his mother.   5.4 This arrangement did not go well and Mother left the placement (without Child P) on at least three occasions. Lambeth CSC issued care proceedings in 2016. At the conclusion of these, a successful application was made for both children to be placed on an SGO in the care of their MGM, her partner and their Maternal Aunt (MA). With the making of the SGO in November 2016, the household consisted of two adults (MGM and MA), three children aged three or under, and another relative who was 16. MA was also pregnant with her youngest child who was born in March 2017.  5.5 Lambeth CSC continued to support the family financially but ended their social work involvement in May 2017 as the children were no longer in their area. The issues surrounding the making of the order are discussed throughout the report but suffice to say at this point that Bexley CSC were unaware of the placement in their area. Agencies continued to liaise with Lambeth, including referring concerns to Lambeth CSC rather than Bexley CSC.    5.6 Contact arrangements (agreed at court by all parties) with their Mother and Father, was facilitated and supervised by the family. Child O had weekly contact with his Mother and weekend contact with his PGM.  Father’s contact was supervised through this arrangement.                                                  3 S20 of the Children Act 1989 allows children to be placed into the care of the local authority with parental agreement  4 The Public Law Outline is a mechanism used by local authorities to advise parents of their intention to issue care proceedings if matters of harm and neglect to their children are not addressed. It allows parents to be legally represented and receive support to help them achieve what they need to do to avoid the local authority going to court.  5  5.7 In addition to his maternal cousins living in the family home alongside him, Child O also has two half siblings on his father’s side. These children were born in 2016 and 2017 respectively and also reside in Bexley.         Key Events in 2017 – Children begin to display behavioural difficulties    5.8 MA had her youngest child in March 2017. It is not clear if Lambeth CSC knew that she had had a baby when the family were closed to them in May of that year.   5.9 In May 2017, Child O’s nursery arranged with MGM and MA that, providing they had permission, Mother could collect to Child O from nursery unsupervised.  Unbeknown to the nursery, this was in direct contradiction to the supervised contact the SGO had set out.  5.10 At the end of May 2017, Bexley CSC received a contact from Queen Elizabeth Hospital (QEH) in relation to MGM having taken an overdose. There was a request for information from Lambeth CSC, but the contact did not progress to a referral because MA confirmed that MGM was not the sole carer for the children.  5.11 In September 2017, the family were experiencing difficulties with Child O (aged 2 and half) and Child P (aged 18 months). MA requested (from health visitor) a review of Child O’s behaviour as she described him as being violent towards other children and he was difficult to manage. His younger sibling was referred by the health visitor to the paediatrician, also due to concerns about his behaviour.      Key events in 2018 – concerns grow about how the carers are coping  5.12 The children’s behavioural difficulties continued into 2018. In late summer, the Health Visitor made a number of visits to the family, as she was concerned for their welfare. The Health Visitor suggested a number of options to try and support them but the family was slow to take them up. NB at this point there were 4 children aged four or under living in the household. MA reported that she had contacted Lambeth CSC for support in the past, but she was informed they do not support SGOs and she should contact Bexley CSC. She had however not done so. After appropriate consultation, the Health Visitor made a referral to Child and Adolescent Mental Health Services (CAMHS) for Child O.  5.13 Amid some growing concerns about how the family needing extra support, the Health Visitor telephoned Bexley CSC and discussed with a duty social worker the fact that children were under an SGO. They advised that if there were concerns and a Special Guardian required support, the Health Visitor would need to complete a referral to Early Help services. In the meantime, the CAMHS referral had been accepted and Health Visitor thought that this was a more appropriate service.  6  5.14 At this time Child O’s nursery also had concerns about his behaviour. The staff reported to Lambeth CSC that Child O ‘had said some things at nursery and needed to make social services aware’. Information gleaned through this process revealed that Child O disclosed that when he was younger, he had fallen into a fire and his mother had ‘kicked him in the head’. It is not clear if the specific information was communicated to them but Lambeth’s response was that the case was not open to them and the children did not reside in their area. They did not however, redirect the nursery to Bexley CSC.  5.15 Child O’s behaviour did not improve and MA attended an initial appointment at CAMHS in late 2018. At the appointment she gave very clear descriptions of his behaviour which included aggression, difficulty regulating his emotions and night terrors associated with being abandoned. Some behaviours were also related to contact (or lack of it) with his mother. Throughout the following few months a number of appointments were missed by the family. When appointments were attended, work focused on management of Child O’s behaviour and exploration of his emotional needs in terms of safety and security. He was reported to be particularly distressed on realising that his father had other children.  5.16 Bexley Portage Service was also involved at this time as it was felt that Child P needed some extra input in terms of his development and behaviour. Although the service was directed at Child P rather than Child O, the worker visited fortnightly and engaged all the children in the household, including the older of the cousins.   5.17 Late in 2018, Probation Services confronted Father when asking about his drug use. Father reported that he saw his son (Child O) every weekend but that he did not use drugs in front of him. The Offender Manager (OM) challenged him in view of his previous conviction for neglect. The OM notified him that they would complete a safeguarding referral in light of this disclosure. There is no evidence on file that this referral was completed.  Key Events in 2019 – MGM experiences some mental health    difficulties.  5.18 In January 2019 MGM was taken to hospital (QEH) having taken an overdose of paracetamol and other medication.  She disclosed that she was having problems in her relationship with her then partner, and with her daughter who she described as ‘a drug addict’.  Following the doctor’s assessment, he recommended for her to be admitted and that a referral to children’s social care should be made. During her treatment over the following few weeks MGM also mentioned domestic abuse associated with her other daughter. No referral to Bexley CSC was made.  7  5.19 In February, Bexley CSC received a notification of an incident from the Police, as MA had been the victim of domestic abuse from her children’s father. The outcome of the contact was to refer to Bexley Women’s Aid who referred to the Multi Agency Risk Assessment Conference (MARAC).  Bexley CSC did not assess any of the children in the household as this was not their practice at that time. This is discussed further in Section 6 Paragraph 42 5.20 Later in February there was an exchange of information between Lambeth CSC and Bexley CSC about Father. This was after the concern (noted in paragraph 5.17) was raised from Probation (to Lambeth) about Father’s contact with Child O whilst under the influence of drugs. Lambeth provided Bexley with information which included some history i.e. Father’s conviction for neglect, the CPP in Lambeth and the eventual removal of the children. The information gave detail about the SGO with MGM and contact arrangements for Father to see Child O by way of a supervised contact with PGM. The information shared does not indicate that the children were residing in Bexley and Bexley CSC’s records do not show what their response was.  5.21 In April 2019, the family was discussed at MARAC in relation to the domestic abuse MA had suffered from her ex partner. It would appear that MARAC attendees were unaware of Child O and Child P in the household. Risks in relation to their cousins were discussed and safety planning went ahead, in relation to MA’s children only. The MARAC referral led to allocation to an Independent Domestic Abuse Advocate (IDVA) who discussed options with MA and supported her with safety planning.  Later in May the MARAC discussion was followed up by the Health Visitor who also discussed safety measures and encouraged MA to liaise with the IDVA.  5.22 In July 2019 the events that led to this CSPR unfolded.  6 Findings  6.1 The following section seeks to explore the questions identified in the Terms of Reference. This analysis is drawn from the written submissions from individual agencies, discussions with the panel and incorporates the feedback from practitioners who took part in the review process.   The quality of the Special Guardianship Assessment including the capacity of the potential carers to look after three small children, their health needs (mental as well as physical) and their ability to place the children’s needs first            Information from the review  6.2 Lambeth CSC contributed to the review in a very open and frank manner.  They acknowledged the limitations in practice surrounding the making of the SGO, 8  whilst also recognising the difficult circumstances in which they were operating at that time. 5 Lambeth CSC conducted their own learning process to enhance the information that contributed to this process. A number of practice issues had already been addressed as part of their on going improvement plan and further learning emerged for them as a result. The following summarises a review of the assessment at that time.  6.3 There were multiple occasions when notifications and checks from Lambeth CSC to Bexley CSC were required and should have been carried out. For example as far back as 2016 when Child O was placed with MGM, Bexley CSC were unaware that a child subject to a Child Protection Plan was in their area. This would have enabled Bexley CSC to add him to their temporary register. The same applied when he became s20 and when the SGO for both children was made.      6.4 The decision to assess MGM and MA as prospective guardians for Child O was taken in the context of them as close family members. They were relatives who were known to both children for all their (albeit short) lives and likely to be able to maintain close links with Mother and Father. This is all in keeping with the principles behind the making of SGOs for families where children are not able to live with their parents i.e. preference should be given to extended members of the family.  6.5 Within the SGO assessment presented to court, there were deficits in the analysis of the family dynamics. This was particularly about how the family would manage the inevitable tension between Mother’s drug dependency and contact with her children. At the start of the SGO assessment, Mother was living in the same household and was asked to move due to the tensions this was bringing. The family seemed to grasp the contact arrangements and were certainly aware of how important it was for the children to maintain their relationship. This was a fine balance to assess as contact took place in the home both pre and post the order with the potential to be increased (with MGM still supervising) if all went well.    6.6 From information gleaned from the review it is clear that the contact arrangements were not adhered to and that Mother played a large role in the family’s life post the making of the order.  At times, this included staying within the household for half of the week, being unsupervised with the children during that time and picking Child O up from nursery.  6.7 The assessment did not take into account what the family would look like over the coming years. MA was a young woman in her early twenties at the time of the assessment with a young child of her own (and another on the way). Analysis of the impact of having 3 (and later 4) very young children to care for                                                 5 Lambeth Children’s Services received a judgment of inadequate from OFSTED in February 2015  9  on the family as a whole did not take place. Child O was a child who had suffered early childhood physical and emotional neglect and the assessment does not explore the resilience of the family to deal with the potential repercussions of that. Further, the placement with both children was not tested prior to the order being made and Child P only joined the household after the court case was concluded. A report recently produced by the judiciary6 makes this (and other issues also pertinent to this review) a strong recommendation e.g. for potential matches where children are not currently residing with the carers, that final orders should be delayed in order to test a placement.  6.8 The SGO was granted within the court arena. Information gained, as part of this process would indicate that the Guardian appointed to act on behalf of the children was not robust in her analysis of the assessment. Challenge by the Guardian on matters of the family’s understanding of risk, how they would manage the contact arrangements and the procurement of statutory checks would have been beneficial.  The CAFCASS records are not sufficient to fully understand the reasons why these were not done but their written submission acknowledges that this practice falls below expected standards.                  Learning and Implications for wider practice 6.9 As a result of learning from this review, Lambeth CSC have undertaken an extensive piece of work around notifications to other boroughs. This has included a review of cases from 2017 to present, to ensure correct notifications had been made. The same exercise has been completed for more historic cases i.e. those made prior to 2017. Lambeth CSC have been engaged in a ‘future proofing’ exercise to ensure that similar issues do not arise in the future. A work step is being built in the electronic data system to ensure that out of borough alerts are completed when necessary for CIN, CP, CLA and SGO cases. This is projected to go live in the autumn of 2020.  6.10 At the time the SGO was made Lambeth CSC acknowledged that quality assurance of the assessments submitted to court was not in place. Further, that their records do not provide an audit trail to fully understand what happened. Since that time practice has changed considerably and improved as part of their overall improvement plan. This includes;   A dedicated SGO team established in 2018 (previously part of the fostering service)   Extensive training has been completed and more is planned, particularly about ‘future proofing’ placements and understanding a family’s capacity (or not) to deal with changing need                                                 6 Recommendations to achieve best practice in the child protection and family justice systems: Special Guardianship Orders  10   Increased monitoring of the progress of the assessment at key stages – Initial meeting, mid way review and a final meeting before a final recommendation is made  A quality assurance process in relation to the assessment from the SGO manager and the SW Manager,   Increased use of group supervision for complex cases  Increased scrutiny of the care plan via the Independent Reviewing Officer (IRO) at the final Legal Planning Meeting (LPM) along with the presiding solicitor.   6.11 Since the time covered in the review Lambeth CSC have put in place a number of measures to improve practice which are covered in the following paragraphs.  6.12 Within the new SGO team the Team Manager offers regular individual supervision and fortnightly group supervision for reflective case discussions including learning from reviews. Once the order is in place staff from both services meet together which helps to consider and embed any longer term issues.  6.13 Strategically, Lambeth CSC have also set up a permanence and adoption board which track permanency and updated the Support Plan format. There is further ongoing work to develop the guidance attached to the plan to ensure that areas are not overlooked e.g. transition planning for children not already in placement and out of borough notifications. There are also on going changes to their electronic data system to support some of the changes.  6.14 In addition to these changes, written agreements about levels and frequency of parental contact will be in the support plan.  Cases will remain open to the SW team until these have been completed, signed off and uploaded.  6.15 It is clear that the Guardian’s independent scrutiny on behalf of the children did not work in this case. CAFCASS failed to make an independent assessment of the children, the family and the proposed placement. The Guardian did not see the children as part of the assessment and did not adhere to the statutory requirements around DBS checks.  6.16 In response to this, CAFCASS have advised that it is their expectation that practitioners see all children unless there is a reason why this is not appropriate. CAFCASS have introduced a new system which will track and monitor visits to children. This came into force at the end of April 2020.  6.17 CAFCASS’s expectations are that Guardians robustly review SGO assessments including health and DBS checks. Audits undertaken by the National Improvement Service and more local service manager audits should 11  reinforce this and the standards should be upheld for all children.   The support offered to the family under the SGO and the quality of the support plan  Information from the review   6.18 Child O had been placed with MGM for a number of months prior to the official making of the SGO. His younger sibling joined him soon after the order was made but he had never lived with his sibling or MGM. This meant that the arrangement (at this point 3 adults, 1 young person and 3 very young children) of them living together was never tested during care proceedings. Further, the burden of this fell to MA as it has transpired through the course of this review that the arrangement was for her to do the majority of the day-to-day caring for the children without the support of the MGM. The reason for this is not clear and these arrangements are not set out in the plan that was agreed at court.  6.19 The SGO support plan was mainly focused on financial support and contact arrangements for the family. Lambeth have acknowledged that it should have been tailored more specifically to Child O and the needs of both carer’s. The author and panel would concur with this view and a recommendation is made to ensure that Lambeth do some development work about support plans that accompany SGOs.  6.20 The support plan lacked a multi agency perspective. Given that these children had moved into a new borough with a different set of resources on offer, there were no multi agency meetings to provide a Team around the Child (TAC). This is something that was overlooked and would have been beneficial to co-ordinate the work needed to support the placement. When the issues surrounding this CPSR came to light, in consulting with practitioners, it became clear that Child O’s nursery, health visitor, portage worker and other services were largely unaware of the extent of the early neglect he had suffered. There was no official handover to services in Bexley when Lambeth closed the case in 2017 and they (Bexley CSC) were never notified. Further confusion was caused for those working with Child O in Bexley because Lambeth continued to fund the nursery place. Thus, when concerns arose they reported concerns to Lambeth but were not re-directed to Bexley to assist. Learning and Implications for wider practice 6.21 The benefits of a TAC approach can be viewed as it being the opportunity for agencies to share information and have a more structured multi-agency response to supporting the placement. They would also have been more knowledgeable about the intentions behind the contact arrangements i.e. that they were to be at restricted times and supervised by the family.   12  6.22 A more detailed and specific plan may have been borne out of such a process tailored to the family’s needs. Given the early neglect Child O had suffered it should have been anticipated in the assessment process that he (and his sibling) might well have some additional needs, especially whilst making the transition to MGM and MA’s care.  Such needs, arising from neglect and the separation from his mother, (his most significant attachment figure) were likely to result in emotional and behavioural difficulties for Child O.  6.23 It is a familiar theme in Serious Case Reviews that those children, who move from one borough to another, do not always receive a seamless service. This is the case here and a vehicle to assist this may have been by more provision in the SGO support plan to handover to agencies in Bexley, while a Team around the Child was established. This would have supported a smoother transition between boroughs and provided clarity for the network in relation to Child O’s needs.  The London Child Protection Procedures7 provide some guidance on transferring children who are subject to Child in Need plans. Section 6.3.4 states;       Although there is no formal requirement to hold a meeting to discuss the transfer of a child in need plan, it would be good practice for the receiving authority to hold such a meeting, especially where the family situation is complex or the children have previously been the subject of a protection plan. 6.24 Consideration could have been given to this but it is likely to have been overlooked as the practitioners from Lambeth CSC continued to work with the family (albeit from a distance) after the children had been placed. From a statutory perspective Lambeth also retained case responsibility for the family as the placing authority for the SGO, so were obliged to continue to support the placement.  It is good practice to afford children who are subject to an SGO, Child in Need (or Early Help) status. In this case it would have created the opportunity to handover services and plan to support the family across the range of agencies that were involved.  6.25 On reviewing Bexley’s offer in relation to Early Help it is clear that at times in the review period the family were struggling and would have benefitted from more structured help under Bexley’s threshold document ‘Effective support for Children, Young People and Families in Bexley’. Towards the end of 2018, there were a number of agencies working with the family (Nursery, Health Visiting, Portage Service and CAMHS) but they were not co-ordinated.  This was a missed opportunity to offer a more effective multi agency approach with a designated Lead Professional. The learning needs to embed the benefits of working with families in this way.                                                   7 http://www.londoncp.co.uk/chapters/chi_fam_bound.html#cin  13  The robustness of the communication between Lambeth Children’s Services and Bexley Children Services including how safeguarding referrals were raised and dealt with   Information from the review  6.26 The review has established that the communication by the placing borough (Lambeth) to the host borough (Bexley) was extremely poor. No notifications were made by Lambeth to Bexley about the children’s residence in their area, despite multiple opportunities for this to happen. More importantly, no background checks were made between Lambeth and Bexley to establish if there were any concerns about the family in terms of the children being placed there.   6.27 Further, when approaches were made to Lambeth CSC from agencies wishing to make referrals or pass on information that was of concern, those agencies were not redirected to Bexley CSC as the children’s place of residence.  6.28 The information sharing by Lambeth CSC falls short of expected standards throughout the period under review. It has not been possible to completely identify from the case records in Lambeth exactly why this was. They have speculated that it was either a lack of compliance or a training need in relation to what would be expected. It further appears to be down to several areas of practice which are outlined as follows:  A lack of scrutiny of the completeness of the SGO assessment in Lambeth to ensure established statutory processes were adhered to  A lack of scrutiny of statutory processes i.e. background checks regarding SGOs within the court arena by the Guardian and the Judge.   Due to the above there was a lack of clarity that Child O and Child P were residing in Bexley, so when Lambeth CSC shared information about the children it was not obvious that they were in their area and likely to be Children in Need.   There was perhaps a lack of curiosity in Bexley CSC about why the information was shared by Lambeth CSC in January and May 2017 and February 2019 and exactly which children the information was about.  This is likely to have been because of confusion about the various sets of children (i.e. Child O’s half siblings on his fathers side and his cousins on his MA’s side). Without the relationships between each of these adults being spelt out, it is likely that the existence of Child O and child P in the household in Bexley was (understandably) overlooked.  A lack of management oversight about the referrals that were received from Probation Services and Child O’s nursery led to the information not being re-directed to Bexley CSC.   Learning and Implications for wider practice 6.29 The importance of information sharing to support children and families is a well 14  rehearsed theme from Serious Case Reviews and now CSPRs. This case is no exception.  Lambeth CSC recognised the lack of information sharing as a wider systemic issue at that time due to the deficits in practice identified at the OFSTED inspection around this time. This has however improved since then. Their written submission demonstrates some of the improvements they have made (cited in paragraph 6.8). These were confirmed by their recent monitoring visit which concentrated on the quality of local authority’s permanence planning.  6.30 Similarly CAFCASS have struggled to understand why this was not noted and challenged by their service. This issue needs be highlighted to their staff through their Learning and Development Bulletin and Quarterly Serious Incident Bulletin as described in their contribution to the review.  Were issues of mental health in the adults known about, understood and assessed appropriately?  Information from the review  6.31 There is some very brief information in the SGO assessment conducted in Lambeth about MGM’s mental health but this was never clarified with health professionals in Bexley. Lambeth CSC have acknowledged that these issues were not addressed adequately within the assessment. There was also a lack of contact between Lambeth CSC and Adult Mental Health services in Bexley, which would have demonstrated best practice.   6.32 After the SGO had been made there were two periods of concern about MGM’s mental health.  In May 2017 MGM took an overdose and was referred to Bexley CSC, as the hospital staff were aware that there were children in her household. The referral was dealt with swiftly on establishing that MGM was not the sole carer for the children. The referral was in relation to Child O’s cousins and this was dealt with appropriately, given the information held by Bexley CSC at that time. It does reinforce the fact that many professionals (including Bexley CSC) were unaware of Child O and his sibling in the household and so equally unaware of their SGO status.  6.33 In January 2019, MGM was admitted to hospital following an acute episode of mental health issues.  She was assessed on the medical ward and she was subsequently transferred to a more specialist mental health unit. She remained on the mental health ward for another two weeks. Community outreach services became involved (over the next nine months) and services were focused on managing her mental health, providing coping strategies and build her self esteem. MGM’s GP practice were aware of the overdoses but made no connection between that and the fact that she was caring for children.  6.34 Staff in the hospital became aware of MGM’s living situation during the assessment period in early January when she disclosed to them that she was one of two guardians to her grandchildren. She mentioned that there were four children 15  living in the household. The assessing doctor recommended that a referral to CSC should be made. This was however overlooked and there was no contact between Adult Mental Health services and Bexley CSC. Services continued to work with MGM and whilst there was some consideration of how her home situation may have impacted on her mental health, there was no assessment of the effect of her poor mental health on the stability of the household or the children’s wellbeing.  Learning and Implications for wider practice 6.35 Oxleas involvement in the review has allowed them to reflect on the importance of a ‘think family’ approach when dealing with clients experiencing mental health difficulties. The lack of referral to Bexley CSC by either the hospital or community mental health services meant that the impact of MGM’s mental distress was not assessed in terms of her capacity to continue caring for the children. Her hospitalisation presumably meant MA was left caring for all the children on her own which would have been a demanding task. Further, the impact of the change of circumstances within the family home from the children’s perspective was never assessed. The emerging picture from the review is that by 2019, the family were experiencing challenges with the children’s behaviour and that domestic abuse was featuring in their lives.  More is said about the domestic abuse in the next section.  6.36 Good practice would indicate that where a parent (or someone in a parenting capacity) has a mental health problem that assessment should be made as a result of collaboration between children’s social workers and adult mental health practitioners. This is to assess any risk but also to ensure that services are provided to support the family.  6.37 The children were registered at the same GP practice as MGM, but little connection was made between them, and the GP practice had limited knowledge of the children’s status or their placement with MGM. When details of MGMs overdose became apparent to them, they displayed no curiosity in ensuring that the children’s needs were met at that time. The Practice noted in their information submitted to the review that they needed to be clearer about what was meant by an SGO and to display more curiosity when the adults and children presented to the surgery.   Were issues of domestic abuse known about, understood and dealt with appropriately including the involvement of MARAC?    Information from the review  6.38  Early in 2019, Bexley CSC received two notifications (in January and February) from the police regarding MA being the victim of domestic abuse. The former took the shape of unwanted messages over social media from MA’s ex partner. The second took place in the family home shared by MA, MGM and the children that resulted in MA being assaulted by her ex partner.  16  6.39  Bexley CSC initially dealt with this as a contact and a manager spoke to MA who advised that she lived with her mother, who had an SGO for two nephews. It is not clear if she mentioned that they all lived together and that the SGO was in fact held jointly between her and her mother. The record of this conversation further states that the nephews were not known on Bexley’s CSC database. The outcome of this contact was to refer to Bexley Women’s Aid (this service was handed over to Bexley Support and Advocacy Service on the 1 April 2019) who in turn referred to MARAC. The family was presented there in early April 2019.  MA was allocated an Independent Domestic Violence Advocate (IDVA) to provide support in relation to the domestic abuse. 6.40 In relation to MA, the IDVA offered an ongoing service for the following three months which MA largely accepted. Safety planning and risk assessment was undertaken and advice offered in relation to legal options and practical measures such as a fireproof letterbox. Within the risk assessment undertaken by Solace, they identified a number of risk factors in relation to MA, which would have impacted on all the family including all four of the children. These were:  Prior physical violence from her ex partner towards MA, witnessed by her daughter   Conflict over the children’s contact with their father following the separation  Threats to kill MA by her ex partner   Previous use of weapons towards MA and her family– including being threatened with a hammer and a brick in the home  High levels of fear – MA stated she was particularly concerned that her ex partner would try to take the children as he had threatened to do so.  Learning and Implications for wider practice 6.41 What we know from research is that abuse is more likely to escalate after separation and therefore this would have been a risky time for both MA and all the children in her care.  6.42 Despite these risk factors Bexley CSC did not assess the children. In their written submission, the reasons Bexley CSC cites for this were that the level of concern was not at the threshold to assess because between the referral and the MARAC meeting, no further concern or referral had been expressed. It is difficult to understand the reasoning behind this decision given the information from the police and the risk assessment via SOLACE, which identified MA as high risk not least because of her recent separation. It was not custom and practice to assess every family with children that were presented to MARAC at that time. It was felt that as well as there having been no other incidents, MA was engaging with support offered from Solace and there was no role for statutory intervention. This practice was revised prior to the events in this review and all children of families discussed at MARAC do now have an assessment.   17  6.43 It has not been possible to ascertain from the review process how the risks to the children were considered at MARAC, as the minutes of the meeting did not give sufficient detail. There was very little contact between the IDVA and CSC. The lack of any formal intervention from CSC at that time meant other agencies were unaware of the issues of domestic abuse within the family or the presence of the other children. Involvement from CSC at this stage would have alerted them to the presence of Child O and Child P in the household and the challenges that they were presenting their carers with.    Issues arising from Management Oversight and Supervision             Information from the review 6.44 The review has identified a number of occasions when supervision, management oversight and wider quality assurance systems within organisations was not robust enough. With the exception of Lambeth CSC there were limited opportunities for supervision and management oversight in many of the agencies due to their limited involvement with the family but there are some key exceptions.   Learning and Implications for wider practice 6.45 Lambeth CSC have acknowledged the lack of management oversight and reflection within their practice. More importantly Lambeth practitioners were hampered by the lack of a wider organisational perspective with appropriate checks and balances, which support individual management decisions.  As we have seen through many case reviews, management oversight needs to be proactive in helping practitioners anticipate risks and needs as children develop and change and there was a lack of curiosity in this case.  6.46 CAFCASS employ a number of practitioners who are ‘self-regulating’. To achieve this status, practitioners are required to achieve a consistent level of good or outstanding grades through regular quality assurance. Attaining this allows practitioners to ‘self-file’ reports and ‘self-close’ cases. This does not change the level of supervision afforded the practitioner otherwise.  All practitioners are required to advise their managers of significant safeguarding issues and all practitioners have 2 case file audits per quarter which are randomly selected and recorded.  This information pulls through to the supervision system for discussion in supervision.  In this case, this was not done until after the care proceedings had concluded and practice was found to be poor. This was addressed with the practitioner but not until after the event and so there was no opportunity to influence the direction of the case. A more thorough piece of work by the appointed Guardian may well have resulted in the placement being challenged. A lack of scrutiny in this case i.e. where a significant issue had not been escalated is important process learning for CAFCASS.  6.47 The health visitor in Bexley did good work in trying to assist the family and she 18  was aware of the children’s SGO status. At that time the supervision policy for Bromley Healthcare did not require children who are subject to an SGO to be taken to supervision. The health visitor did not consider that they were at the level that they needed to be discussed with a manager. In particular, although there were issues of behaviour management, there were no concerns about the care that the children were receiving and both carers were said to be doing their best.  Bromley Healthcare have reconsidered this policy as a result of their learning from this review and have added children on SGOs to their list of children to be brought up for supervision.  This is a positive move as it is likely that the majority of children subject to an SGO will have some level of additional need.  How was the voice of the child represented by agencies?  6.48 There is little doubt that Child O was loved very much by his carers. Caring for very young children however is a particularly hard task. As demonstrated earlier in the narrative, little attention was paid to this at the time of the SGO assessment or thought about how this may pan out in the future.  6.49 Child O’s earlier lived experience is well documented in the information provided by Lambeth CSC. The information provides a picture of poor early parenting and attachment, and a sometimes harmful environment that placed him at risk.  6.50 Child O’s life with his aunt and MGM is less well documented. Available information suggests that, although he was very likeable, he could be aggressive, withdrawn and event violent towards other children and adults. This behaviour is likely to be as a result of his inner distress and he communicated it in the only way he knew how. The effects of early neglect, the effects of domestic violence and the subsequent abandonment he felt by his parents should not be underestimated, especially at such a tender age. These issues were noted by CAMHS and attempts to work with the carers to support him to feel safer had very limited success due their lack of insight.   6.51 It is not clear how Child O understood his circumstances about why he went to live with his aunt and MGM. At the time of the SGO, Child O would have been about 18 months old, so it would have been difficult to carry out any preparatory work but some words and pictures may have assisted. It is significant that the support plan did not contain recommendations about future Life Story Work or other therapeutic interventions, designed to help him come to terms with his circumstances, as he grew older.  The plan was not child centred and mainly contained details of financial support.  Of particular concern should have been how the family would manage contact arrangements and the importance of these being regular, sustained, safe and a positive experience for all. As it turned out, contact with his parents (or the lack of it) was a source of great distress for Child O.   As this area did not feature strongly in the SGO assessment, it is unsurprising that it was not included in the plan.  19  6.52 More thought needed to be given about the damaging effects of Child O’s experience of neglect and therefore anticipating difficulties which may occur later on in life.  As we have seen, there was no handover between boroughs and no provision in the plan to provide a Team around the Child. In addition there was no forethought for any support for any members of the family. There is learning for Lambeth CS about how SGO placements are supported, particularly when they are in another local authority.  The report references a number of initiatives currently being undertaken by Lambeth CS to address these systemic difficulties.   6.53 Later, individual agencies such as the Health Visitor, nursery and Portage Services did recognise his needs and the referral to CAMHS was timely and appropriate. Having a multi agency co-ordinated plan would have strengthened the approach these agencies took to provide support to Child O and his family.   7 Family Contribution.  7.1  Consultations with key family members are a very important aspect of any review and the author and Bexley SHIELD are very grateful that two sides of Child O’s family felt able to contribute.   The information they shared is contained in this section in the following paragraphs.        Contribution from Paternal Grandmother (PGM) 7.2 The Overview Author had a telephone consultation with PGM towards the end of the CSPR process. Unfortunately, a face to face meeting was not possible due to the national restrictions imposed as a response to the Covid 19 pandemic in the autumn of 2020.   At this time the care proceedings arising from this incident had concluded, and Child O was placed with her (an SGO by Bexley, placed in Lambeth).  PGM was open, honest and helpful in her comments. It was disappointing to hear that she felt as though she had not been supported with Child O at the point him being placed with her in the summer of 2020. At the time of writing, she was awaiting a service from CAMHS for Child O, help with contact arrangements and ‘Life Story’ work to help him make sense of his circumstances. PGM had hoped to be able to continue the work that had started by CAMHS in Bexley, but this was not possible and so has created a gap in the service Child O received.  She does have good support from Child O’s school and his previous foster carer.   7.3 In relation to the first set of care proceedings, she said that there were a number of things that could have gone better. For example, she recalled a number of meetings where the social worker was not able to attend. The person who came in their place was not familiar with the family and so was not able to be helpful. She also recalled social workers meeting in restaurants and discussing important and confidential information, which she did not think as very professional.  20  7.4 PGM stated that she had been happy with her contact arrangements under the original and she had Child O to stay every weekend. He did not display any behavioural difficulties whilst with her and she feels that this was because of the one to one attention she could give.  At MGMs house, there were 3 other very young children and they were not able to give the same degree of attention. She was therefore acutely aware of the difficulties that MGM was having and felt pleased to be able to offer Child O the level of contact that she did. PGM was also able to facilitate some contact between Child O and his father.   7.5 PGM was aware that the contact arrangements for Child O’s mother were not clear and she believes that this caused confusion. She believes that MGM needed more details about how the contact arrangements should work and the lack of them contributed to the incident where Mother was alone with Child O.  7.6 PGM did not really understand why Child O was not placed with her in the original set of proceedings as (particularly with hindsight), she understood how difficult it could be for MGM and MA to have all four children. She had understood at the time it was because maternal grandmothers’ ‘take precedence’ over the paternal side of the family. At the time she had accepted this explanation but now realises that this is not correct.  PGM was also aware that MGM had barely met Child P when he was placed with her. She found it difficult to understand why she (MGM) had not been able to have contact with him and then was placed straight away after the care proceedings had ended.   7.7 PGM also reflected on the parents’ drug use and wondered if they had been addicted to a more serious drug such as heroin whether they would have been referred to social care earlier. She felt as though their drug use was initially not taken as seriously as it should have been. This led to the children and especially Child O to have very negative early experiences.               Contribution from Maternal Grandmother (MGM) and Maternal Aunt (MA) 7.8   Just prior to publication of the report, the Overview Author had a telephone consultation with MGM and MA. They were both able to be candid about their experience and how the contact with services had been for them.  7.9 Both MGM and MA were aware of the difficulties that the children’s mother was undergoing and had supported Lambeth in the original Child Protection Plan and subsequent care proceedings. They attended meetings, made themselves available for assessments and appeared in court when necessary. They live in a big property and although they were very busy, they were happy with the outcome when the children were placed with them. They enjoyed their family unit even though there were very small children to care for. They recalled that professionals who came to the house would comment that it was ‘like a nursery’. The children all had their own rooms and there was lots of space for them to play.   21  7.10 Their experience of Lambeth Children’s Services, however, was not a good one. They recalled trying to contact the allocated social worker by telephone and email and this not being successful. They were frustrated and felt as though they were in the dark much of the time. For example, they were not clear about any support plan that may have been agreed at court, especially in relation to ensuring that Child O had access to therapeutic help. Similarly, the contact arrangements with their mother were explained as ‘it is up to you to manage’. They were aware that contact should be time limited, but they thought that after so many years those stipulations could be relaxed. They were also confused as Lambeth had closed their case, but still making the SGO payments. They did not realise therefore that they could have accessed services from Bexley, as this was not explained.  7.11 When Child O began to display behavioural difficulties and distress, their best resource was the health visitor who they recalled as being extremely helpful. They also got help from the Portage Service and the nursery were always very understanding about Child O’s difficulties. They were very aware that Child O’s struggles were often linked to contact with his mother, especially if this did not take place when it should. He was very bright and knew exactly when she should be visiting. His behaviour became distressed and aggressive if she did not arrive which often happened. They were grateful to the health visitor for getting them a service from CAMHS for him and were disappointed when this could not continue after he moved from theirs.  7.12 MGM and MA were very upset when the children were removed from their care by Bexley CSC, two weeks after the incident leading to this review. MGM was aware that she had not divulged her own mental health problems but had not wanted to disclose this to people she did not know. She considered that she had had enough treatment and help at the time for it not to be an issue. She feels that a better way forward would have been to have discussed it with her first and then Bexley CSC may have realised that it was no longer an issue. She also felt that the presence of MA and her other (adult) child would mitigate against any risks that she posed and that workers arriving and removing them was extremely harsh. Both MGM and MA found this deeply upsetting. In thinking about what other help would have made a difference, they thought that having somebody to be available to talk to would have benefited them both.  8 Summary of Lessons  8.1 There is a significant lesson arising from this review for all the organisations involved, in relation to the importance of thorough background checks when conducting SGO assessments. Triangulating information provided by potential carers is essential to maintain rigour in the assessment process. Child protection systems, which aim to ensure placements are safe and are made in the best interests of children, require a system of checks and balances to support the work 22  of the practitioner.  8.2 During the course of the review Lambeth CSC have acknowledged that their SGO assessments did not receive sufficient independent scrutiny via their care planning processes. In this case it meant the assessment was not scrutinised by the organisation and was not fit for purpose. There was evidence within the review that this was not peculiar to this case but was a systemic issue that needed to be addressed.   Since that time, Lambeth CSC have put numerous measures in place to reduce the risk of these systemic failures reoccurring.  8.3 Formal scrutiny via the court system and the children’s guardian (who represents the child in court) also failed to provide the further checks and balances designed to ensure that children’s best interests are served.  8.4 The review has underlined the importance of ensuring that SGO placements are supported by a robust support plan that is tailored to the individual needs of the children. This includes any children who are existing members of the household and their potential carers. This is especially important (as in this case) when placing a child ‘out of borough’ so that the receiving authority and local services can step in to assist in supporting the placement.  8.5 Children who are subject to SGOs are likely to have additional needs. Best practice in supporting both the placement and any transition would be to develop a network around the child. This network can then work as a team to ensure that the family are linked into to local services that can help them. A formal handover between local authorities with an exchange of relevant information would be optimum practice to confirm this is in place.  It was also apparent during the review that many practitioners (including key staff such as the health visitor) working with the family were either unaware of the SGO or unaware of the specific arrangements for contact. Some practitioners were aware of its existence but were unsure of its meaning.  8.6 There was a lack of consideration of the future needs of the children in this family placement and a lack of recognition of the level of chronic neglect Child O experienced in his formative years. Therefore there was no provision made to address this once Child O was in placement. There is learning for practitioners from both authorities in how best to identify and address this. The lack of a formal handover mentioned above meant that services in Bexley were unaware of the extent of Child O’s needs. Again Lambeth CSC have taken this learning point on board and have made some headway in tackling the issue.   8.7 The review illustrates the importance of a ‘Think Family’ approach and joint working between children and adult services. Communication by mental health services to Bexley CSC was poor. This meant that the children’s’ needs arising from their carer’s own vulnerabilities were never assessed.  23  9 Recommendations   9.1 Lambeth Safeguarding Children Partnership to assure themselves that Children’s Social Care in Lambeth have made sufficient progress in the quality of SGO assessments and associated support plans. Further that there are now robust quality assurance measures in place.   This will ensure that assessments have been undertaken with sufficient rigour, and that associated support plans are targeted to meet the identified physical and emotional needs of the child/ren placed on a permanent basis with their guardian/s.  9.2 Both Lambeth and Bexley Safeguarding Children Partnerships to review their training programs to ensure that there are briefings, information and/or training available for frontline services on;   The legislation governing, and the meaning of different types of placements such as SGOs, CLA, adoptive placements etc. that are open to LA’s when considering the future of children who are unable to live with their birth parents  9.3  Both Lambeth and Bexley Safeguarding Children Partnerships to oversee a multi agency review of current arrangements for Children In Need that are also subject to SGOs. This is to ensure that the needs of children in SGO placements are met wherever they are placed.  9.4 In line with the above Lambeth and Bexley Safeguarding Children Partnerships to ensure that for children who are subject to SGOs and placed in another borough, practitioners are aware of the need to transfer these with an appropriate support plan and that they are transferred as Children In Need.  9.5  Lambeth and Bexley Safeguarding Children Partnerships to adopt the practice guidance issued by the Family Justice Council (2020), particularly in relation to;    Enhanced support/training for potential SG carers  The focus in the guidance on the relationship between the carer and the child; i.e. the assessment process may be extended to ensure that there is a robust understanding of the relationship between the child and the carer and to test the strength of the placement before the making of the final order   Quality of support plans  9.6 Bexley Social Care should seek assurances about their own special guardianship assessments, planning processes and support packages in the light of the lessons from this review. This should be overseen and scrutinised by the Partnership.  9.7 Bexley SHIELD to encourage and promote the use of genograms as a tool to understanding family dynamics, when assessing all families but particularly where the make up of a family is complex.  24  9.8 The lessons from this review should be shared with members of the Safeguarding Adult Board in Bexley. There should be some joint consideration of the lessons from this review about the need to ‘Think Family’ between Bexley Children’s Partnership and The Safeguarding Adult Board. This is to include establishing a joint approach between CS and Adult Mental Health when working with carers with mental health difficulties   Jane Doherty Independent Social Work Consultant  March 2021  