Serious injury of a 2-year-11-month-old boy in June 2016 from third-degree burns. Joe had been the subject of a child protection plan for over two years, due to presence of family violence in the home, and continued to receive support through a Child in Need Plan from January 2016. Father had previously been in jail and was known to mental health services. Mother continually refused to disclose information regarding new partner and was misusing drugs. Joe lived in temporary housing with his mother. On the day of the incident he was found home alone by the buildings manager. Mother was arrested and sectioned under Mental Health Act and taken to a psychiatric hospital; later diagnosed as suffering from an episode of drug induced psychosis. Lessons identified include: protection of children will be compromised if a child protection plan is not working and there is insufficient insight into safeguarding processes; lack of robust inter- and intra-agency decision making jeopardises childrens safety; family and kinship are critical members of the safeguarding network and should be regarded as such. Methodology based on the Welsh Child Practice Reviews Guidance, taking a multi-agency approach, focussing on systemic strengths and weaknesses. Recommendations include: to ensure a robust, timely multi-agency process that scrutinises child protection plans for children who are the subject of a child protection plan for 18+ months and evaluate impact; professionals to be supported in gathering evidence and triangulating evidence to improve risk assessments.
      
 Title:  Serious case review: Joe. LSCB: Croydon Safeguarding Children Board Author: Ghislaine Miller Date of publication: 2018  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.                                                                                         Serious Case Review   Joe                                                     CSCB SCR  Joe - Publication Feb 2018 2  Why This Case Is Being Reviewed   On 30.6.16 Joe (2 years old) was found in a room in a temporary housing establishment by the buildings manager. He was alone and appeared to be suffering from severe injuries. Joe was subsequently admitted to a specialist burns hospital where it was found that he was suffering from 3rd degree burns over 25% of his body.  His mother was arrested and was later sectioned under the Mental Health Act and taken to a psychiatric hospital. She was later diagnosed as suffering from an episode of drug induced psychosis. The case was referred to Croydon Serious Case Review Sub Group on 12th July 2016 and a decision was made that this case met the criteria for undertaking a Serious Case Review (SCR), as specified in Working Together 2015.  Methodology   The methodology used for this serious case review is based on the Welsh Child Practice Reviews Guidance.1It is a nationally recognised model that features the following components:   Establishment of the Child Practice Review Panel  A Practitioners Learning Event   A Child Practice Review Report   It is a model that takes a multi-agency collaborative approach, with a focus on systemic strengths and weaknesses. The goal is to move beyond the specifics of the case (what happened and why) to identify the deeper, underlying issues that are influencing practice more widely. It is these generic patterns that count as lessons from a case, and changing them should contribute to improving practice more widely. Data came from reviewing a range of multi-agency documents, meetings with a multi-agency review team, with the practitioners involved, and with family members.                                                             1 Protecting Children in Wales: Guidance for Multi-Agency Child Practice Reviews, Crown Copyright, 2012.                                          CSCB SCR  Joe - Publication Feb 2018 3 Process  In line with this methodology, a Child Practice Review Panel was formed to undertake this SCR. This team of multi-agency senior managers had no direct line management of the case at the time. Their responsibilities were to assist in providing relevant information, read and analyse documentation and contribute to the lessons learnt. The Review Panel met on five occasions2 and included the following membership:    - Croydon Health Services (including Croydon University Hospital, Health Visitors and School Nurses and Family Nurse Partnership)  - Metropolitan Police, SCR Team  - Croydon Children’s Services  - Croydon Clinical Commissioning Group, (including GP Practice)  - Croydon Housing Needs  - Best Start Croydon Early Help (Early Intervention and Support Services)  - South London and Maudsley NHS Foundation Trust (SLAM)- Adult Mental Health  - Croydon Safeguarding Children Board   Methodological Comment  There was a wide range of multi-agency services involved with this family and there was good attendance at the Review Panels by most of these agencies. Mental Health Services were only minimally involved in providing services to father, although it was felt important that they contribute to this SCR. However, despite efforts to gain the involvement of the safeguarding lead from this service, attendance was only achieved at two of the meetings towards the latter stages of the process. Croydon Community Rehabilitation Company Services were invited, but did not attend. The absence of these key safeguarding agencies is relevant to Lesson 3.                                                            2 A flow chart detailing the Child Practice Review process is contained in Appendix 2.                                         CSCB SCR  Joe - Publication Feb 2018 4 The Lead Reviewer and Chair   Two independent people were appointed to lead this review, Ghislaine Miller was appointed as the Lead Reviewer and Bridget Griffin as Chair of the Review Panel. Both are experienced Serious Case Lead Reviewers and are independent from all the agencies. During this SCR, due to unforeseen circumstances, the Lead Reviewer withdrew. Bridget Griffin took on the role of Lead Reviewer and the position of Chair was taken up by the Safeguarding Board Manager.   The Learning Events   Learning events are a significant element of the review and all practitioners involved with the child or the family attended these with line managers wherever possible. These events provide a unique opportunity to hear the views of professionals who provided services to the child and family during the period under review. They are a key source of information for the Lead Reviewer and supports how lessons are learnt.   Three learning events took place, they were led by the Lead Reviewer and the Chair and were well attended by multi-agency practitioners. The first event examined in detail the time under review, enabling a multi-agency perspective to be gained. This exercise brought out the story of multi-agency involvement, helping to identify key periods of time that were significant and allowing the group to see how practice unfolded and how services were delivered from an inter-agency perspective.   The Review Panel discussed the contributions made by the practitioners, reviewed and analysed the documentation and several tentative lessons and hypotheses were agreed for further exploration. These were then discussed at the next Learning Event, practitioners were asked to consider whether they agreed with these lessons and whether the lessons were applicable to other cases. The purpose of this exercise is to test out with practitioners the validity of the emerging lessons and, based on their experience in Croydon, to seek their input as to whether the issues are systemic and thus resonate with a wider range of cases. Based on this feedback the lessons were either dismissed, modified or agreed.                                          CSCB SCR  Joe - Publication Feb 2018 5 After further analysis of the data, the Review Panel decided there was insufficient evidence to confirm two of the hypotheses (Ref: Appendix 1) and concluded that two alternative lessons should be included (Lessons 1 & 6).  The final stage of a learning event is to ask practitioners to identify lessons they have learnt that will inform their own practice and that of their service area. All practitioners engaged in this exercise with commitment and several important learning objectives were identified to be taken forward.   Interviews with Practitioners  This particular methodology does not normally involve interviews with members of staff.  As it was not possible for all practitioners to be part of the learning events, five key practitioners who were unable to attend were interviewed separately.   Involvement of Family Members  Unfortunately, despite several attempts, it was not possible to meet with Joe’s mother. The Lead Reviewer met with Joe’s maternal grandparents.  Joe’s father, paternal aunt and paternal grandmother agreed to have a telephone conference conversation with the Lead Reviewer and the Board Manager. Unfortunately, paternal grandmother was not able to take part in this conversation.  Father spoke about his worries about mother’s care of Joe, citing the frequent visitors to the home. He confirmed he saw mother and Joe at the home address on many occasions during the time under review.  He said the purpose of these visits was to check that Joe was safe. He was not able to offer a view about the services that were provided.   On speaking to Joe’s maternal grandparents and to paternal aunt, it was clear that they had not been aware of the concerns about mother’s care or about the services that had been involved. Both sides of the family said had they known about the extent of concerns, they would have been more involved and would have monitored the care provided to Joe more closely.                                           CSCB SCR  Joe - Publication Feb 2018 6  Croydon Safeguarding Children Board are grateful for the time given by family members to this SCR. Terms of Reference   The Welsh Child Practice Review methodology presets several practice areas to be analysed as part of any review, these were discussed at the first scoping meeting involving representatives from Croydon Serious Case Review Panel and are contained within Appendix 3.    The Welsh Model encourages a time line of about a year, so that the review can focus on recent practice and learning lessons that are relevant to current practice and service provision. Thus, the review covered just over 1 year, from 1st June 2015 -  1st July 2016. However, agencies were keen for the history of multi-agency involvement to be considered and where relevant this history has been referenced in this report.   An integrated multi-agency chronology was completed, and agencies produced a short single agency summary covering the time line.  This was produced to assist the Serious Case Review Sub-Group in scoping this review and to assist the work of the Child Practice Review Panel.  The purpose of the review  Working Together (2015) states a Serious Case Review should:   provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;   be written in plain English and in a way that can be easily understood by professionals and the public alike; and   be suitable for publication without needing to be amended or redacted.                                            CSCB SCR  Joe - Publication Feb 2018 7 And in response, the Local Safeguarding Children Board should:   Oversee the process of agreeing with partners what action they need to take in light of the SCR findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions3.   Key Areas of Analysis – A summary   The following is a summary of the key areas requiring analysis in this case (as detailed in Appendix 3):    How well was the psycho-social history4 of the child and family considered when providing services and achieving desired outcomes?  How well did the multi-agency services assess and manage risk?  How well did plans meet the needs of the child and family?    Explore the rationale for the duration of the child protection plan and consider how thresholds were applied and decisions made in relation to the various levels of service provision.  How well did multi-agency services challenge each other and were there any obstacles that hindered practice decision making and service provision?    Identify whether there were obstacles or difficulties in this case that prevented agencies from fulfilling their duties (this will include consideration of both organisational issues and other contextual issues).  After all documents had been read and reviewed by the panel, several concerns were identified about the effectiveness of the child protection case conference process and the Lead Reviewer was asked to pay particular attention to this safeguarding process.                                                             3  Working Together to Safeguard Children. DfE 2015    4  Psycho-social history is a term applied to the psychological and social history of the parent.                                          CSCB SCR  Joe - Publication Feb 2018 8   Family Composition  Family Member  Age at incident (where relevant) Joe  2 years 11 months  Rebecca (sister) 7 years Mother  25 years  Father  30 years   Significant Events   The history of multi-agency service involvement was considered as part of this SCR. A time line of significant events from 1985 – April 2015 is contained in Appendix 4.   Period under review: 1st June 2015 – 29th June 2016      Date                                                            Significant Events   1.6.15 Announced Social Work (SW) home visit: Joe seen - home observed to be untidy and cluttered, Mother reports no contact with Father.  4.6.15 Landlord reports to Housing. Mother evicted from property due to ‘noise nuisance, men in and out of property possible drug use and damage to property’. 9.6.15 Mother moves to a B&B (offer of new home withdrawn after mother missed appointments with housing). 11.6.15 Core Group Meeting: Mother did not attend. 25.6.15 Announced SW home visit: property presented as clean and tidy. Mother reported no contact with father. 30.6.15 Father attended SW office requesting contact with Joe. July 2015 Father referred to Mood, Anxiety and Personality (MAP) services by his GP citing possible psychosis. 1.7.15 Maternal Grandmother (MGM) contacted Kingston CSC stating mother is requesting return of Rebecca to her care. MGM expresses her view that mother is not able to look after her – advice given. 8.7.15 Paternal Grandmother (PGM) contacted SW requesting contact with Joe, states mother continued to have contact with father whilst he was in prison. 10.7.15 Announced SW visit: contact between Joe and father discussed. 14.7.15 Father released from prison and attends SW office with PGM requesting contact with Joe. 22.7.15 Core Group Meeting: Health visitor and social worker. 29.7.15 Child Protection (CP) Case Progress Review: SW, Child Protection Chair and Unit Manager. 30.7.15 Police called to remove father from PGM’s home due to aggressive behaviour.                                         CSCB SCR  Joe - Publication Feb 2018 9 Aug 2015 Father attends a (SLAM) Assessment: noted he has been imprisoned on three occasions with the most recent being breach of an injunction against his ex-partner (mother) “with whom he has a 2-year-old child”. Father started on antipsychotic medication. 26.8.15 Child in Need Risk Screen completed by the care coordinator (SLAM). The risk screen completed stated father did not have any dependent children and had no access to children. 28.8.15 Announced SW visit: SW gained entry after 20 mins Joe and Rebecca at home with mother. 2.9.15 Review Child Protection Case Conference: Joe remained the subject of a child protection plan under categories of emotional and physical abuse. 3.9.15 SW supervision with manager: Plan - to progress to Public Law Outline5.  14.9.15 Police attended Paternal Grandparents (PGP) address: concern that Joe’s father was experiencing a mental health episode -father escorted from the premises. 13.10.15  Core Group Meeting.  16.10.15 Father arrested by police for assault and criminal damage at PGP home.  9.11.15 Early Help worker allocated to provide parenting support. 12.11.15 Home visit Early help: lack of engagement by mother leads to offer of services at children’s centre rather than parenting support. 19.11.15 Re-ablement team (SLAM) meet father with his Community Psychiatric Nurse (CPN): Decision to close his case due to father’s non -engagement. 20.11.15 Father’s CPN refers to ‘Active Minds’ for assessment. 21.12.16  Case Review: CP plan 2+ years (Quality Assurance Manager, Unit Manager & SW). 13.1.16 Review Child Protection Case Conference:  Joe’s name removed from a CP plan. Feb ‘16 Mother accommodated in a multi-occupancy temporary housing. The Buildings Manager notices mother appeared ‘spaced out’ and is told by other residents that she is using cannabis and taking cocaine (information gained during the review, not known to professionals at the time). 10.2.16 Core Group Meeting: Mother’s non- engagement with the Children’s Centre noted. 24.2.16 Care coordinator (SLAM) refers Father to SNAP (supported housing). 7.3.16 SW4 allocated. 22.3.16 Father presents as homeless to SLAM office. 29.3.16 Housing confirm with SLAM that Father has had been evicted from two bed and breakfast facilities, re-housing not possible due to father’s behaviour. 31.3.16 Father discharged from the Mood, Anxiety and Personality (MAP) service due to non-engagement. 7.4.16 Child In Need (CIN) meeting: Concerns discussed including mother’s non-engagement and observation of Joe presenting with ‘watchful wariness’, escalation of case back to child protection discussed.  8.4.16  Concerns noted about mother’s continued contact with men who pose a risk. 11.4.16 SW visit: mother continues to refuse to give details of “fiancé”. Case transferred to Best Start Early Intervention Team SW4 allocated. 17.5.16 SW5 allocated (Best Start). 6.6.16 SW5 raises concerns with manager about inability to see mother and Joe after 3 attempts to make contact, lack of sustained changes since 2013 - escalation back to CP discussed. Outcome: to be reviewed after CIN meeting. 22.6.16 Re-referral received from the GP by SLAM: clarity around Father’s diagnosis requested plan made for non-urgent medical assessment. 27.6.16 CIN meeting: SW, Nursery Staff and Mother. 29.6.16 Joe found at home by buildings manager with severe burns.                                                         5 The Public Law Outline (PLO) is a Practice Direction under the Family Procedure Rules which are mandatory court rules, this sets out what should happen before care proceedings are issued.                                         CSCB SCR  Joe - Publication Feb 2018 10     Events under the Timeline – an appraisal of practice- a synopsis    All those professionals who knew Joe were shocked and saddened to hear of Joe’s injuries.  The subsequent criminal investigation and this SCR process have been difficult for all those involved. Despite this, professionals and family members have contributed fully and been open and reflective about the professional response to Joe.   Joe was at risk of significant harm for two years and six months and whilst it is the view of the Review Panel that Joe’s horrific injuries could not have been predicted, it was concluded that opportunities were missed to provide Joe with the protection he needed.   The Review Panel were struck by the number of services providing support to this family.   These services were provided with the intention of making a positive difference to Joe’s life.    However, the view of the Review Panel was that there was a lack of proper consideration of the family history, insufficient involvement of the kinship and the full safeguarding network, a lack of evidence based decision making, repeated unresolved concerns about drug use and little understanding of possible impact, poor child protection planning, poor management oversight and a lack of inter-agency and intra- agency challenge leading to drift.      During the time covered by this review there were considerable challenges faced by services, particularly Children’s Services. These challenges included an unusually high turnover of front line social workers and managers, high vacancy rates, exceptionally high caseloads of significant complexity and insufficient management support or guidance. This context should be held in mind whilst reading this appraisal.                                              CSCB SCR  Joe - Publication Feb 2018 11 1st June 2015 – 1st September 2015   At the start of this period, Joe had been the subject of a child protection plan for over 2 years under the categories of emotional and physical abuse. The health visitor and social worker worked well together, they made regular announced and unannounced visits to the family home and on occasions these visits were made jointly.   As a result, there was excellent communication between these two key professionals. The joint visits that took place enabled the sharing of information and demonstrated unity within the professional network.   During a home visit made to the family home on the 1st of June 2015, mother was asked whether she had contact with Joe’s father as there were ongoing concerns about the risks he posed to Joe, mother stated she was having no contact and this was accepted.   However, when the housing records were released as part of this SCR, the records for the same period showed that a housing officer had recently observed a male leaving the house (believed to be the father of Joe) but as housing services were not included in the safeguarding network, this information was not shared.  The absence of housing services involvement in the safeguarding of Joe and the undue weight placed on parental self-report meant that the risks to Joe were under-estimated.   In addition, although it was right to continue to evaluate the risks posed by father, mother had a history of neglectful parenting and evidence suggested that there was little improvement in the parenting she provided to Joe since his birth. The undue focus on father meant that the risks posed by mother were not properly considered.    A core group meeting was held at the required time on 22nd July 2015 and was attended by the health visitor, social worker and mother. At this meeting, concerns about the length of time Joe had been the subject of a child protection plan were appropriately discussed. Professionals were right to raise these concerns as Joe had been the subject of a child protection plan for 2 years and six months.                                           CSCB SCR  Joe - Publication Feb 2018 12 This is of concern both locally and nationally and children who are the subject of a child protection plan for 2 years are expected to be the subject of management review to ensure effective action is taken.   During this time, Croydon Children’s Services were changing the existing processes for reviewing these children.  There were considerable delays in these management reviews, and as a result Joe’s case had not been reviewed.   The absence of a management review left Joe at continued risk of harm, and left front-line practitioners (including the chair) without the management guidance they needed. It is understood that a new inter-agency reviewing process for children subject to a child protection plan for 2 years is currently being implemented, this is discussed later in the report.   On 29th July 2015 a ‘child protection progress case review’ took place involving the Child Protection Chair, the Social Worker and the Unit Manager for the Social Work Team. It was agreed that the social worker would refer Joe for a developmental assessment and ascertain whether there were any restraining orders on father.  These decisions did not reflect the seriousness of this case.  At this point, the only assessment available was a pre-birth assessment which had been completed when mother was living in Kingston, no core assessment had been completed in Croydon. This meant that there was no comprehensive understanding of Joe’s needs or of mother’s parenting capacity and no bench mark on which progress (or the lack of it) could be measured. The absence of a core assessment was not discussed at this meeting, this was an important omission.  It was understood that if there is a pre-birth assessment on the child’s file, the current data recording system in Children’s Services does not prompt social workers to complete a core assessment. In addition, it was learnt that the social work report to conference is often regarded as an assessment update.                                          CSCB SCR  Joe - Publication Feb 2018 13 This approach does not meet the needs of children, for children to be adequately safeguarded dynamic risk assessments are critical and social work reports to conference should not be regarded as a substitute for an updated assessment. (This is discussed later in this report.)    Whilst the decision to pursue a paediatric assessment could have been an attempt to gain evidence to support legal action, this was not explicit in the recording of this meeting as it should have been. Importantly, the lack of time scales set for the assessment and the absence of a clear plan to progress with Public Law Outline (as a prerequisite to court proceedings) contributed to the drift in this case and left the social worker without the management guidance that was needed.   There had been repeated recommendations made at case conferences for mother to:  disclose the names of all household visitors to enable an assessment of risk  refrain from drug and alcohol misuse  give permission for maternal grandmother to be contacted  engage in parenting work  keep all health appointments And for the case to progress under Public Law Outline.   None of these recommendations had been progressed and this was not challenged by the CP chair or the manager. This lack of challenge left Joe at continued risk of harm.    During June, July and August 2015, the social worker made regular announced and unannounced visits to the family home. Mother was challenged about her non-attendance at various appointments and about her non-engagement with the child protection plan.  The social worker was right to challenge this non-engagement and was tenacious in her efforts to gain access to the family home to see Joe.  However, in the absence of management guidance to the contrary, much of the social worker’s time was taken up negotiating the feasibility of supervised contact arrangements between Joe and his father and this diverted the social work focus away from the risks posed by mother.                                             CSCB SCR  Joe - Publication Feb 2018 14 After receiving a referral from father’s GP, reporting concerns that father was suffering from psychosis, the South London Adult Mental Health service (SLAM) met with father in August 2015 and completed an initial ‘risk screen’. Father reported he had no dependent children and had no contact with any children and this self-report was accepted.   At the time, father was making several attempts to have contact with Joe through the social worker.  However, information available to other professionals suggested that father was having contact with Joe.  As SLAM was not included in the safeguarding network around Joe, they were unaware of Joe.   Review Child Protection Case Conference: 2/9/15  This case conference was held within the required time frame and was attended by the health visitor, social worker and mother. Probation and the Police Child Abuse Investigation Team (CAIT) had been invited, but did not attend. CAIT sent a report and this was included in the social work report. No report or update was provided by Probation and Adult Mental Health Services (SLAM) were not invited. It is questionable whether the membership of this conference was quorate, and this should have been discussed.  The London Child Protection Procedures state that when there are no other professionals having direct contact with the child, minimum quoracy can be overridden.  However, it is important to consider any professional group, services or family members who may have valuable information to share.  In this case, adult mental health, housing, paternal and maternal grandparents all had valuable information to share, but they had not been invited to attend and the absence of their contribution was not acknowledged. Had they been invited to contribute, vital information about the risks to Joe6 would have been known and the safeguarding network around Joe would have been strengthened.                                                          6 Including information from housing about concerns from landlords, information about father’s mental health and information from MGM about her observations of mother and father who were visiting her home in another London Borough                                         CSCB SCR  Joe - Publication Feb 2018 15 The plan that was included in the social work report was not the plan made at the previous case conference, this plan related to a case conference that took place in December 2014. Although the child protection plan in the social work report for conference was incorrectly included, the plan from the previous conference was correctly reviewed in the conference and professionals had been following this plan.   The health visitor report to this conference was good, the template allowed the health visitor to provide full information about her involvement and to provide a good description of Joe’s perspective. The historical background and current risks were clearly outlined and the lack of compliance by mother with the child protection plans was highlighted. Indeed, mother had not engaged with the child protection plan and so the vast majority of the recommendations remained unmet.   The social work report appropriately recorded observations of Joe and these observations gave a reasonable (albeit limited) picture of Joe. The social worker concluded that mother ‘could provide basic care to Joe’ and that there was a ‘good attachment’ between Joe and his mother. There was no evidence provided to support these assertions and the use of terminology such as this, without any supporting evidence, can have unintended consequences for how risks to children are understood.  There was an over emphasis placed on the social work view that mother was committed to ending her relationship with Joe’s father and the focus of concern in the social work report (and the conference) was on the risks father posed to Joe. Mother’s lack of compliance with the child protection plan and the lack of progress made by services to implement the plan was not discussed.   The reasons for this lay partly in the lack management support provided to the professionals and partly in the primary focus of the child protection plan. Joe was the subject of a plan under the categories of emotional and physical abuse. The rationale for these categories was stated as being the risk of Joe living in a household where there was domestic violence and this category is commonly used in these circumstances.                                           CSCB SCR  Joe - Publication Feb 2018 16 However, whilst the category of emotional and physical abuse was arguably appropriate at the Initial Child Protection Conference in May 2013 subsequent concerns about mother’s care of Joe, her lack of engagement with the CP plan, father’s departure from the family home (and the view of the professionals that he was not having contact) should have led to a change in this category. The category of neglect that had been used in Kingston when Joe’s sister was the subject of a child protection plan should have been used. The continued use of the emotional and physical abuse category had the effect of diverting skewed the plans and decision making away from neglect and promoted an overriding focus on the risks posed by father.  At this conference, information was shared about father and this included information from paternal grandmother that mother had been in contact with father whilst he was in prison. A report from the police suggested that father had been in the family home when Joe was present in May 2015:   In May of this year a police report states they were called to the address and believed father had been present in the property, evidence that people had been up late drinking at the address house in poor condition stale air no bed sheets toys all over lager cans lying around.   This information appeared to be set aside in favour of mother’s reports that she was having no contact with father and the evidence of neglect was overlooked.   In the absence of a focus on mother’s neglect, the assertion that there were now changes in mother’s relationship with father led to a false optimism that Joe no longer required a child protection plan. The chair concluded that the risks had reduced and expressed a view that a Child in Need (CIN) plan could be made.   The view of the chair was contrary to the view expressed by the social worker (that the child protection plan should continue for a limited period to allow for monitoring) and to the view of the health visitor (who was clear that the risks remained), but neither the social worker nor the health visitor challenged the position the chair was taking.                                           CSCB SCR  Joe - Publication Feb 2018 17  None of the professionals had been provided with the management support they needed and the absence of inter-agency and intra-agency oversight and challenge compromised decision making.  Just prior to the conference ending, mother responded inappropriately to a request to disclose details of her new partner. Based on this response, the chair decided that the CP plan should continue and that Joe should be placed under the category of neglect. The decision to change the category was correct, mother had not engaged with many of the recommendations made at all previous conferences and there was evidence that mother was unable to prioritise Joe’s needs above her own.   It would have been expected practice for the chair to be explicit about the evidential basis for changing the category and for this to be clearly recorded.  However, the reasoning recorded in the minutes was muddled. That said, a more robust plan was made at this conference. This plan identified several outstanding actions from previous case conference and gave some clear timescales for completion of tasks (including the need to seek legal advice).   However, although the decision to change the category to neglect was recorded in the conference minutes an administrative error led to Joe’s name remaining on the list of children subject to a CP plan under the category of emotional and physical abuse, and so the focus of concerns remained on father.  The reason for this error was said to be due to the reduction of administrative staff and the high volume of conferences in Croydon. This is discussed later in this report.                                                 CSCB SCR  Joe - Publication Feb 2018 18  3rd September 2015 - 7th January 2016   On the 3rd of September (the day after the conference), a management decision was recorded on Children’s Services case file:    to progress the case for Public Law Outline (PLO) 7, tasks to be completed (before progressing to PLO):   paediatric assessment of Joe and   case to be discussed with senior management.   These were clear management decisions and were appropriate to the risks in this case. However, these decisions were not discussed with the social worker as part of a formal supervision session (as they should have been) and no timescales were set for the completion of tasks.   Mother had been regularly asked to disclose the details of her partner, on the 16th of September 2015 the social worker asked for these details again, and asked if Joe was ever left in his care. Mother agreed that Joe was left in his care but refused to provide details of her new partner.   This was a key point in the case, a manager had noted on the file that the case should progress to PLO and this new information suggested that Joe was being cared for by an unknown male. There was suspicion that mother was pregnant and, given mother’s history, it was reasonable to conclude that both Joe and any unborn child may be at risk from this man. No action was taken in response to this information, it was merely recorded on file.   It was not possible to understand why no action was taken although it is understood that at this time there were unacceptably high caseloads held by social workers and a high turnover of staff, both of which would have had an impact on practice standards.                                                             7 Public Law Outline is the initial stage of legal proceedings                                          CSCB SCR  Joe - Publication Feb 2018 19 On the 25th of September 2015, a manager made a note on the case file asking to be informed if the case progressed to PLO. This should have formed part of a supervisory meeting with the social worker to ensure they were appropriately guided in their work, this did not happen.    A core group meeting was held within the expected time on the 13th of October 2015 and included mother, the health visitor and the social worker.  The plan made at the previous case conference was correctly included in these minutes. This showed that whilst some of the tasks appeared to be in progress, the most essential tasks at this point (that of gaining legal advice and gaining the details of mother’s new partner) had not been taken forward and the manager’s decisions (recorded on file) were not discussed. It was not possible to fully conclude why, although given that these decisions had not been discussed with the social worker, it is entirely possible that at the time of the core group the social worker was not aware of these management decisions.     During the next few weeks, the social worker made several visits to the household and attempted to engage mother with the work of the Family Engagement Partnership (FEP)8 team. On several occasions, both the social worker and the FEP worker could not access the home and struggled to receive any response from mother, as a result there was little contact with Joe.   Over this period, there was no evidence found to suggest that the manager drew the social worker’s attention to their decisions, no evidence found that the social worker was aware of these decisions, and no attempts were made to progress the case to PLO.   On the 21st of December 2015, a Quality Assurance Manager (who was manager of the CP chair) met with the social worker and the manager. This was recorded as a meeting to review the case of a child on a child protection plan for more than 2 years, it is unclear why the chair (who held a central position of authority within the case conferences) was not present.   This was an opportunity to realise the risks in this case and take forward the outstanding task of progressing the case to PLO, the agreement reached at the meeting was recorded as:                                                          8 FEP: An Early Help service for children under 5 and their families.                                         CSCB SCR  Joe - Publication Feb 2018 20 “some tasks have to be completed before the CP plan could end, but others could be managed under a CIN plan or TAF (Team Around the Family)”. This contradicted both the CP plan and the management decisions recorded on Joe’s file.   In addition, the decisions were not made with key safeguarding partners and partners were not informed of the decisions. This reflected the single agency approach to decision making on high risk cases such as these9 operating at the time and meant that there had been no effective challenge to Children’s Services about the significant delays. This is discussed later in the report.     13th January 2016 – 16th May 2016   Review Child Protection Case Conference:  13th January 2016 The conference was attended by the newly allocated social worker, health visitor and the family support worker. Relevant issues in relation to quoracy and the involvement of the full safeguarding network have been previously discussed and equally apply to this conference.   The social work report to the conference briefly detailed Joe’s wellbeing and these comments were generally positive. However, only 2 visits to the family had taken place since the last child protection conference. Despite this limited social work involvement, the social worker noted a “good attachment” between Joe and his mother and asserted that Joe’s basic needs were met> The quality of this report fell below expected practice standards,  relevant issues relating to the quality of social work reports and the use of misleading terminology are explored later in this report.    The conference was conducted using a ‘Strengthening Families’ approach; the format and structure of the meeting was of a far better quality than that previously seen. However, there were several problems in the quality of information sharing, assessments, and decision making.                                                           9 Children subject to a CP plan for over 2 years                                         CSCB SCR  Joe - Publication Feb 2018 21 Reports presented to the conference, outlining changes in family circumstances since the last conference, were almost entirely based on mother’s self-report and this self -report had not been triangulated with other sources of evidence. Critical information about mother’s new partner and her suspected pregnancy was not shared.   The police report stating that Joe’s father had come to the attention of the police on four occasions since the last conference was not discussed.   Reports of Joe being withdrawn and observations that he could appear “frozen - wanting to cry but unable to do so” were not regarded with the seriousness these observations warranted.    During the conference, a statement was made that maternal grandmother was allowing unsupervised contact to take place between mother and Joe’s sister (Rebecca) and this was regarded as a positive sign. In fact, this contact had been taking place since 2013 as maternal grandmother (MGM) was not aware that Joe was the subject of a child protection plan.   Importantly, by allowing Rebecca to stay with her mother, MGM was unknowingly placing Rebecca at risk of significant harm. Had she been contacted, valuable information would have been known about mother’s ongoing relationship with Joe’s father and Joe’s safeguarding network would have been strengthened.   This SCR identified that twelve recommendations from the last case conference had not been completed. These related to key areas of the child protection plan that had remained unmet for the duration of child protection planning.   These included but were not exclusive to:  the need to seek legal advice with the intention of progressing to PLO  mother to disclose the details of household visitors  mother to disclose the details of her new partner  maternal family to be contacted   a core assessment to be completed                                         CSCB SCR  Joe - Publication Feb 2018 22  During the child protection conference, the lack of progress in these key areas was not acknowledged.  In addition, of critical importance was mother’s drug mis-use; but there had been no objective assessment or monitoring of this.  Despite external evidence to the contrary, mother’s self- report that she was not using drugs was taken at face value.   As a result, there was no consideration about how her drug use might be impacting on Joe, on mother’s own mental health, or on her capacity to change. Mother’s drug use was only minimally referenced within the child protection conferences and at this last conference it was not discussed.   The newly allocated social worker reported a good relationship with mother, this relationship seemed to influence their professional opinion as an overly positive report was presented about the parenting Joe was receiving. This report was not supported by the evidence that was available.   The conference placed disproportionate weight on the involvement of a family support worker (FSW) and mother’s attendance at the Children’s Centre, this was cited as evidence of her “engagement and motivation” and of her ability to safeguard Joe. In fact, due to mother’s lack of engagement, the Best Start Early Intervention Team had decided they were unable to offer a service and only saw mother on two occasions at the Children’s Centre. In addition, mother had attended the Children’s Centre for only 3 (out of a possible 20) sessions.  Conference members decided that the threshold for a child protection plan was no longer met and Joe’s name was removed from a child protection plan. Monthly social work visits were recommended, the health visitor was asked to see Joe “if and when required,” mother was asked to attend the Children’s Centre twice a week, and there was a recommendation that the case was not closed until a CIN meeting took place.   The decision to remove Joe’s name from a child protection plan was not based on any evidence suggesting that there had been material changes in Joe’s lived experiences, or the risks he faced.                                         CSCB SCR  Joe - Publication Feb 2018 23 Joe remained at risk of significant harm and the plan agreed at the conference did not adequately safeguard Joe from future harm.    The lack of a core assessment, and the poor quality social work reports, provide a partial answer for the absence of coherent risk assessment and planning. However, it is important to note that the safeguarding of children can never be achieved by one professional or by one service. There was a need for all agencies to take ownership of the poor safeguarding practice in this case and take appropriate action to ensure Joe was the subject of legal proceedings.   At this time there was a high turnover of social workers in Croydon, staff were holding unacceptably high caseloads, there was little management guidance and insufficient support and challenge provided from both within Children’s Services and across the multi-agency services.      Providing services to Joe as a Child in Need: 14th January 2016 – 11th April 2016   Typically, when a child protection plans ends, the level of scrutiny and support reduces. This is appropriate and necessary but carries with it the potential for families to be left relatively unsupported or with inadequate monitoring.10  On the 7th April 2016,  a child in need (CIN) meeting took place and correctly held in line with the recommendation made at the previous child protection conference that the case should not be closed to Children’s Social Care before a CIN meeting was held.  Housing was not invited to this meeting as they should have been, but the meeting was appropriately attended by the Probation Service, the Family Support Worker, the Health Visitor and the newly allocated social worker.   The meeting correctly identified several long-standing concerns, including concerns about mother’s recent withdrawal from services.                                                            10 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 – 2014 (DfE 2016).                                         CSCB SCR  Joe - Publication Feb 2018 24 During this meeting, Joe was described as exhibiting “watchful wariness” but as a full picture of Joe had not been previously gained it was not possible to know whether this was Joe’s normal presentation or something new that may have been prompted by a change in the care he was receiving. Although there was little description of what this meant, it was a critical observation that should have resulted in far greater attention paid to Joe; including opportunities to undertake a close observation of Joe’s overall emotional and behavioural development and well-being. However, as the term of ‘good attachment’ had thus far been used to describe Joe’s relationship with mother this may have served as an antidote to this concerning observation.    The meeting concluded mother stopped engaging with services as soon as Joe’s name was removed from a plan and decided that the case should be escalated back up to statutory child protection services.  Despite this decision, three days later, Joe’s case was transferred to the Early Intervention Services. No effective action was taken by any of the services to challenge this decision.  It is understood that there is now a pathway in place encouraging and guiding the process of professional challenge from within Early Intervention Services to enable swift escalation of cases to statutory services where needed. As a result, no lesson has been formulated in relation to this issue although the lack of multi-agency challenge that is explored in Lesson 2 is relevant.    Involvement of the Early Intervention Team (Best Start) 11th April – 29th June ‘16  On the 11th of April 2016, a social worker from the Best Start Team was allocated. However, this social worker was not involved with the family as they left the service shortly after allocation. Over 4 weeks later, another social worker was allocated (this was the fifth social worker during the period under review). Given the concerns in this case, this delay in allocation was poor practice.  It was understood that at this time there were a high volume of cases being transferred to this team, management oversight was in the process of being established, and there were few procedures in place facilitating challenge about the transfer of cases. Changes to this transfer process have now been made, resulting in strengthened management oversight and challenge.                                         CSCB SCR  Joe - Publication Feb 2018 25 No specific lessons have been identified in relation to this, although the issues identified in Lesson 2 are relevant.  The social worker made several attempts to contact mother, but was unsuccessful. On the 6th of June 2016, the social worker discussed the case with the team manager and expressed significant concerns about Joe and the drift in the case.  The social worker’s early grasp of the risks was commendable and for the first time the impact on Joe of mother’s cannabis use was appropriately raised as a significant area of concern.  In the absence of a clear agreement between services, specifying how escalation could be achieved, the manager felt it was important to gather as much evidence as possible to achieve successful escalation.   The manager advised that a child in need (CIN) meeting should take place before attempts could be made to escalate the case back up to statutory child protection services. Whilst the rationale for this approach is understandable, this led to further delay.  Over the next 3 weeks, the social worker gathered evidence to achieve escalation; arrangements were made for a CIN meeting, Joe was observed at nursery and several visits were made to the family home. The social worker appropriately challenged mother’s use of cannabis and expressed her concerns about the routine delays she experienced when attempting to gain entry to the home. She challenged mother about her lack of engagement with services and evidence found on ‘Face Book’ relating to mother’s drug use and her association with unknown males, this was excellent social work practice.     At a CIN meeting on the 27th June 2016, the social worker again appropriately raised her concerns. However, two days later (before further action could be taken) Joe was found at home by the Buildings Manager with severe burns to his body. The action taken by the Buildings Manager to safeguard Joe was commendable.  Key Lessons  A total of nine lessons have been learnt from this case, all of which are pertinent to the multi-agency safeguarding system.                                          CSCB SCR  Joe - Publication Feb 2018 26 Many of the lessons are interlinked, meaning that changes in one part of the system may ultimately have a positive impact on other areas of learning and development identified within this report.  The appraisal of practice details how the child protection conferences and the child protection plans made at these conferences did not provide Joe with the protection he needed.  The first three lessons are focused on the services provided to children who are the subject of child protection case conferences and plans.   The first lesson looks at the internal mechanisms within Local Authority Children’s Services that enable child protection case conferences and child protection planning to take place and the management oversight and support required to ensure these mechanisms provide children with the protection they need.  Lesson 2 explores the importance of multi-agency challenge and Lesson 3 explores the importance of involving the full multi-agency network in safeguarding children.  Lesson 1: When Child Protection Conferences and Child Protection Plans are not working as they should, and there is insufficient oversight of these crucial safeguarding mechanisms, the protection of children will be compromised.  The appraisal of practice outlines several issues relevant to this lesson including the quality of social work reports to the conferences, concerns about the plans made for Joe, administrative mistakes in relation to child protection plans and recording , the lack of implementation of child protection plans, the absence of a core assessment, the fragility of the evidence base on which decisions were made, the lack of analysis, the categorisation in use and the absence of effective management oversight.   It was understood that multiple factors contributed to this position and that a ‘Strengthening Families’ approach to child protection conferences was introduced in Croydon in November 2013 and has more recently been subject to review.  Whilst this approach will improve practice in this area, it will not address some of the systemic shortcomings identified in this case.                                          CSCB SCR  Joe - Publication Feb 2018 27 Members of the Review Panel were asked whether these vulnerabilities were relevant to a wider range of cases and the following factors were identified as continuing to impact on service delivery, including, but not exclusive to:    the reduction of administrative staff employed to support child protection conferences  systems errors within the data recording system that lead to the wrong plan appearing in the case file and to there being no trigger to prompt the completion of an updated assessment    the high caseloads of child protection chairs,  the lack of robust management oversight (that is overly focused on performance indicators and process at the expense of practice oversight and guidance)   the systemic organisational tolerance of poor quality social work reports and assessments (and the lateness of submission)  the low status ascribed to child protection recommendations  the conflict that can exist between chairs and team managers when recommending legal advice,   the lack of escalation of concerns by chairs   The inter-agency sharing of information, discussion, challenge and joint planning that is achieved through the mechanism of child protection conferences should not be underestimated. These components underpin the multi-agency system that routinely achieves the protection of children. However, if these processes are eroded and the intrinsic value of this multi-agency risk assessment and decision-making forum is not sufficiently supported and reviewed, the protection of children will be compromised.                                                 CSCB SCR  Joe - Publication Feb 2018 28                                                                                                 Lesson 1:  Issues for the Board  - CSCB and Children’s Services to review the quality assurance data 11  currently provided to ensure that the standard of this data is sufficient to enable adequate evaluation of child protection services.  - Child protection chairs must be routinely expected to challenge how children are safeguarded. Their effectiveness in providing challenge should be the subject of regular review and evaluation both internally within Children’s Services and by the CSCB.    - Children’s Services to conduct an internal review of the issues identified and determine how these issues will be addressed. CSCB to review and evaluate impact of changes.  Note: The recent Ofsted inspection (June- July 2017) has identified similar issues, CSCB should consider the issues raised in this lesson and recommendation made above to determine whether current action is sufficient.    Lesson 2: The lack of robust inter-agency and intra-agency decision making and challenge, about the services provided to children who are the subject of child protection plans, jeopardises children’s safety.   This lesson explores the critical role of inter-agency and intra-agency challenge in safeguarding children and demonstrates how the absence of this challenge has a significant impact on whether the right services are provided to children when protecting them from harm.                                                          11 Ref: Analysis of Data of Children Subject to Child Protection Plan May 2016. Croydon Safeguarding and Quality Assurance Service (presented to CSCB Oct’16)                                           CSCB SCR  Joe - Publication Feb 2018 29 The issues identified in this lesson are not particular to Croydon, Serious Case Reviews conducted across the UK frequently refer to the absence of professional challenge in safeguarding work.12  Joe was the subject of a child protection plan for 2 years and six months. As identified in the appraisal of practice, there were several key areas of the child protection plan that were not implemented and were simply rewritten into the plan for almost the entire duration of child protection planning. There was no evidence that members of the professional network effectively challenged this status-quo, instead the same recommendations were simply repeated.   A critical part of the plan was to seek legal advice and to progress matters under the Public Law Outline. But despite this recommendation being constantly repeated, it was not progressed. This was not challenged by multi- agency partners, by the various child protection conference chairs, or by managers.  The lack of inter-agency and intra-agency challenge has been mentioned in the appraisal of practice and needs no further exploration. However, it is of note that in the Learning Event managers and practitioners spoke of feeling concerned that Joe was not being adequately safeguarded, but were unable to explain why no challenge was made.   When Joe’s child protection plan was at danger of exceeding the maximum 2-year period, in line with established custom, practice and procedure, Joe’s case was the subject of management scrutiny.  A review of the plan was conducted by the Police Child Abuse Investigation Team (CAIT) in August 2014, to challenge: “the ineffectiveness of the child protection plan”, this was completed without reference to the agencies involved and resulted in no effective change to the status quo.                                                           12 Case reviews: National case review repository (NSPCC)                                          CSCB SCR  Joe - Publication Feb 2018 30 Another review was completed by the operational manager responsible for the allocated social worker and the manager responsible for the child protection chair, their responses are detailed in the appraisal of practice.   In summary, there were differing views about what should happen in this case but in any event their observations and concerns made little difference to the course of events. Of relevance is the disparate way in which this multi-agency management system worked to consider the question of Joe’s protection there was no consultation across the agencies involved and there was no effective challenge to the status quo.   As part of this SCR, relevant local policies were reviewed. There was no policy found that addressed the review of children subject to child protection plans for 2 years. 13 Two policies were found outlining the steps that need to be taken to escalate concerns about a case. One was an internal Children’s Service document addressing the role of the Independent Reviewing Officer (and child protection chair)14 and the other a CSCB escalation policy.15   Whilst it is important that both CSCB and Children’s Services have such a framework in place, it was understood that there is no information available to understand how effective these polices are in facilitating challenge and as there was no expressed challenge/disagreement to the plans in this case these policies did not apply.   In addition, in the absence of a framework that sets a cultural tone to working practices (i.e. one that encourages professional curiosity, debate, challenge and respectful uncertainty) the overriding focus on disagreements and escalation can inadvertently lead professionals and services to view challenge in a negative light and the current focus of existing policies on disagreements or disputes (that require a process to be followed to reach resolution) may run the risk of dissuading inter-agency and intra-agency debate and challenge.                                                           13 It was understood that a new policy is currently being written 14 Croydon’s Escalation and Resolution Protocol for Children, Families and Learning Partnership March 2015 15 Croydon Safeguarding Children Board Escalation Policy. Resolution of professional disagreements in work relating to the safety of children. March 2015                                          CSCB SCR  Joe - Publication Feb 2018 31                                                     Lesson 2: Issues for the Board  - Members of the multi-agency network to outline what steps will be taken to improve the quality of their contribution to child protection conferences and decision making and how the absence of challenge will be addressed. CSCB to evaluate impact.   - CSCB to ensure that there is now a robust timely multi-agency process in place that scrutinises child protection plans for children who are the subject of a child protection plan for 18+ months and evaluate impact.    Lesson 3: The restricted view held about which agencies are part of the safeguarding network, and who holds responsibility for safeguarding children, results in valuable information not being shared and leaves the onus of responsibility with the few.  The phrase “Safeguarding is everyone’s responsibility” lies at the heart of statutory guidance and practice, dictating how children are safeguarded. Working Together 2015, The Munro Review of Child Protection16, various SCRs, research and associated literature are clear that children can only be safeguarded within a multi-agency partnership characterised by shared responsibility. These collective responsibilities include shared multi-agency ownership of assessments, analysis, plans and outcomes, and includes multi-agency partners across the management hierarchies.   There were several examples in this case indicating that this shared responsibility did not translate to multi-agency practice on the front line and this left the onus of responsibility with a handful of practitioners. This lesson explores how the composition of the safeguarding network had a significant impact on the services provided.                                                         16 Munro review of child protection: a child-centered system. Department for Education May 2011                                          CSCB SCR  Joe - Publication Feb 2018 32  At the start of this SCR, the Review Panel concluded that although there was either minimal or no apparent involvement by Housing, Community Rehabilitation Company and Adult Mental Health Services, there was a need to include the full safeguarding network in this SCR and representatives were invited to attend.  Housing services were a consistent member of the panel but as identified in the methodological limitations, there was inconsistent representation from Adult Mental Health Services and the London Community Rehabilitation Service did not attend.    This was reflected in the case, housing had significant involvement, but this was not shared at the time, at one-time Probation Services were active in the safeguarding network but overall they had limited involvement, and whilst there were evident concerns about father’s mental health, adult mental health services were not included in the safeguarding network.  The absence of these safeguarding partners was important for several reasons. In terms of housing services, it was only when gathering information for the purposes of this SCR that the extent of information known about the family became clear, this included important information about the anti-social behaviour of mother and allegations by landlords and neighbours of “noise nuisance, drug dealing and prostitution.” 17 Had this been known by the professional network, it would have provided valuable information to strengthen the protection of Joe.   In terms of the Community Rehabilitation Company services, they were involved with father at various times but they were not routinely invited to case conferences.18 It has been argued that when father was in prison he was not receiving services from the Community Rehabilitation Company, so they were not involved. This rigid definition of the safeguarding network should have been challenged.                                                           17 There was no corroborating evidence to suggest mother was involved in prostitution 18 Probation were invited to one CP conference (out of a possible 6 of the 6 conference minutes reviewed) but did not attend                                          CSCB SCR  Joe - Publication Feb 2018 33 Whether the Community Rehabilitation Company services were actively involved or not, they could have been asked to provide important guidance and support in seeking information from the prison service that would have assisted in gaining a greater understanding of father to inform the protection of Joe.  Likewise, although adult mental health services were not consistently involved in providing services given the ongoing unanswered questions about father’s mental health advice and guidance from this service would have provided valuable information to support decision making.   As part of this SCR, the minutes of six child protection case conferences were reviewed and showed that the only professional attendees of the CP conferences were the police, the health visitor, the chair and the social worker. In 4 (out of a possible 6) case conferences no police representative was present19 and in the final conference that removed Joe’s name from the child protection plan only the health visitor, social worker and chair were present.  It was the view of the Review Panel that the absence of safeguarding partners at case conferences was not unusual, the suggested reasons for this include a lack of knowledge about which services are involved in family life and the non- attendance of services. It is understood that a relatively recent report to the CSCB has identified this as an area of concern and action is currently being taken to address this, the effectiveness of this action is not known at the time of writing.      The importance of including the full safeguarding network in these critical planning forums is undisputed. Responsibility for ensuring the right people are invited commonly sits with Children’s Services in the form of the allocated social worker. This reliance on one individual does not create a safe system, it is the responsibility of all agencies to have systems in place to support the contribution of multi-agency staff, across a range of adults and children’s services.                                                             19 It was understood that police policy is that they will only attend an initial case conference and will attend future case conferences only ‘as and when ‘required.                                           CSCB SCR  Joe - Publication Feb 2018 34                                                                                               Lesson 3: Issues for the Board  - Recent SCR’s in Croydon have highlighted concerns about the lack of involvement by housing services in safeguarding children and several measures have been put in place that have strengthened this area of safeguarding practice. CSCB are invited to review improvements that have been made and consider if anything further is now needed.  - Are safeguarding partners adequately prioritising and facilitating the attendance/contribution of relevant staff at case conferences? How will this be evidenced and kept under review?    - What systems need to be put in place to ensure that the full safeguarding network is correctly identified and that the attendance/involvement of all safeguarding partners is achieved?  Lesson 4: There was sufficient information about various concerns that should have allowed clear judgements about risk to be made but the over focus on assessments and self -report caused significant drift.   ‘The balance of probabilities’ is the standard of proof used in all care proceedings and should be used as the governing principle in safeguarding work. There was sufficient evidence in this case to suggest that this standard of proof had been met, but instead there appeared to be a perennial seeking of evidence to prove that Joe was the subject of harm beyond all reasonable doubt. (and a converse position of decision making based on a highly questionable evidential base in the form of self – report)                                             CSCB SCR  Joe - Publication Feb 2018 35 Throughout the documentation the quest to obtain assessments about father, was strikingly repetitive.   “……excessive emphasis on assessment can lead to drift or failure to proactively work with families.” 20  Child protection plans recommended that assessments were needed to assess father’s cognitive functioning, his mental health needs, his anger management, his use of drugs and the risk he posed of sexual abuse. These assessment proposals were variably repeated within the time under review, and in the conferences that preceded this period.   These assessments were never achieved so whilst plans rightly identified action needed to ensure Joe’s safety from his father, there was sufficient evidence held across the agencies that should have led to a judgement that - on the balance of probability - Joe’s father posed a significant risk to Joe. Whilst this was tentatively inferred by the actions taken, the perpetual seeking of assessments to confirm this risk resulted in an undue focus on father and came at the expense of making plans that sought to address the risks posed by mother.    There was sufficient information to suggest that mother was a long-term cannabis user, that she mis-used alcohol, regularly had loud parties at the home when Joe was present, was not prepared to inform agencies about a variety of household visitors who could pose a risk to Joe, was not engaging with plans and services and was not prepared to place Joe’s needs above her own. Judgments about the care Joe was receiving were too often based on mother’s self-report and on the evidential criteria used in criminal law (i.e. beyond reasonable doubt).  Had these judgements been based on the correct legal threshold (i.e. on the balance of probability), the risks to Joe would have been successfully identified.  No audits could be found to show that the comparison of these care judgements has been the subject of quality assurance activity in Croydon.                                                          20 Brandon et al – Triennial Analyses of Serious Case Reviews 2011-2014                                         CSCB SCR  Joe - Publication Feb 2018 36 The recent Ofsted inspection has identified the poor quality of risk assessments; including the over reliance on self -report, lack of a sound evidential base and lack of analysis. The action already being taken to address these issues should be considered alongside this finding and the recommendation that has been made.       Lesson 4                                                  Lesson 4:  Issues for the Board   - Professionals to be supported in gathering evidence and triangulating evidence to improve risk assessments, ensuring that judgements about risk are based on a sound evidential base that properly considers the balance of probability/ likelihood of harm.     Lesson 5: Some of the terminology used by professionals in safeguarding work requires greater explanation and scrutiny to understand what it means, using this terminology without adequate explanation risks assumptions being made that compromise a child’s safety.  There were terms used within assessments, reports, minutes of case conferences and core group meetings that were used to denote aspects of the care Joe received. Examples include: “(Mother) is able to provide basic care”, “(Joe) seems to have a good attachment to mother”.  These terms frequently appeared within the narrative but were accompanied with little description of what they meant, or the meaning for Joe.  The use of these terms can have a powerful emotive impact on professional thinking and can active as an antidote to a wider context of serious concerns. (as they did in this case.) The repeated assertion that a parent can provide “basic care” is a not an unusual statement to see within assessments, minutes of case conferences, reports and case recordings, but what this means in practice is often unclear, and is prone to subjective interpretation.   For some basic needs are as simple as food, water and shelter and if this is the definition that was used to describe the care that Joe received then this may well have been correct.                                           CSCB SCR  Joe - Publication Feb 2018 37 However, children’s basic needs are more complex than this and the question of whether Joe’s emotional and psychological needs were being met should have been considered. Joe was living in an unstable environment that featured drug use, frequent household visitors, a visibly chaotic home, a notable lack of stimulation and frequent concerns that mother was not taking him to required appointments, to assert that Joe’s basic needs were being met was arguable.   Again, it is not unusual to see the terms ‘good attachment’, ‘strong attachment’ or ‘insecure attachment’ in case documentation across agencies, when describing the relationship between a child and a carer, but this is rarely explored or challenged.  If the relationship between a carer and child is described as a “good attachment”, and taken at face value, this can serve to be a powerful emotive description of the relationship between a child and carer.   In an article in ‘Community Care’21 with the headline: “Never use the word ‘attachment’ again”, according to an expert on attachment theory (Professor David Shemmings) the terminology of ‘good’ or ‘strong attachment’ should not be used:  A child can have a strong attachment to someone they are very insecure with….  When working with babies and very young children it is particularly important to appreciate this stage of development, their vulnerability and resultant dependency on their primary care giver for food shelter warmth and protection and to be aware of how this survival instinct can be wrongly interpreted as attachment.  Understanding the relationship from the child’s perspective, should involve in- depth observation and exploration of the interaction between a carer and child:   Observations of different aspects of the child’s routine at various times of the day can evidence a parent’s sensitivity, availability and attunement and provide a rich and invaluable source of attachment-based information.22                                                           21 J. Silman, Community Care 9/8/16  22 Professor David Shemmings quoted in Community Care 9/8/16                                         CSCB SCR  Joe - Publication Feb 2018 38  Issues for                                               Lesson 5: Issues for the Board - The Strengthening Families approach is a helpful way of encouraging practitioners to detail their observations. CSCB to review the implementation of this approach to evaluate whether the issues identified in this finding are being satisfactorily addressed.   - CSCB to seek assurances that front line staff are being provided with effective supervision that allows for case reflection, and facilitates informed professional judgements.  - How can the knowledge and experience of professionals within the multi-agency network be used to support an understanding of child development and parent – infant relationships?   Lesson 6: Contemporary cultural acceptance of the use of cannabis has led to a normalisation of its use, this has impacted on professional judgements on the question of risk posed to children who are living in households where its use is commonplace.      Throughout documentation seen as part of this SCR, there were frequent references to mother’s cannabis use. At various times, professionals noted the smell of cannabis in the household and there were records held by the police and housing services recording complaints of drug use by mother and a variety of household visitors.  However, the potential impact on Joe, on mother’s parenting capacity (and her capacity to change) rarely featured in professional recordings and despite Joe often being observed as ‘drowsy’, it was not properly considered as a risk factor. It was only towards the end of professional involvement that the risks of this substance misuse started to be recorded by social worker 5 and for the first time the impact on Joe was considered: “Joe presented as though passively exposed to cannabis in his demeanour” and concerns were expressed about: “Joe’s continued exposure to poor parenting relating to cannabis use”.  Research stresses that exposure to parental substance misuse does not inevitably lead to poor outcomes for children.                                          CSCB SCR  Joe - Publication Feb 2018 39 Of crucial importance is that each situation is assessed according to the specific drug(s) in use, duration, frequency, impact, age and development of the child/ren in the household. Importantly, in the use of cannabis, there should be an awareness that if certain vulnerability factors are present there is a risk that the user may develop mental health difficulties.  Research published by the NSPCC 23, presents evidence that parental substance misuse can harm children’s development, both directly through exposure to toxins in utero and indirectly through the impact it has on parenting capacity and on the home environment in which children are brought up:  The nature and severity of the harm not only differs with the age of the child, but is heavily influenced by the broader context in which substance misuse occurs, including factors such as poverty, social isolation, inadequate parenting skills and parental conflict. Child maltreatment or neglect might exist when limited finances are prioritised for the procurement of drugs/alcohol over basic needs of the child. It may take the form of poor monitoring leading to accidents in the home due to impaired judgement resulting from acute intoxication, being unresponsive to the child’s emotional or material needs and/or failing to provide a stable nurturing environment.   In addition, the way in which the drugs are obtained (and the potential of additional risks posed) is noted to be an important consideration. This SCR has found that the generic use of the term ‘cannabis’, is potentially misleading. Under this umbrella term sit a range of variants of the plant (such as ‘skunk’ or ‘sinsemilla’) which have varying chemical properties and variable potency. Recent research24 into the properties of cannabis currently available on the ‘street market’ is showing an increase in the availability of higher potency cannabis, and a growing concern about the risks of heavy cannabis use on the mental health of users:                 ……..frequent use of the drug can increase the risk of psychosis in vulnerable people.25                                                         23 Estimates of the number of infants (under the age of one year) living with substance misusing parents:  Dr Victoria Manning, National Addiction Centre, Institute of Psychiatry: NSPCC  2009 24 Therapeutic Advances in Psychopharmology: Published by Sage 2012  25 Cannabis: Scientists call for action amid mental health concerns The Guardian April 2016                                          CSCB SCR  Joe - Publication Feb 2018 40 The Review Panel were curious about the sparse attention paid to mother’s drug use and attempted to understand why it was the subject of only sporadic subjective observation by professionals, with little analysis of impact. The view of the Review Panel was that the growing normalisation of cannabis use, including the decriminalisation of its use within contemporary society, may well be a key factor in the lack of attention paid to the risks.  The legalisation of cannabis continues to be the subject of popular debate, with some politicians and some mainstream political parties taking a libertarian view to its use.26  Research from a UK longitudinal study27 reports ‘accommodating attitudes’ to drug use, especially by non-users, and ‘a degree of cultural accommodation of illegal drug use’.   It is not within the scope of this SCR to enter this debate. However, the Review Panel were keen to highlight how these societal influences may have a significant impact on the assessment of risk to children. It was felt important to draw the attention of CSCB to the growing concerns about the potential risks to children and the risks of mental health difficulties (including the onset of an acute psychotic episode) for certain vulnerable users.  Issues f                                                                                Lesson 6: Issues for the Board                      - This SCR is not suggesting that an alarmist approach is taken to the issue of cannabis use, the changes in the chemical formation of the drug and the implications for the wider population are issues for consideration by public health agencies. It is recommended that a proportionate approach is taken to this issue so that its use is properly considered as possible risk factor. (balanced alongside the individual characteristics of each case) The Board is invited to debate this issue and consider what response is needed.                                                             26 Such as the UK Green Party  27 The Normalization of ‘Sensible’ Recreational Drug Use. Further Evidence from the North West England Longitudinal Study Howard Parker Lisa Williams Judith Aldridge First Published November 2002                                          CSCB SCR  Joe - Publication Feb 2018 41 Lesson 7: Family and kinship are critical members of the safeguarding network but if they are not routinely regarded in this way valuable information that could strengthen the protection of children will be lost.   In a system that is working well, a child’s kinship is enabled to make a valuable contribution to the lives of children who are the subject of statutory intervention; supporting children in situations of risk or in times of family difficulties, giving professionals information to inform assessments and plans about a child’s needs, wishes and feelings and providing a safe environment for a child when needed.   When children are seen outside of the context of kinship, or when judgments are made about this kinship that are not based on proper assessment, there will be a narrow focus on supporting children and their immediate families through professional intervention alone and significant information that could strengthen how a child is safeguarded will be lost.  When the Lead Reviewer met with Joe’s maternal grandmother and her partner, it was learnt that they had only been contacted once28 during the time under review. Paternal and maternal family members had not been informed that Joe was the subject of a child protection plan and so were unaware of the concerns about Joe’s safety. Members of Joe’s maternal family were caring for Joe’s sister (after another London Borough had removed her from mother’s care because of longstanding concerns about neglect). Joe’s sister was known to the professionals involved as she often visited her mother and would stay with her mother and brother at their home.    Child protection case conference referred to this kinship and recommended that they should be contacted. When discussing the reasons why this kinship was not contacted by professionals it seemed that although they were aware of this kinship, the importance they could play in safeguarding Joe was overlooked.   It was understood that mother would not give consent to contact being made with family members, and professionals believed that her consent was required.                                                          28 Contact was made with MGM by Best Start, during the latter part of the period under review                                         CSCB SCR  Joe - Publication Feb 2018 42 It seemed that the lack of consent is commonly cited, and accepted, as justification as to why family members are not involved in safety planning.  Safeguarding a child is the paramount principle in law and, when acting to safeguard a child, a lack of consent can be overridden.  The child should be at the centre of all decision making, it was in Joe’s interests for this kinship network to be engaged.   Valuing the kinship in the life of a child, and the important contribution that this kinship can make in the protection of children has been raised in a recent SCR in Croydon,29 and has been the subject of national research.30   Insufficient weight is given to information from family, friends and neighbours and there is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk.                                                 Lesson 7: Issues for the Board   - CSCB are encouraged to review the steps that have already been taken in response to the recent SCR to ensure that the involvement of the kinship in safeguarding work has been strengthened and to consider what else may be needed.    Lesson 8: The quality of engagement with services by parents is often used as a basis to determine both the degree of risk to a child and the type of services that are provided, but how this is judged is currently unclear.  There is a wealth of literature 31 and guidance about engagement or non-engagement by parents with services.  The terminology currently used to describe non-engagement by parents or carers include terms such as: disguised compliance, resistant families, false compliance etc. and many serious case reviews have identified this as an area of concern.                                                          29 CSCB SCR Claire 2017  30 Ten pitfalls and how to avoid them. What research tells us? Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln NSPCC September 201O  31 Such as: Yatchmenoff 2005, Shemmings, Shemmings and Cook 2012, Turney 2012. Forrester, Westlake and Glynn 2012, Laird 2013, Ferguson 2011, Fauth et al. 2010. Calder, McKinnon and Sneddon 2012, Platt and Turney 2012.                                         CSCB SCR  Joe - Publication Feb 2018 43 These issues of resistance and disguised compliance have been identified in previous biennial reviews, as well as in much of the literature and again were identified in many of the SCRs in this cohort.32    During the time under review, there were several occasions when reports to the case conference described mother as ‘engaged’ and this judgement seemed to form the basis of professional opinions that the child protection plan should end (April 2015, September 2015 and January 2016). However, this judgement was based on the relationship the social worker or other professionals had achieved with mother or on mother’s self -report, not on changes that would have made a difference to Joe. The basis of these judgements was both subjective and situational.  Decisions about the quality of engagement can be pivotal in safeguarding children from harm, the degree of engagement shown by parents or carers with services needs careful analysis and judgements should not be predicated on a subjective opinion or a situational context.   Central to this judgement are the needs of the child and whether these needs are being met in time for the child.  In this case (despite frequent requests), many aspects of the plan were never implemented by mother (e.g. household visitors were never identified, Joe was not taken to required health appointments, mother was dishonest about her drug taking and was often not at home when announced visits had been arranged).    During the Learning Events, practitioners said it was not uncommon for judgments about engagement to be predicated on the quality of a relationship that exists between a service user and a professional. It is not an area that has been the subject of performance management nor is it something that can be easily audited.                                                               32 Brandon et al – Triennial Analyses of Serious Case Reviews 2011-2014                                         CSCB SCR  Joe - Publication Feb 2018 44                                                      Lesson 8: Issues for the Board   - The recommendations made previously, relating to evidence based assessments and decision making and the improvements needed in the quality and quantity of management supervision and oversight, will have a significant impact on this. As a result, no specific recommendation is made. SCB are invited to consider what more may be needed.   Lesson 9: In Croydon, frontline staff working with children and their families provide much needed care and protection to hundreds of children. If the contribution they make is not sufficiently recognised, there is a risk that the morale of the work force will be detrimentally affected. This will have an inevitable impact on the recruitment and retention of staff and ultimately on the services provided to children and their families.   Everyday across the country, multi-agency practitioners provide services to children and their families that protect them from harm and enable children to reach their potential. The number and range of services provided are vast and the number of practitioners who strive each day to achieve these outcomes with dedication, commitment and passion are countless. Many of these practitioners give more to the work than they are paid to do and in the most part these practitioners are rarely acknowledged for the difficult and challenging work that they undertake, and for the lives they change for the better.   There were several examples of good practice in this case, the panel have chosen two examples to demonstrate this:        When the social worker in the Best Start Team started to visit the family, she was very quickly concerned and made several astute observations about the home environment including the time it took mother to open the door when she visited (and the meaning of this in terms of the possible risks to Joe within this home that mother may be attempting to hide).                                          CSCB SCR  Joe - Publication Feb 2018 45 She was clear she could smell cannabis in the hallway and, despite mother’s denial, she strongly suspected mother was taking drugs. When she raised these issues with mother, she was very clear about her concerns and the changes that were expected.   The social worker had read the file and so understood the history of the case, she knew that despite the repeated concerns about mother’s use of drugs this had not been properly investigated and was aware that she had to remain vigilant. She was clear that mother’s use of drugs was likely to having a significant impact on Joe, both in terms of his experiences at home and on mother’s engagement to achieve desired changes. She also knew that mother’s drug use had financial implications for the family and was concerned about how these drugs were being supplied, and the implications for Joe’s safety. She chose not to be reliant on mother’s self-report when she denied her use of drugs instead she accessed her face book page, this provided valuable information that triangulated evidence of the long-standing concerns.  The social worker focused on the lived experience of Joe, displayed professional curiosity, used her intuition to access contemporary social media to triangulate her concerns and was tenacious in clarifying the risks. She appropriately raised all her concerns with mother and was committed to challenging the status-quo that had existed for several years.   The availability of systemic social work training provided her with significant post- qualifying professional development, and the availability of reflective supervision within the service provided important support to her in her role. Unfortunately, this effective professional practice came at a late stage of service intervention; drift was endemic in the case and for child protection action to be taken (in the form of a strategy meeting/child protection response) the case had to be referred back to Children’s Social Care.    The Buildings Manager of the residential complex where Joe lived had responsibility for the running of the building. She felt a sense of responsibility for the residents so when residents needed support, she did what she could to support them. This went beyond the responsibilities of her specific role in the organisation, but it was this attitude that may have saved Joe’s life.                                           CSCB SCR  Joe - Publication Feb 2018 46 When she saw mother without Joe, she felt concerned about mother’s presentation and wondered where Joe was. She went to mother’s flat and, noticing that the door was open, went inside and found Joe on the floor.   She was shocked by the extent of Joe’s injuries, but managed to compose herself and maintained a calm manner, she spoke softly to Joe whilst calling the emergency services. During the 20-minute wait for assistance, she soothed Joe and playfully engaged and reassured him until the paramedics arrived. The manager was neither expected to take this kind of action nor was she trained in safeguarding work, her actions embodied the mantra: ‘safeguarding is everyone’s responsibility’ (regardless of position, role or circumstance).                                                   Lesson 9: Issues for the Board   - CSCB to consider the benefits of routinely completing learning reviews that learn from examples of good practice.  - Children’s Services to explore in greater detail the work of the Best Start Social Work Team to examine what supported the good practice that was demonstrated and consider whether any systemic features can be promoted more widely.                                                     CSCB SCR  Joe - Publication Feb 2018 47 Appendix 1.                     Additional Learning    The impact of staff changes on how children are protected  At various points throughout this review, the changes of staff combined with the changes of address of the family were raised. This led to the panel testing out a hypothesis that these changes can lead to ‘risks being unnoticed making effective, timely safeguarding work very difficult to achieve’. It was clear that there were several changes of staff within Children’s Social Care (e.g. 5 social workers) but the same turnover of staff was not apparent in the wider multi-agency group (e.g.  the same health visitor worked with the family for the duration of service involvement). It was the view of Joe’s maternal grandmother that the changes of staff had a significant impact on mother and her engagement with services, and there is no doubt that this can have an impact on working relationships.   However, this SCR has found that it was not so much the changes of staff that had the greatest impact, it was the vulnerabilities identified in the lessons. It was concluded that if these remain unaddressed, the multi-agency safeguarding work can be overly dependent on the individual relationships between front line staff and the family. This is unsustainable in a working environment where changes of front line staff are a perennial feature. Changes in the system that stand the test of time are required, regardless of organisational change and changes of staff, to mitigate against this risk.     Fathers as a source of risk and a source of protection   On the information available at the start of this review there was a concern that Joe’s father (both as a source of risk and possible safety) had not been fully considered and this was due to the lack of value placed on fathers in the lives of children. As this SCR progressed it became clear that father was clearly regarded as a risk, assessments were pursued and plans were made that considered this risk. It was equally clear that practitioners were keen to promote the bond between father and Joe, and were involved in some protracted negotiations to enable supervised contact to happen. As a result, this hypothesis was dismissed as having no relevance to this case.                                         CSCB SCR  Joe - Publication Feb 2018 48 Appendix 2.                                                         Child Practice Review Process  First Review Panel  Practicalities including Learning Event participants and their preparation Sense making of the situation First pass at issues and questions to explore Set dates and venue for Learning Event  Second Review Panel Confirming tasks done Checking on participants Further thoughts and issues  Engaging with Family Members   Learning Event Learning Identifying effective practice Possible action points  Post Learning Event Writing up learning points and circulate to participants to check for accuracy/agreement  Draft Report   Third Review Panel Discussion of draft report  Fourth Review Panel  (NB: a 4th meeting might not be necessary. If things are straightforward there is a possibility all of this can be done at the third panel meeting) Finalising report Outline action plan  Feedback to Family  Presentation to SCB                                                                                                CSCB SCR  Joe - Publication Feb 2018 49 Appendix 3.                  TERMS OF REFERENCE FOR EXTENDED PRACTICE REVIEW   Core Tasks  Determine whether decisions and actions in the case comply with the policy and procedures of named services and LSCB.   Examine interagency working and service provision for the whole family  Determine the extent to which decisions and actions were child focused.   Seek contributions to the review from appropriate family members and keep them informed of key aspects of progress.   Take account of any parallel investigations or proceedings related to the case.   Hold a learning event for practitioners and identify required resources.    For extended reviews ONLY. In addition to the review process, to have particular regard to the following:    Was previous relevant information or history about the child and/or family members known and taken into account in professionals' assessment, planning and decision-making in respect of the child the family and their circumstances? How did that knowledge contribute to the outcome for the child?   Did agencies contribute appropriately to the development and delivery of the multi-agency plan?   What aspects of the plan worked well, what did not work well and why? To what degree did agencies challenge each other regarding the effectiveness of the plan, including progress against agreed outcomes for the child? Was the protocol for professional disagreement invoked? Were the respective statutory duties of agencies working with the child and family fulfilled?   Were there obstacles or difficulties (such as substance and alcohol misuse and DV) in this case that prevented agencies from fulfilling their duties? This should include consideration of both organisational issues and other contextual issues?  Were the statutory duties of all agencies fulfilled?                                                CSCB SCR  Joe - Publication Feb 2018 50 Appendix 4.                              History of Significant Events 1985 – April 2015     Date                                                         Events  1985 Father of Joe born.  1990  Mother born –  the youngest of 3 children.    1996  Mother’s father died, mother is provided with bereavement counselling.   July – Sept 2000  Mother is accommodated by Kingston CSC.  Oct 2000 Father arrested for robbery/assault.   Dec 2003 Father found in the possession of cannabis.   May 2004 Father arrested for possession of an offensive weapon.  March 2007  Father noted by GP to be unkempt and ‘not acting normally’.   May 2008  Mother arrested on suspicion of attempted robbery and theft.  June 2008 Mother noted to be verbally abusive to police when challenged for using out of date travel card and was reported as being known for anti-social behaviour.   Nov 2008  Pre-birth assessment and conference after Mother came to attention of police when father of unborn child assaulted her.  Reports note concern about mother being under the influence of alcohol ‘or other substances’. Decision of conference – CIN services to be provided. March 2009  Rebecca born. April 2009  Case closed to Kingston after advice and support provided. July 2009 Mother stopped in a stolen car - Rebecca present. Sept 2009  Mother with Rebecca seen by police rolling a cannabis cigarette - given a warning. Sept 2009 Mother arrested for assault. Dec 2009 Police called to a domestic incident – Rebecca present. Jan 2010 Mother arrested on suspicion of burglary. Jan 2011 Neighbour refers to Kingston reporting multiple loud parties, use of alcohol and drugs – poor/ chaotic home environment noted. Initial Assessment commenced. Feb 2011  Mother issued with a notice to quit her housing due to anti-social behaviour. Feb 2011 Father of Joe convicted of assault and battery on ex- partner and receives a custodial sentence. April – June 2011 x 5  Neighbours and police report concerns about use of cannabis in the house. August – November 2011 Continuing concerns about mother’s use of cannabis, chaotic lifestyle, loud parties, unkempt family home, lack of access to home, lack of insight, concerning associates, and continuing DV incidents in the family home when Rebecca present results in a CP conference -  Rebecca placed in the care of maternal grandmother.                                          CSCB SCR  Joe - Publication Feb 2018 51 November 2011 x 2 Mother evicted twice from different residencies. November 2011- Feb 2013 24 recorded incidents across agencies relating to Joe’s father & mother involving cannabis use, alcohol misuse, domestic incidents including assault of mother and loud arguments. Father’s parents contact the GP on 3 occasions concerned about her son’s unusual behaviour and anger management.   Feb 2013  Kingston CSC refer to Croydon CSC stating mother pregnant and listing history of previous concerns and current concerns for unborn child due to use of cannabis, domestic abuse, anti- social behaviour and history of neglect of Rebecca.   Feb 2013 Midwife refers concerns – pre-birth assessment to take place in Kingston Croydon CSC take NFA as uncertain about mother’s housing situation /confirmed residency in Croydon.  March 2013 Croydon accept case responsibility – case unallocated.  April 2013 Croydon Housing serve statutory order for noise nuisance father seen at property.   15th April 2013 Father convicted for threatening mother, court adjourned for reports prior to sentencing.  29th April 2013 Police called to mother’s address due to father’s threatening behaviour.   May 2013  Court Hearing: Residence Order granted to MGM for Rebecca.  21st May 2013 Father received 6-week custodial sentence   22nd May 2013 Initial CP conference: Joe made the subject of a plan under the categories of physical and emotional abuse.  30th July 2013 Joe born.  6th Aug 2013 Police called to maternity ward when father becomes volatile.  6th Aug 2013 Father seen at SW office is volatile and abusive. 14th Aug 2013 Review Child Protection Conference Joe remains subject to a CP plan under the categories of physical and emotional abuse.  Sept 2013 Police called to home x 3 for disturbances when mother and father present.  October – Dec2013  Various contact arrangements negotiated with family members. Concerns about mother’s cannabis use.   15th Jan 2014 Review Child Protection Conference. Joe remains subject to a plan under the categories of physical and emotional abuse.  22nd Jan 2014 Police attend home address after mother reports father’s presence at the address.                                          CSCB SCR  Joe - Publication Feb 2018 52 12th Feb 2014  Father arrested for assault on mother, bail conditions included a requirement not to go near mother’s address.   29th April 2014 Mother alleges to police father assaulted her in her home – appeared under the influence of drugs or alcohol.    1st May 2014  Police visit the address after a call from neighbour’s mother reports assault by father.  18th June 2014  CSC Review of file: 16 serious incidents between April ’12 and May2014 between mother and father – Joe has come to the attention of the police 10 times since birth.   8th July 2014  Father subject to an 18-month suspended sentence for domestic violence offences.   July – Aug 2014  SW’s unable to access the home or see Joe.  Aug – Dec 2014  Police called to home x 3 for domestic violence incidents  13 Nov 2014 Review Child Protection Conference. Joe remains subject to a plan under the categories of physical and emotional abuse. Minor changes in levels of risk – legal planning meeting to take place.  7th Jan 2015  Father convicted for multiple breaches of restraining order and receives custodial sentence.   15th April 2015 Review Child Protection Conference. Joe remains subject to a plan under the categories of physical and emotional abuse.                                                                 CSCB SCR  Joe - Publication Feb 2018 53 References    Brandon et al – Triennial Analysis of Serious Case Reviews 2011-2014.  Croydon Children’s Services: Croydon’s Escalation and Resolution Protocol for Children, Families and Learning Partnership March 2015.  Croydon Children’s Services: Analysis of Data of Children Subject to Child Protection Plan May 2016 (Croydon Safeguarding and Quality Assurance Service).  Croydon Safeguarding Children Board Annual Report 2013/14 & 2014/15  Croydon Safeguarding Board Serious Case Review Claire (2017).  Croydon Safeguarding Children Board Escalation Policy. Resolution of professional disagreements in work relating to the safety of children. March 2015.  Guardian Newspaper: Cannabis: Scientists call for action amid mental health concerns (reported: April 2016).  London Child Protection Procedures (LSCB: 2015).  Munro review of child protection: a child-centered system (Department for Education May 2011). NSPCC: Case reviews: National Case Review Repository (2017)  Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 – 2014 (DfE 2016).  Ten pitfalls and how to avoid them. What research tells us? Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln NSPCC September 2010.   Therapeutic Advances in Psychopharmology: Published by Sage 2012.   The Normalization of ‘Sensible’ Recreational Drug Use. Further Evidence from the North West England Longitudinal Study Howard Parker Lisa Williams Judith Aldridge First Published November 2002.  Working Together to Safeguard Children. DfE 2015.  